A Modified Alfieri - Mitral valve repair for ischemic mitral valve regurgitation

Introduction:

Ischemic Mitral Regurgitation (IMR) occurs in 30% to 50% of patients after acute myocardial infarction (AMI) due to left ventricular remodeling, leading to valve dysfunction and tethering of the posterior leaflet. Treatment typically involves revascularization and mitral valve replacement or repair using various techniques in addition to annuloplasty. Although subvalvular interventions like chordal cutting or papillary muscle approximation have been proposed, they have not been widely adopted.

The classic Alfieri technique is an edge-to-edge repair that lacks a sufficient coaptation zone, a key factor for long-term mitral valve function.

The modified Alfieri repair addresses this by approximating the A2-P2 leaflets 5-10 mm above their edges and using undersized ring annuloplasty. This technique aims to simplify ischemic mitral valve repair while ensuring adequate coaptation for sustained valve performance.

Methods:

This single-center prospective study involved eight male patients, with a mean age of 73 years and a mean EF - 42%, undergoing a modified Alfieri mitral valve repair with undersized open ring annuloplasty for severe Ischaemic Mitral Regurgitation (IMR) between February and October 2024. Six patients also had concurrent CABG. Primary outcomes were hospital and all-cause mortality, while secondary outcomes included recurrence of MR, heart failure hospitalizations, and valve-related events (bleeding, thromboembolism, endocarditis, reoperation).

Results:

No major adverse cardiac events, including mortality or recurrence of MR, were reported in a 6-month follow-up of patients who underwent a modified Alfieri mitral valve repair. Two patients showed improvements in ejection fraction, which increased from 25% to 40%, and in NYHA score, which improved by 2 points. A more detailed and updated follow-up, including surgical videos and echocardiographic images, will be presented at the conference.

Conclusion:

The modified Alfieri technique is a simple, effective procedure with no adverse short-to-mid-term outcomes. It improves leaflet coaptation, valve function, and ejection fraction.