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(Circulation. 2002;106:e173.)
© 2002 American Heart Association, Inc.

Images in Cardiovascular Medicine

Alfieri Mitral Valve Repair

Clinical Outcome and Pathology

Salvatore Privitera, MSc, MD; Jagdish Butany, MBBS, MS, FRCPC; Robert J. Cusimano, MSc, MD, FRCSC; Candice Silversides, MD, FRCPC; Heather Ross, MD, FRCPC; Richard Leask, PhD

From the Departments of Cardiac Surgery (S.P., R.J.C.), Pathology (J.B., R.L.), and Cardiology (C.S., H.R.), Toronto General Hospital (University Health Network), and University of Toronto (S.P., J.B., R.J.C., C.S., H.R., R.L.), Toronto, Ontario, Canada.

Correspondence to Jagdish Butany, MBBS, MS, FRCPC, Toronto General Hospital, 200 Elizabeth St E4-322, Toronto, Ontario M5J 3R2. E-mail jagdish.butany{at}uhn.on.ca

A 64-year-old man with three previous myocardial infarcts, congestive heart failure, and severe mitral regurgitation underwent orthotopic heart transplantation. Four years previously, he had undergone coronary artery bypass grafts (x2), left ventricular (LV) volume reduction, and an Alfieri repair of the mitral valve (MV). Post-repair transesophageal echocardiography (TEE) revealed a double-orifice MV with mild mitral regurgitation, LV short-axis end-diastolic diameter of 61x59 mm (reduced from 72x64 mm), and a MV area of 2.3 cm² by pressure half-time method. LV ejection fraction remained at <20% (Figure 1, A through C).

View larger version (47K): [in this window] [in a new window]   Figure 1. A, TEE short-axis view shows double-orifice mitral valve (asterisks) and the Alfieri repair site (arrow). B, TEE 2-chamber view shows double-orifice mitral valve and region of repair (arrow). LA indicates left atrium; LV, left ventricle. C, TEE with Doppler color flow characteristics through double-orifice mitral valve.

The heart showed LV dilatation and features of previous surgery. The MV had two orifices, with diameters of 2.2 and 1.6 cm, separated by a central, thick, firm, smooth-surfaced bridge of tissue from the anterior to the posterior leaflet (Figure 2A). The ventricular surface was somewhat nodular (Figure 2B) with extensive fibrosis and giant cell reaction to the pledgetted Ticron suture (Tyco, Figure 3).

View larger version (88K): [in this window] [in a new window]   Figure 2. A, Atrial view of the mitral valve showing the double orifice and the Alfieri repair site with tissue growth over the suture site (arrow). A indicates anterior leaflet. B, Ventricular view. The double orifice (asterisk) and repair site (arrow) are seen. Arrowhead indicates surgical stitch.

View larger version (133K): [in this window] [in a new window]   Figure 3. A longitudinal section through the Alfieri repair site, with extensive fibrosis on ventricular (arrow) and atrial surfaces with fibrous tissue extending into interstices of the pledgettes (asterisk). A indicates anterior leaflet; P, posterior leaflet. Stain: Movat pentachrome. Original magnification x1.0.

The Alfieri repair was designed to reduce the MV orifice size, or improve coaptation, in order to restore MV competence. Although mobility of the leaflets is reduced with altered flow patterns, significant mitral stenosis is not produced.

Footnotes

The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.

Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.

This Article Extract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Privitera, S. Articles by Leask, R. Search for Related Content PubMed PubMed Citation Articles by Privitera, S. Articles by Leask, R. Related Collections CV surgery: transplantation, ventricular assistance, cardiomyopathy CV surgery: valvular disease