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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 5 of 12

Figure 2. Paracommissural edge-to-edge. Alfieri’s technique in a case of a postero-medial commissural prolapse due to previous
endocarditis (ring annuloplasty still to be added). In this situation, the configuration of a single-orifice valve is maintained

Anterior leaflet prolapse
When the prolapsing lesion is limited to the central scallop of the anterior leaflet (A2), the edge-to-edge
[25]
technique provides excellent late outcomes, thus avoiding the need of artificial chordae implantation . In
a series of 139 patients, a 17-year survival rate of 72.4% ± 7.89%, freedom from cardiac death of 90.8% ±
4.77% and freedom from reoperation of 89.6% ± 2.74% were reported. Recurrence of MR grade ≥ 3+ was
documented in 12.5% (17/135) of cases. At multivariate analysis, the predictors of MR recurrence include
the presence of a greater-than-mild residual MR at discharge (HR: 7.4; 95%CI: 2.5-21.2; P = 0.001) and the
[26]
use of a pericardial rather than a prosthetic ring annuloplasty (HR: 2.8; 95%CI: 0.9-8.7; P = 0.06) .

Paracommissural edge-to-edge
Commissural lesions remain very challenging to repair, even for most experienced surgeons [Figure 2]. On
the other hand, the application of the edge-to-edge technique can fixate the valve in a few minutes. Indeed,
results in 115 patients treated with paracommissural edge-to-edge technique combined with annuloplasty
ring showed a 2-year recurrence of severe MR in only 2 patients (1.9%), again without evidence of mitral
[27]
stenosis . Similarly, the Cleveland Clinic reported encouraging data on more than 100 of patients treated
[28]
with closure of the prolapsing commissure .
Functional mitral valve disease
Mitral regurgitation in the setting of ischemic or non-ischemic dilated cardiomyopathy is secondary to both
apical tenting of the leaflets and annular dilatation in remodeled ventricles. In the presence of moderate
tethering and a relatively small ventricle, the application of an undersized annuloplasty using a complete
rigid or semirigid ring may be an effective solution. When leaflet tethering is more pronounced (coaptation
depth > 1 cm), it has been proposed that the association of a central edge-to-edge technique could enhance
the durability of the repair. Unfortunately, Bhudia and colleagues showed a 2-year recurrence rate of
[11]
moderate-to-severe MR post-operatively in secondary MR of 24% . However, in this series the application
of flexible bands was probably not enough to support the annulus and prevent its further dilatation, which
was the common finding at reoperations. Better results were described by the Alfieri’s group, with a 5-year
freedom from repair failure of 95% ± 3.4%, significantly higher as compared to that of isolated annuloplasty
[29]
without edge-to-edge (77% ± 12.1%; P = 0.04) .