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Triple-Orifice Repair of Severe Mitral Regurgitation With Multiple Jets

Tuesday, April 14, 2020

Fucci C, De Cicco G, Benussi S. Triple-Orifice Repair of Severe Mitral Regurgitation With Multiple Jets. April 2020. doi:10.25373/ctsnet.12121200

A 41-year-old male patient presented with sinus rhythm, PAPS 44 mm Hg, left atrial dimention 45 mm, LVEF 70%, severe mitral regurgitation with mechanism, A2-P2 prolapse, and A3-P3 prolapse. A triple-orifice repair (TOR) with annuloplasty was performed. At intraoperative TEE, the three orifices showed a mean total valve area of 2.9 cm2 with no residual regurgitation and no sign of valve stenosis (gradient 4.0 mm Hg). At 12-month follow-up, TTE showed no recurrence of MI and stress TTE showed persistent effective valve function at peak exercise. The patient showed significant NYHA functional class improvement (from III to I).

The TOR, which derives from the edge-to-edge technique (E2E) originally described by Alfieri et al in 1995 (1), allowed the correction of complex valve dysfunctions with an easy and quick procedure and reproducible results. After more than a decade of experience in this setting of cardiac surgery, this video shows, once again, that the three orifices correct MI with multiple-site jets, enhance diastolic transmitral flow without restriction, with disappearance of minor jets thanks to the use of the mitral ring. The application of a complete ring was intended to stabilize the repair but also to reduce undue stress on the anchoring stitches, as shown by some experimental or computational studies about the E2E techniques (1-3). Medium-term of results of such MR techniques showed stable and effective MV function during stressful hemodynamic conditions. In conclusion, this video indicates that the TOVR technique is effective in correcting complex Barlow mitral valves with multiple jets.


  1. Fucci C, Sandrelli L, Pardini A, Torracca L, Ferrari M, Alfieri O. Improved results with mitral valve repair using new surgical techniques. Eur J Cardiothorac Surg. 1995;9:621–626.
  2. Nielsen SL, Timek TA, Lai DT, Daughters GT, Liang D, Hasenkam JM. Edge-to-edge mitral repair: tension of approximating suture and leaflet deformation during acute ischemic mitral regurgitation in ovine heart. Circulation. 2001;104(2 Suppl 1):I29–35.
  3. Dal Pan F, Donzella G, Fucci C, Schreiber M. Structural effects of an innovative surgical technique to repair heart valve defects. J Biomech. 2005;38:2460–2471.


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I would be cautious to present such techniques as the long term results are not known. Placing annular sutures, bringing the annulus together and doing the water test first, will show the true prolapsing segments. Then focussed gortex loop technique can give a better physiological repair than the current one proposed. Just my opinion.
If we go ahead using such unphysiologic techniques we will certainly and quite rightly loose all our mitral cases to the cardiologists and finally our competence in mitral valve repair.
With all due respect, and agreeing with the first comment above, this is another example of making Barlow's repair needlessly complex. The primary problem is annular dilatation. The multiple jets are from the clefts between the scallops which are exposed. Per the technique or Dr G. Lawrie - 1. place sutures or, using running suture, a large (41 - 43 ) complete flexible ring (to decrease circumference 25-30 %) 2. Water test usually shows nothing is more needed. 3. if there is excelssive prolapse - add neocords to adjust. Lawrie reported excellent long term results long ago.
Dear colleagues, thank you for your comments. We would never have proposed this technique without a solid study especially in terms of follow up. Therefore, we invite you to read the article published in Int J Cardiol. 2013 Sep 10; 167 (6): 2623-9 (Triple-orifice valve repair in severe Barlow disease with multiple-jet mitral regurgitation: report of mid-term experience. Fucci C, Faggiano P, Nardi M, D'Aloia A, Coletti G, De Cicco G, Latini L, Vizzardi E, Lorusso R). As can be deduced from the reading, this technique is addressed to a particular subgroup of patients with extreme Barlow and multi-jet mitral regurgitation. The article was not mentioned in the references and we apologize for this, but we have mentioned the first work on the double orifice which shows that our experience and philosophy date back to 1995. The philosophy was based on the need to correct a severe Barlow disease with prolapse of both leaflets by relying on a technique that it was simple, therefore easier to reproduce, and effective; and the same philosophy has led us to widen attention from severe Barlow disease to extreme Barlow disease. “Severe” and “extreme” is not a matter of sematics, because it is connected to the extension of the mitral pathology that Omran and associates have proven to be of great importance for mitral repair success (J Am Soc Echocardiogr. 2002 Sep;15(9):950-7). An effective technique does not necessarily have to be physiological, and we think this can also applies to mitral surgery. The effectiveness of a surgical technique must be assessed on the basis of its long-term results. In other words, duration/durability and freedom from symptoms, that is what patients and, more specifically, cardiologists demand and require. Most of the time, in the above-mentioned subgroup of patients (“subgroup of patient” are the key words of our reply) a combination of multiple/different and time-consuming surgical procedures are required. Hence, our fast, safe, and easily reproducible technique represents a suitable alternative for its excellent results in terms of mitral competence and freedom of reintervention. On behalf of all authors Giuseppe De Cicco
I would agree with the first three comments. In my opinion the edge to edge approach in PMR should only be used as a bailout procedure for specific indications like for the treatment of SAM if the primary repair has failed. I am certainly against the addition of a second edge to edge stich in A3/P3 for two reasons: a) the first one would have been sufficient to treat the MR (together with the annuloplasty and b) in the long term follow up the 41 y.o. patient will be left with one orifice in the A1/P1 area and moderate degree of stenosis (especially on exertion). I would have treated this patient with the loop technique [4 loops for the A2 (two from the posteromedial papillary muscle and two from the anterolateral) and 4 loops for the P2 ( two from the posteromedial and two from the anterolateral)] plus annuloplasty with a flexible band of large size. With this approach the valve area would have been around 3,8 cm2 and would be stable for life.

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