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Belluschi et al. Mini-invasive Surg 2020;4:58 I http://dx.doi.org/10.20517/2574-1225.2020.48 Page 3 of 12

factors indicating an increased mitral valve deformation (such as coaptation distance ≥ 1 cm; tenting area
2
> 2.5-3 cm ; complex jets etc.) or a high level of local and global LV remodeling account for an unfavorable
[18]
repair .
In the presence of relevant comorbidities and high surgical risk, a percutaneous edge-to-edge procedure
may be considered in patients with primary or secondary MR, who remain symptomatic despite optimal
medical therapy (including CRT if indicated), with echocardiographic screening required for perioperative
risk stratification and assessment of suitability (class IIb; level C). The Heart Team may consider this
transcatheter option after careful evaluation of other strategies (i.e., left ventricular assistant devices or
heart transplant).

THE IDEA
At the beginning of the 90’s, a young woman who suffered from symptomatic severe mitral valve
regurgitation asked Professor Alfieri’s to perform her own surgery. However, despite a comprehensible
feeling of anxiety and fear of the intervention, another reason justified her melanchony: the unlikelihood
of having a pregnancy after surgery. Indeed, her anterior mitral leaflet lesion appeared to be not suitable
for a conventional repair. Alternatively, the durability of a bioprosthesis would have been very poor and
a mechanical prosthesis would have drammatically increase the risks of a potential pregnancy. It was in
this scenario that Professor Alfieri, particularly impressed by the aspiration of the young lady to become a
mother, had the intuition of anchoring the prolapsing scallop of the anterior leaflet to the facing segment
of the posterior leaflet, which had normal mobility. This concept of a valve with a double-orifice was
derived from the world of congenital diseases. Previously, he had occasionally observed that patients with
a congenital double-orifice valve rarely had a pathological evolution in regurgitation. In other words, the
double-orifice design, derived from “a congenital mistake”, would have become now a simple solution to fix
complex anatomical mitral valve lesions. Despite the uncertainties of a new surgical procedure, Professor
Alfieri obtained the informed consent from the patient and an efficient mitral valve repair was achieved
with the novel “Alfieri’s Edge-to-Edge” technique. A few years later, the patient gave birth to three healthy
children.

THE SURGICAL TECHNIQUE
Usually, the “double orifice” repair starts with the inspection of the valve and the analysis of the target
lesion (see next paragraph). Once the indication for the adoption of the edge-to-edge technique has been
identified, the proper repair begins. After identification of the central portion of the valve, the edge-to-
edge suture (generally 4-0 polypropylene) is placed exactly in the middle of the leaflet and, then, a matress
followed by a running suture is extended on both sides (antero-lateral and postero-medial), to cover the
regurgitant jet site [Figure 1]. The injection of saline solution helps to test the hydrodynamic competence
of the repaired valve. The resulting double-orifice valve area can be directly measured by Hegar dilators (at
2
least 2.5 cm for a normal size patient) and assessed by intra-operative trans-oesophageal echocardiography
(TOE).

Moreover, the application of a complete or a partial prosthetic ring prevents further annular dilatation.
In addition, it helps in reducing the stress on the edge-to-edge thus preserving long-term durability of
the repair. Indeed, it has been demonstrated that the absence of an annuloplasty ring is associated with
higher repair failure: in a series of 260 patients undergoing edge-to-edge repair, 52 of them did not received
an annuloplasty for severe annular calcification (n = 44) or absence of annular dilatation (n = 8). The
5-years freedom from reoperation was 92% and 70% in those who annuloplasty was performed or not,
[19]
respectively . Similarly, in a series of 61 patients treated with the Alfieri’s technique at the beginning of
the experience without annuloplasty, the long-term results were not satisfactory: the 12-years the freedom
[20]
from recurrence of moderate-to-severe MR was 43% and the freedom from reoperation was 58% .