title: Edge-to-edge surgical mitral valve repair in the era of MitraClip: what if the annuloplasty ring is missed?
abstract: OBJECTIVE
  The purpose of this review is to define the role of annuloplasty in the surgical edge-to-edge repair, an issue that seems particularly relevant in the current MitraClip era, when more than 15 000 patients have been submitted to a percutaneous transcatheter edge-to-edge repair without concomitant annuloplasty.
  
  
  RESULTS
  Only a few studies have reported the clinical and echocardiographic outcomes of the ringless edge-to-edge mitral repair. In all of them, however, only mid-term data were provided. Recently, the long-term results of the surgical edge-to-edge procedure performed without a concomitant annuloplasty in a selected group of patients with degenerative mitral regurgitation have been published.
  
  
  CONCLUSIONS
  The surgical edge-to-edge technique should always be combined with prosthetic ring annuloplasty in order to provide excellent long-term outcomes in patients with degenerative mitral regurgitation. The overall long-term results of the surgical edge-to-edge technique without annuloplasty are not satisfactory. The ringless edge-to-edge technique is not effective in the challenging setting of extensively calcified annulus. In patients without annular calcification, in whom annuloplasty was intentionally avoided, the ringless edge-to-edge repair provides acceptable results in the mid term but is associated with a high failure rate in the long term. In the MitraClip perspective, these findings emphasize the need for a reliable annuloplasty to improve the long-term outcomes of the currently available transcatheter edge-to-edge procedure.
authors.affiliation: Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy.
authors.forename: Michele
authors.initials: M
authors.lastname: De Bonis
authors.forename: Elisabetta
authors.initials: E
authors.lastname: Lapenna
authors.forename: Alberto
authors.initials: A
authors.lastname: Pozzoli
authors.forename: Andrea
authors.initials: A
authors.lastname: Giacomini
authors.forename: Ottavio
authors.initials: O
authors.lastname: Alfieri