Barlow's Mitral Valve Disease: A Comparison of Neochordal (Loop) and Edge-To-Edge (Alfieri) Minimally Invasive Repair Techniques.
BACKGROUND
Barlow's mitral valve (MV) disease remains a surgical challenge. We compared short- and medium-term outcomes of neochordal ("loop") versus edge-to-edge ("Alfieri") minimally invasive MV repair in patients with Barlow's disease.


METHODS
From January 2009 to April 2014, 123 consecutive patients with Barlow's disease (defined as bileaflet billowing or prolapse [or both], excessive leaflet tissue, and annular dilatation with or without calcification) underwent minimally invasive MV operations for severe mitral regurgitation (MR) at our institution. Three patients (2.4%) underwent MV replacement during the study period and were excluded from subsequent analysis. The loop MV repair technique was used in 68 patients (55.3%) and an edge-to-edge repair was performed in 44 patients (35.8%). Patients who underwent a combination of these 2 techniques (n = 8 [6.5%]) were excluded. The median age was 48 years, and 62.5% of patients were men. Concomitant procedures included closure of a patent foramen ovale or atrial septal defect (n = 19), tricuspid valve repair (n = 5), and atrial fibrillation ablation (n = 15). Follow-up was performed 24.7 ± 17 months postoperatively and was 98% complete.


RESULTS
No deaths occurred perioperatively or during follow-up. Aortic cross-clamp time (64.1 ± 17.6 minutes versus 95.9 ± 29.5 minutes) and cardiopulmonary bypass (CPB) time (110.0 ± 24.2 minutes versus 146.4 ± 39.1 minutes) were significantly shorter (p < 0.001) in patients who received edge-to-edge repair. Although patients who underwent edge-to-edge repair received a larger annuloplasty ring (38.6 ± 1.5 mm versus 35.8 ± 2.7 mm; p < 0.001), the early postoperative resting mean gradients were higher (3.3 ± 1.2 mm Hg versus 2.6 ± 1.2 mm Hg; p = 0.007) and the mitral orifice area tended to be smaller in this group (2.8 ± 0.7 cm(2) versus 3.0 ± 0.7 cm(2); p = 0.06). The amount of residual MR was similar between groups (0.3 ± 0.6 versus 0.6 ± 1.0 for edge-to-edge versus loop procedures, respectively; p = 0.08). More than mild MR requiring early MV reoperation was present in 3 patients who underwent loop procedures (4.4%) and in no patients who had edge-to-edge procedures (p = 0.51). During follow-up, 2 patients (1 in each group) required MV replacement for severe MR. The 4-year freedom from MV reoperation was 92.8% ± 5.0% in the Alfieri group compared with 90.9% ± 4.6% in the loop group (p = 0.94).


CONCLUSIONS
Minimally invasive MV repair can be accomplished with excellent early and medium-term outcomes in patients with Barlow's disease. The edge-to-edge (Alfieri) repair can be performed with reduced operative times when compared with the loop technique, but it results in mildly increased transvalvular gradients and mildly decreased valve opening areas without any difference in residual MR.
Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.
Jaqueline G
JG
da Rocha E Silva
Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.
Ricardo
R
Spampinato
Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.
Martin
M
Misfeld
Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.
Joerg
J
Seeburger
Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.
Bettina
B
Pfanmüller
Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.
Sandra
S
Eifert
Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.
Friedrich W
FW
Mohr
Division of Cardiac, Thoracic and Vascular Surgery, Columbia University Medical Center, New York, New York. Electronic address: mb3851@cumc.columbia.edu.
Michael A
MA
Borger
D000328:Adult; D015331:Cohort Studies; D005260:Female; D040181:Genetic Diseases, X-Linked / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D058386:Mitral Valve Annuloplasty / Q000379:methods*; D008945:Mitral Valve Prolapse / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D061646:Operative Time; D013997:Time Factors; D016896:Treatment Outcome