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Page 2 of 12 Belluschi et al. Mini-invasive Surg 2020;4:58 I http://dx.doi.org/10.20517/2574-1225.2020.48

correction”, the first standardized and reproducible toolbox of surgical techniques to treat mitral valve
[3]
regurgitation . This approach which is based on the reconstruction of the native valve anatomy mainly
through the resection of the prolapsing and excessive tissue, has become a surgical landmark for the art of
mitral valve repair, providing optimal long-term outcomes, especially in isolated prolapse of the posterior
[4]
leaflet . However, the results of these “anatomical reconstructions” in the setting of anterior, bileaflet and
[5]
commissural lesions were reported to be less promising .
In 1991, the Italian cardiac surgeon Professor Ottavio Alfieri introduced a surgical technique for the repair
[6]
of mitral regurgitation, named “edge-to-edge” (later known also as the “Alfieri’s stitch”) . This revolutionary
method was based upon a “functional” rather than “anatomical” conceptualization of the valve repair. In
this way, the application of a suture at the site of the regurgitant jet, between the facing free margins of the
anterior and posterior leaflets (usually A2 and P2), creates a “double-orifice” valve without residual prolapse
of one or both leaflets. Indeed, the most common indication for the edge-to-edge repair is represented by
bileaflet prolapse in the setting of Barlow’s, where the excess of myxomatous tissue allows the application
of a strong and wide suture, extending along the entire free margins of the central scallops (“central edge-
to-edge” or “double orifice repair”). Given the increased risk of systolic anterior motion (SAM) of the
anterior mitral leaflet, the iatrogenic fusion of both leaflets by application of the Alfieri’s stitch reduces the
fluctuation of the anterior leaflet towards the left ventricular outflow tract (LVOT). On the other hand,
the closure of the whole commissural area to treat non-central lesions (“paracommissural edge-to-edge”)
preserves the single orifice configuration of the native valve. In addition, the concomitant use of a complete
or partial prosthetic ring decreases the tension on the edge-to-edge suture, allowing for further stabilization
of the annulus and enhances the overall durability of the repair.

Simplicity and reproducibility represent the main reasons for the success of the Alfieri’s stitch, a truly
versatile surgical technique which has been adopted in thousands of patients [7-13] . This paves way for a
breakthrough in the world of cardiac surgery, particularly in percutaneous mitral valve repair .
[14]
In this review we will briefly discuss the history of the edge-to-edge mitral valve repair, beginning from its
origins, through the initial criticisms, reasons for success, to its ultimate percutaneous evolution.

INDICATIONS FOR MITRAL SURGERY
As stated by the 2017 ESC guidelines on the treatment of valvular heart disease, surgery (especially repair
whenever possible) is indicated in cases of severe symptomatic primary mitral valve regurgitation with left
[2]
ventricle ejection fraction > 30% . In addition, in asymptomatic patients, the presence of Left Ventricle
Ejection Fraction (LVEF) ≤ 60% or Left Ventricle End Systolic Diameter ≥ 45 mm, atrial fibrillation or
a systolic pulmonary pressure ≥ 50 mmHg predict a worse outcome and therefore surgery should be
considered as well. Whenever long durability is predicted, early repair is encouraged.

Severe secondary mitral regurgitation in patients undergoing CABG with LVEF > 30% is another
indication for surgery (class I; level C). However, when LVEF is < 30% but the patient still has an option
for revascularization and there is evidence of myocardial viability, surgery should be considered (class IIa;
level C). If revascularization is not indicated, surgery may be considered in those patients who remain
symptomatic despite optimal medical management (including CRT if indicated) and have a low surgical
risk (class IIb; level C).

Compared to replacement, surgical mitral valve (MV) repair has shown optimal early-, mid- and long-
[15]
term results, with a lower peri-operative mortality rate . In experienced centers, at 20 years, the reported
[16]
MR recurrence rate after repair is around 10% . On the other hand, repair for secondary MR has shown
to be less durable, with a significant rate of recurrence at 2 years . The presence of echocardiographic
[17]