Edge-to-edge mitral valve repair without annuloplasty ring: are we wearing the wrong sneakers?

Take Home Message

The transaortic approach for mitral valve regurgitation as edge-to-edge without an annuloplasty ring cannot be widely recommended as itself. The final message should be that the annuloplasty ring is part of the edge-to-edge technique for MV repair, and it cannot be overlooked, under no circumstances.


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My Special Comment


By Ovidio A. García-Villarreal, MD

Cardiac Surgery. Consultant in Private Practice. Monterrey, México.

email: ovidiocardiotor@gmail.com


Since the Seminars in Thoracic and Cardiovascular Surgery does not accept submissions other than by invitation, the proposal to write in the Editor’s corner of LACES is a quite feasible chance to respectfully present our viewpoints. That said, I have read with careful attention the commentary by Forcillo et al. [1] about how effective is the Alfieri’s stitch to address the mitral valve (MV) regurgitation in the context of aortic valve surgery throughout transaortic approach. Several important remarks should be done in this regard. The edge-to-edge technique was initially conceived and published by Alfieri et al. as a simple solution for complex situations [2]. Nevertheless, we have to make it very clear that, even though the edge-to-edge technique has never been the first choice for surgical MV repair, there are rules that cannot be violated such as the use of an annuloplasty ring as a fundamental and medullar part of any MV repair. In fact, De Bonis et al. have repeatedly demonstrated the fact that the lack of annuloplasty ring is the most important predictor for failure after edge-to-edge technique [3-5]. In other words, when the edge-to-edge technique is combined with ring annuloplasty, it provides very satisfactory long-term results. The technique proposed by the authors [1] lacks the possibility of placing an annuloplasty ring through the transaortic route. In the light of the foregoing, and transferring the results by De Bonis to daily practice, this suggests that we should be very careful in recommending this type of ringless technique. The same problem can be found with the use of the MitraClip, since it is a ringless therapy. However, MitraClip is just recommended for patients in Stage D of heart failure, with no other option in the setting of functional MV regurgitation; or patients with high or prohibitive risk for surgery with primary MV regurgitation [6]. 


Therefore, we can summarize that this transaortic approach for MV regurgitation as edge-to-edge without an annuloplasty ring cannot be widely recommended as itself. The final message should be that the annuloplasty ring is part of the edge-to-edge technique for MV repair, and it cannot be overlooked, under no circumstances. 

  1. Forcillo J, Thourani V. Commentary: Indication creep: rebranding the Alfieri stitch during aortic surgery. Seminars in Thoracic and Cardiovascular Surgery (2021). doi: https://doi.org/10.1053/j.semtcvs.2021.06.021.
  2. 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;122:674-81. doi: 10.1067/mtc.2001.117277.
  3. De Bonis M, Lapenna E, Taramasso M, et al. Very long-term durability of the edge-to-edge repair for isolated anterior mitral leaflet prolapse: up to 21 years of clinical and echocardiographic results. J Thorac Cardiovasc Surg 2014;148:2027-32. doi: 10.1016/j.jtcvs.2014.03.041.
  4. De Bonis M, Lapenna E, Maisano F, Barili F, La Canna G, Buzzatti N, Pappalardo F, Calabrese M, Nisi T, Alfieri O. Long-term results (≤18 years) of the edge-to-edge mitral valve repair without annuloplasty in degenerative mitral regurgitation: implications for the percutaneous approach. Circulation 2014;130(11 Suppl 1):S19-24. doi: 10.1161/CIRCULATIONAHA.113.007885.
  5. De Bonis M, Lapenna E, Pozzoli A, Giacomini A, Alfieri O. Edge-to-edge surgical mitral valve repair in the era of MitraClip: what if the annuloplasty ring is missed? Curr Opin Cardiol 2015;30(2):155-60. doi: 10.1097/HCO.0000000000000148.
  6. Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP 3rd, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM 3rd, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;143(5):e35-e71. doi: 10.1161/CIR.0000000000000932.