Contemporary application of the edge-to-edge repair.

The edge-to-edge technique was introduced into the surgical armamentarium of mitral valve repair in the early 1990s. From the beginning, it appeared to be an attractive approach because of its simplicity, reproducibility and effectiveness even in complex settings. Several institutions around the world adopted this surgical method in selected patients with mitral regurgitation due to different causes and mechanisms (1-8). More recently, the edge-to-edge concept has also become the basis of the most widespread percutaneous method of correcting mitral regurgitation (9). Unlike traditional repair techniques, which aim for an anatomical reconstruction of the diseased valve, the basic concept behind the edge-to-edge approach is that the competence of the mitral valve can be effectively restored with a ‘functional’ rather than an ‘anatomical’ repair. Appropriate patient selection is crucial and transesophageal echocardiography (TEE) provides all the anatomical and functional features that are essential to decide whether this surgical option is suitable for a specific case. In particular, important details are given by the TEE regarding the cause and mechanism of mitral regurgitation, the degree of annular dilatation (which has important implications for the risk of stenosis after repair), the presence of annular calcification, the precise site and extension of the regurgitant jet and the likelihood of postoperative systolic anterior motion (SAM). The location of the regurgitant jet is particularly important because the free edge of one leaflet is sutured to the corresponding edge of the opposing leaflet at exactly the same level in order to restore mitral valve competence. When the regurgitation originates in the central part of the valve, the edge-to-edge repair produces a mitral valve with a double orifice configuration (double orifice repair). On the other hand, when mitral insufficiency occurs near a commissure, the edge-to-edge leads to a surgical closure of the commissure (‘paracommissural edge to-edge repair’). Under these circumstances, the mitral valve will have a single orifice with a relatively smaller area when compared with the preoperative value. The suture has to be placed in exact correspondence with the regurgitant jet and has to be as short as possible in order to eliminate mitral regurgitation without inducing stenosis. Valve distortion has to be carefully avoided as well. A ring annuloplasty should be used and a final mitral valve area of at least 2.5 cm should be left in normal sized patients. The edge-to-edge technique is usually performed through a conventional midline sternotomy or a minimally invasive approach, with excellent results (10,11).