Alfieri Mitral Valve Repair
Clinical Outcome and Pathology
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 (×2), 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 61×59 mm (reduced from 72×64 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).
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).
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.
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.