How I Assess and Repair the Barlow Mitral Valve: The Edge-to-Edge Technique

  • Michele De BonisEmail author
  • Ottavio R. Alfieri


The main cause of mitral regurgitation (MR) in the western world is degenerative mitral valve disease, which usually leads to prolapse or flail of the posterior, anterior, or both leaflets. Mitral valve repair has become the treatment of choice of degenerative MR providing predictable and durable results in most patients.1,2 The most favorable outcomes have always been reported with isolated prolapse of the posterior leaflet treated by a simple procedure like quadrangular resection and annuloplasty. On the other hand, less gratifying results and more demanding surgical techniques have been associated with correction of mitral regurgitation due to anterior leaflet or bileaflet prolapse.3–6 To increase the feasibility of repair in those more difficult settings, a new surgical technique, named edge-to-edge, was introduced by our group more than 15 years ago. The basic principle of the edge-to-edge is that the competence of a regurgitant mitral valve can be restored with a functional rather than an anatomical repair. This can be obtained by suturing the free edge of the diseased leaflet to the corresponding edge of the opposing leaflet, exactly at the site where regurgitation occurs. When the regurgitant jet is located in the central part of the mitral valve, the application of the edge-to-edge technique produces a mitral valve with a double orifice configuration. In this case, the operation is conventionally defined as double orifice repair, and the two orifices can have similar or significantly different sizes depending on the extension and location of the suture performed. On the other hand, when the regurgitant jet is located in the commissural area, the application of the edge-to-edge technique at this level creates a single orifice mitral valve with a relatively smaller area. This second instance is usually called paracommissural edge-to-edge. There are situations in which the regurgitant jet of the mitral valve is not a single one. Particularly, in the setting of Barlow’s disease with severe bileaflet prolapse, for example, multiple regurgitant jets are usually found along the entire line of coaptation of the anterior and posterior leaflet. In this case, the edge-to-edge approximation of the middle scallop of the anterior and posterior leaflet (A2 and P2) allows the elimination of most of the mitral insufficiency while the residual smaller regurgitant jets are effectively corrected by the association of a ring annuloplasty.


Mitral Valve Mitral Regurgitation Mitral Stenosis Mitral Valve Repair Anterior Leaflet 
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  1. 1.
    Yun KL, Miller DC. Mitral valve repair versus replacement. Cardiol Clin. 1991;9:315-327.PubMedGoogle Scholar
  2. 2.
    Olson LJ, Subramanian R, Ackermann DM, et al. Surgical pathology of the mitral valve: a study of 712 cases spanning 21 years. Mayo Clin Proc. 1987;62:22-34.PubMedGoogle Scholar
  3. 3.
    Gillinov AM, Cosgrove DM, Blackstone EH, et al. Durability of mitral valve repair for degenerative disease. J Thorac Cardiovasc Surg. 1998;111:734-743.CrossRefGoogle Scholar
  4. 4.
    Braunberger E, Deloche A, Berrebi A, et al. Very long-term results (more than 20 years) of valve repair with Carpentier’s techniques in nonrheumatic mitral valve insufficiency. Circulation. 2001;104(12 Suppl 1):I8-I11.PubMedGoogle Scholar
  5. 5.
    Mohty D, Orszulak TA, Schaff HV, et al. Very long-term survival and durability of mitral valve repair for mitral valve prolapse. Circulation. 2001;104:I-1-I-7.CrossRefGoogle Scholar
  6. 6.
    Flameng W, Herijjers P, Bogaerts K, et al. Recurrence of mitral valve regurgitation after mitral valve repair in degenerative valve disease. Circulation. 2003;107: 1609-1613.CrossRefPubMedGoogle Scholar
  7. 7.
    Maisano F, Schreuder JJ, Oppizzi M, et al. The double-orifice technique as a standardized approach to treat mitral regurgitation due to severe myxomatous disease: surgical technique. Eur J Cardiothorac Surg. 2000;17:201-205.CrossRefPubMedGoogle Scholar
  8. 8.
    De Bonis M, Lorusso R, Lapenna E, et al. Similar long-term results of mitral valve repair for anterior compared with posterior leaflet prolapse. J Thorac Cardiovasc Surg. 2006; 131(2):364-368.CrossRefPubMedGoogle Scholar
  9. 9.
    Gillinov AM, Shortt KG, Cosgrove DM 3rd. Commissural closure for repair of mitral commissural prolapse. Ann Thorac Surg. 2005;80:1135-1136.CrossRefPubMedGoogle Scholar
  10. 10.
    Lapenna E, De Bonis M, Sorrentino F, et al. Commissural closure for the treatment of commissural mitral valve prolapse or flail. J Heart Valve Dis. 2008;17:261-266.PubMedGoogle Scholar
  11. 11.
    Lapenna E, Torracca L, De Bonis M, et al. Minimally invasive mitral valve repair in the context of Barlow’s disease. Ann Thorac Surg. 2005;79(5):1496-1499.CrossRefPubMedGoogle Scholar
  12. 12.
    Alfieri O, Maisano F, De Bonis M, et al. The double-orifice technique in mitral valve repair: a simple solution for complex problems. J Thorac Cardiovasc Surg. 2001;122:674-681.CrossRefPubMedGoogle Scholar
  13. 13.
    Timek TA, Nielsen SL, Lai DT, et al. Mitral annular size predicts Alfieri stitch tension in mitral edge-to-edge repair. J Heart Valve Dis. 2004;13:165-173.PubMedGoogle Scholar
  14. 14.
    Maisano F, Redaelli A, Pennati G, et al. The hemodynamic effects of double-orifice valve repair for mitral regurgitation: a 3D computational model. Eur J Cardiothorac Surg. 1999; 15:419-425.CrossRefPubMedGoogle Scholar
  15. 15.
    Borghetti V, Campana M, Scotti C, et al. Preliminary observations on haemodynamics during physiological stress conditions following double orifice mitral valve repair. Eur J Cardiothorac Surg. 2001;20:262-269.CrossRefPubMedGoogle Scholar
  16. 16.
    Maisano F, Torracca L, Oppizzi M, et al. The edge-to-edge technique: a simplified method to correct mitral insufficiency. Eur J Cardiothorac Surg. 1998;13(3):240-245.CrossRefPubMedGoogle Scholar
  17. 17.
    Agricola E, Maisano F, Oppizzi M, et al. Mitral valve reserve in double-orifice technique: an exercise echocardiographic study. J Heart Valve Dis. 2002;11(5):637-643.PubMedGoogle Scholar
  18. 18.
    Frapier JM, Sportouch C, Rauzy V, et al. Mitral valve repair by Alfieri’s technique does not limit exercise tolerance more than Carpentier’s correction. Eur J Cardiothorac Surg. 2006;29:1020-1025.CrossRefPubMedGoogle Scholar
  19. 19.
    Carpentier A. Cardiac valve surgery. The French correction. J Thorac Cardiovasc Surg. 1983;86:323-327.PubMedGoogle Scholar

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© Springer-Verlag London Limited 2010

Authors and Affiliations

  1. 1.Department of Cardiac SurgerySan Raffaele University HospitalMilanoItaly

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