EJCTS Click here for details of sales representative
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Jean-Marc Frapier
Bernard Albat
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Frapier, J.-M.
Right arrow Articles by Albat, B.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Frapier, J.-M.
Right arrow Articles by Albat, B.
Related Collections
Right arrow Valve disease

Eur J Cardiothorac Surg 2006;29:1020-1025
© 2006 Elsevier Science NL

Mitral valve repair by Alfieri's technique does not limit exercise tolerance more than Carpentier's correction

Jean-Marc Frapier a , * , Catherine Sportouch b , Valerie Rauzy b , Philippe Rouviere a , Stéphane Cade b , Rolland G. Demaria a , Jean-Marc Davy b , Bernard Albat a

a Department of Thoracic and Cardiovascular Surgery, Arnaud de Villeneuve Hospital, CHU, 34295 Montpellier CX 5, France
b Department of Cardiology, Arnaud de Villeneuve Hospital, CHU, Montpellier, France

Received 6 October 2005; received in revised form 7 February 2006; accepted 13 February 2006.

* Corresponding author. Tel.: +33 4 67 33 6272; fax: +33 4 67 33 6275. (Email: jm-frapier{at}chu-montpellier.fr).


   Abstract
Top
 Abstract
1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
 5. Conclusions
 Appendix A
 References
 
Objective: The main goal of this study was to evaluate if the edge-to-edge mitral repair could be a limiting factor for exercise tolerance and to compare these results to those of classical techniques. Methods: Between 2000 and 2002, 54 consecutive patients were operated on for mitral valve regurgitation (MR). Twenty-five patients were operated with Alfieri's technique (group A) and 29 patients with Carpentier's technique (group C). The mean age was 63.9 years in group A and 63.8 years in group C (p = 0.98). After a mean follow-up of 16.2 ± 12 months, survivor patients were seen at the outpatient clinic, by the same physician for a clinical evaluation, an echocardiogram at rest and at peak exercise, and received a cardiorespiratory exercise testing with maximal oxygen uptake (VO2 max) recording. Results: Clinical status improved with 0% of the patients in class NYHA III or IV in either group postoperatively versus 77% preoperatively. There was no significant MR in 80% of cases in group A versus 89.6% in group C (p = 0.54). The mean mitral valve area was 2.5 and 2.9 cm2 in groups A and C, respectively (p = 0.018). The mitral gradient at rest was 3.8 and 3.3 mmHg (p = 0.31) and the mitral gradient at peak exercise was 8.5 and 9.7 mmHg (p = 0.22) in groups A and C, respectively. Cardiorespiratory exercise testing showed a mean VO2 max of 73.7 ± 15% of normal value in group A versus 79.6 ± 13.1% in group C (p = 0.18). Conclusion: Alfieri's technique has the same efficiency on improvement of MR and clinical status than classical repair. Despite a higher restriction of mitral valve area at rest in group A, gradient and mean VO2 max at peak exercise were similar in both groups.

Key Words: Mitral valve repair • Exercise tolerance


   1. Introduction
Top
 Abstract
 1. Introduction
2. Material and methods
 3. Results
 4. Discussion
 5. Conclusions
 Appendix A
 References
 
Mitral valve repair can be performed on the vast majority of patients with degenerative mitral regurgitation (MR) with the help of classical techniques developed by Carpentier [1]. However, when faced with an anterior or with a bileaflet prolapse, as in Barlow disease, those classical techniques could reach their limits. In order to provide ‘a simple solution to this complex problem’, Alfieri proposed his edge-to-edge repair [2]. This technique is gaining acceptance due to its simplicity, reproducibility, and efficiency. However, some concern is rising about its potential restrictive character, especially during exercise [3]. The main goal of this study was to evaluate if the edge-to-edge mitral repair could be a limiting factor for exercise tolerance and to compare these results to those of classical techniques. Then, two contemporary series of consecutive patients operated on either by Alfieri's technique or by Carpentier's technique were compared retrospectively by a short-term clinical evaluation, echocardiogram at rest and at peak exercise and cardiorespiratory exercise testing with maximal oxygen uptake recording.


   2. Material and methods
Top
 Abstract
 1. Introduction
 2. Material and methods
3. Results
 4. Discussion
 5. Conclusions
 Appendix A
 References
 
2.1 Population
Between February 2000 and December 2002, 54 consecutive patients were operated on for mitral valve regurgitation. Twenty-five patients were operated with Alfieri's technique (group A) and 29 patients with Carpentier's technique (group C). There was no significant difference between the two groups regarding basic preoperative data (Table 1 ). When etiology and regurgitation mechanism were evaluated, we found (Table 2 ) that the main type of lesion was a bivalvular prolapse in group A and a posterior valvular prolapse in group C. For the two groups, after median sternotomy, operative procedures were conducted on normothermia with bicaval cannulation and cold blood antegrade cardiolplegia. In group A, all the patients underwent an edge-to-edge repair. A particular attention was paid to the diameter of both neo-orifices, which should never be less than 19–20 mm of diameter as measured by Heggar dilatators at the end of edge-to-edge apposition. In group C the majority of patients were treated by quadrangular resection following Carpentier rules. Both types of procedures were performed by two senior surgeons. The first criterion of decision was the lesion encountered. Patient's age being the second. Eventually, the final decision was surgeon preference. There was a higher proportion of ring annuloplasty performed in group C (p = 0.043) than in group A (Table 3 ). After a mean follow-up of 16.2 ± 12 months (range 2–42 months), survivor patients were seen at the outpatient clinic, by the same physician for a clinical evaluation, an echocardiogram at rest and at peak exercise, and were offered to perform a cardiorespiratory exercise testing with VO2 max recording.


View this table:
[in this window]
[in a new window]
  		Table 1. Basic preoperative data
 

View this table:
[in this window]
[in a new window]
  		Table 2. Etiology and regurgitation mechanism by echo
 

View this table:
[in this window]
[in a new window]
  		Table 3. Peroperative procedures
 
2.2 Echographic analysis
Real-time phased array echo-Doppler recordings were obtained at rest and during maximal exercise before and after surgery (Acusson sequoia, Siemens, Mountain view, CA, USA). Two experienced investigators carried out the examinations. Images were stored on videotape for subsequent analysis.

2.2.1 Mean value of three measurements was considered for each variable
LV diameters were determined from two-dimensional parasternal long-axis view. Calculations of LV fractional shortening were then derived from diameters. The ventricular volumes were recorded from apical four-chamber view to evaluate LV ejection fraction. Continuous-wave Doppler was used to obtain mean transmitral pressure gradient (modified Bernoulli equation) and maximal velocity of tricuspid Doppler tracing in order to estimate systolic pulmonary artery pressure (a fixed value of 10 mmHg was added as an estimated right atrial pressure). The mean valve area was assessed by three different methods: pressure half time (PHT), standard continuity equation, and planimetry. In the Alfieri's group, both orifices were visualized in short-axis view and the total mitral valve area (MVA) was calculated as the sum of the two individual geometric orifice areas. Mitral regurgitation when present was recorded and quantified with usual criterions [4]. At peak exercise only mean transmitral pressure gradient was recorded by an apical four-chamber view. To facilitate Doppler measurements during exercise, the site on the chest where optimum Doppler waveforms had been recorded at rest was marked before starting exercise. In order to obtain data from a healthy population regarding the evolution of transmitral gradient during exercise, a group of 10 healthy volunteers, mean age 42.7 years (range 16–65 years), was also studied by echo at rest and peak exercise.

2.3 VO2 max recording
Cardiorespiratory exercise testing with VO2 max recording has been previously described in detail [5]. Briefly, exercise tests were performed on an electrically braked cycle ergometer (Cardionics, Bruxelles, Belgium) with heart rate (HR), blood pressure, and ECG monitoring. Expired flow and oxygen and carbon dioxide partial pressures were continuously monitored on a breath-by-breath basis using a cardiopulmonary exercise test (Brainware Metasys, La Valette, France). O2 uptake (VO2 ml/min and ml/(kg min)), and O2 production (VO2, l/min) were calculated by averaging the breath-by-breath data over 30 s. The exercise test consisted of a 3-min rest period, followed by the maximal exercise test, which started with a 3-min warm-up at 20 W with a minimum constant pedaling rate of 60 rpm. The workload was then increased by 10 W every minute. Subjects were asked to continue exercise until exhaustion. The criteria for prematurely stopping the test were defined as follows: serious cardiac arrhythmia, fall in blood pressure, ECG changes compared to resting value, and chest pain. For every subject, the observation of at least three of the four following criteria was necessary to consider that VO2 peak was obtained: stability of heart rate at a value close to the predicted maximal HR; stability of oxygen uptake despite the increase in workload; respiratory ratio >1.10; and the inability of the subject to maintain a pedaling rate of 50 rpm [6]. Predicted value of maximal oxygen consumption (PVO2) was calculated with use of the Wasserman equation, normalizing VO2 max for age, gender, weight, and height. The results were expressed as the percent of the theoretical PVO2 value. VO2 max was considered as normal when it was superior to 85% of PVO2. The limitation was considered as minor between 84 and 70% of PVO2 and severe under 69%.

2.4 Statistical analysis
Continuous variables are shown as means ± SD and were analyzed using the two-tailed Student's t-test for paired or unpaired groups as appropriated. Categorical data are shown as counts and percentages and were analyzed using Fisher's exact test or Pearson's {chi} 2 test as appropriated. Mann and Whitney Wilcoxon test was used for nonparametric data. Probability value (p) of less than 0.05 was considered significant. Statistical analysis was performed using GraphPad Prism 4.00 for Windows (Graph Pad Software, San Diego, CA, USA) and S.A.S 8.2 (SAS institute, Cary, NC, USA).


   3. Results
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
4. Discussion
 5. Conclusions
 Appendix A
 References
 
3.1 Survival and reoperation
There was no hospital mortality in either group. There was one noncardiac death (gastric cancer at 1 year) and one cardiac valve-related death (prosthetic valve endocarditis after valve replacement) in group C. Reoperation was conducted in 2 (6.8%) patients in group C at 12 and 14 months postoperatively. Neither late death nor reoperation occurred in group A.

3.2 Clinical status
Improvement of the NYHA status was as effective for patients of group A than for group C (Fig. 1 ).


Figure 1
View larger version (30K):
[in this window]
[in a new window]
  		Fig. 1. Improvement of NYHA status. Bold numbers represent mean NYHA class for each group, before and after surgery. p value is the result of Wilcoxon test between median values (nonbold data) before and after surgery inside of each group. The difference between groups A and C was not significant regarding preoperative values (p = 0.20) and postoperative values (p = 0.52). Improvement of NYHA class between groups A and C was not significantly different (p = 0.1).

 
3.3 Echographic results
Postoperatively, there was a significant reduction (Fig. 2 ) of the mitral regurgitation and of the mean systolic pulmonary artery pressure (MAP) in both groups (Table 4 ). There was a slight increase of the left ventricular ejection fraction (LVEF) for group A and no significant difference for group C (Table 4). Mitral valve area was significantly different between two groups with a higher surface for group C (Table 4). Mitral gradient at rest and at peak exercise were not significantly different between two groups. There was a significant increase of the mitral gradient at peak exercise as compared to the resting value for both populations. This augmentation value was slightly higher in group C than in group A. When patients with and without prosthetic annulus where compared in each group, no significant difference could be demonstrated (Fig. 3 ). In the group of healthy volunteers, the mean gradients at rest and at peak exercise were 1.37 ± 0.27 mmHg (range 1.1–2 mmHg) and 3.6 ± 1.71 mmHg (range 1.7–7.3 mmHg), respectively.


Figure 2
View larger version (29K):
[in this window]
[in a new window]
  		Fig. 2. Improvement of echographic mitral regurgitation. Bold numbers represent mean MR grade for each group, before and after surgery. p value is the result of Wilcoxon test between median values (range) before and after surgery inside of each group. The difference between groups A and C was not significant regarding preoperative values (p = 0.18) and postoperative values (p = 0.14). Improvement of MR grade between groups A and C was not significantly different (p = 0.93).

 

View this table:
[in this window]
[in a new window]
  		Table 4. Postoperative echographic data
 

Figure 3
View larger version (33K):
[in this window]
[in a new window]
  		Fig. 3. Postoperative mitral valve gradients. Gradients at rest: 3.8 mmHg in group A versus 3.3 mmHg in group C (p = 0.31). Gradient at peak exercise: 8.5 mmHg in group A versus 9.7 mmHg in group C (p = 0.22).

 
3.4 VO2 max recording
Cardiorespiratory exercise testing with maximal oxygen uptake recording could be performed in 43 patients, 21 in group A and 22 in group C. The VO2 max was 18.1 ± 5.9 ml/(kg min) in group A versus 19.0 ± 4.2 ml/(kg min) in group C (p = 0.56) corresponding to 73.7 ± 15.1% and 79.6 ± 13.1% (p = 0.18) of PVO2. In detail, 28.6% of the patients from the Carpentier's group had no limitation versus 28.5% from the Alfieri's group, minor limitation for 48.7% versus 47.6%, severe limitation for 22.7% versus 23.8%, respectively. There was no more cardiogenic limitation in group A than in group C (three patients in each group).


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
5. Conclusions
 Appendix A
 References
 
4.1 Efficiency
Efficiency of edge-to-edge repair on MR has been previously reported with short-term results of 91% of the patients being free from significant MR at 2 years [7]. Several factors influence those results. Etiology, namely ischemic MR, is an important one, with an increasing rate of MR recurrence over time [8]. In an experimental study [9], it has been shown that edge-to-edge procedure alone (so-called Alfieri stitch) did not prevent acute MR. Annuloplasty seems mandatory. Moreover, the lack of annuloplasty is one of the most important factors of failure, with a decrease of 92% (with annuloplasty) to 79% (without annuloplasty) of the patients being free from reoperation at 5 years [10]. Whether this absence of ring is due to normal sized mitral annulus [11] or to annular calcification [12], all studies have demonstrated a higher reoperation rate in case of bow-tie suture alone. One of the explanations of the necessity of concomitant ring annuloplasty in edge-to-edge repair was afforded by Timek et al. [13] showing that the tension on Alfieri stitch was dependant of the mitral annulus size. A further dilatation of the left ventricle and annulus will lead to recurrent MR. In our series, 5 (20%) patients of group A exhibited a moderate to severe MR at follow-up echocardiography. It is noteworthy that all five were ringless patients. Nevertheless, reduction of MR was also efficient than in group C of patients treated by classical techniques of repair where 3 (10.3%) patients presented a significant MR (p = 0.93) at follow-up. All three have had a ring annuloplasty added at the time of surgery.

4.2 Surface restriction
If both types of repair decrease mitral valve area, the reduction caused by edge-to-edge repair is more pronounced with a reduction rate of more than 50% [11] of MVA. Our mean value of 2.5 cm2 in group A is close to the result of other papers showing a mean MVA from 2.1 to 2.9 cm2 [7,14,15]. However, in a group of Barlow disease, this postrepair mean MVA was evaluated as high as 3.7 cm2, probably because of higher annulus diameter in this pathology [11]. In classical repairs, mean MVA after quadrangular resection in the literature vary from 2.6 to 2.7 cm2 [16–18], which is very close from our averaged 2.9 cm2 value. Despite the higher MVA reduction, edge-to-edge repair does not seem to induce more transvalvular gradients than classical repair.

4.3 Hemodynamic parameters
Indeed, gradients at rest were not significantly different between two groups. Values of 3.8 mmHg (group A) and 3.3 mmHg (group C) were close to those reported in the literature [3,8,19] Both were more elevated than the 1.37 mmHg mean mitral gradient (MMG) obtained in our group of healthy volunteers or than the 1.4 mmHg value of a previous report [20]. However, they remain behind the 5 mmHg threshold recognized as a pathological value [21]. At peak exercise, the MMG increased in both groups without significant difference up to 8.5 mmHg (group A) and 9.7 mmHg (group C). When we analyzed the difference between rest and peak exercise values, we found that the mean gradient increase was slightly more elevated in group C. As ring annuloplasty was predominantly performed in group C, we made a second comparison between subgroups with and without prosthetic ring in order to encompass this bias. This showed that mitral gradient increase was not significantly different between two subgroups of patients with an annuloplasty. No difference could be found between patients without ring but their number was not sufficient in group C to draw any conclusion. Edge-to-edge repair per se is therefore no more restrictive at peak exercise than classical repair.

4.4 Impact on exercise tolerance and clinical status
Maximum oxygen uptake (VO2 max), used in cardiac disease as a prognosis factor, is a good mirror of exercise capacity of a patient [5]. In this report, we have shown that mean VO2 max/PVO2 was not severely depressed and not significantly different between two groups. And eventually, only three patients in each group exhibited a cardiogenic limitation. Other causes of sub-optimal VO2 max test were mainly restrictive respiratory syndrome or peripheral cause (muscular deconditioning, knee or hip arthritis). We did not perform VO2 max test before surgery due to this severe clinical impairment. So we were not able to compare the pre- and postoperative values. Other authors [22,23] have shown no difference on pre- and postoperative VO2 max. However, on both reports, the mean preoperative NYHA class was radically lower (1.79 and 1.9), with up to 30% of the patients in class I as compared to our 7.4% rate. Nevertheless, the 74–80% mean VO2 max/PVO2 obtained in our report reflect well the excellent postoperative clinical status, with a mean NYHA class of 1.4 in both groups as compared to the mean preoperative classes 3.2 and 2.9 in groups A and C, respectively. So, despite the restrictive effect induced by mitral repair, whatever the technique used, the efficiency on exercise tolerance and improvement of clinical status is high and not technically dependent.

4.5 Limitations of the study
This study was a retrospective analysis. If both groups were not significantly different for basic parameters such as age, sex, NYHA class, LVEF, and MR grade, the mechanism of MR was significantly different between group A (predominant bileaflet disease) and group C (majority of posterior leaflet prolapse) which could prevent further analysis. Exercise tolerance, as judged by cardiorespiratory exercise testing with maximal oxygen uptake recording, was only performed postoperatively. Mean follow-up is short and no conclusions regarding the long-term evolution of edge-to-edge repair group can be drawn.


   5. Conclusions
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
 5. Conclusions
Appendix A
 References
 
Alfieri's repair has a more restrictive surface at rest than classical repair. However, it shows the same gradient at rest and the same mitral gradient at peak exercise, the same efficiency on MR reduction and clinical status improvement and provides the same exercise tolerance than Carpentier's repair. Its use seems to us a good option in complex form of MR.


   Appendix A
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
 5. Conclusions
 Appendix A
References
 
Conference discussion

Dr H.-J. Schaefers (Homburg/Saar, Germany): Ottavio Alfieri has always maintained that the edge-to-edge technique should never be used alone but some form of annuloplasty is vital in order to prevent recurrence. Now, you have analyzed a medium size group of patients with that some without and some with annuloplasty. Have you seen a difference between the two: (A) in terms of gradient and exercise, and (B) in terms of recurrent MR? You have had some recurrences.

Dr Frapier : Regarding the difference about gradients with and without annuloplasty, there was no difference, but there was a huge difference of recurrence of MR in group A. We had six patients who had recurrence of MR grade 2 or 3, and all of these patients didn’t have had an annuloplasty at the time of operation because of annulus calcification or because of the fear of restriction in a small annulus. So, the lack of annuloplasty is the main factor of recurrence in this technique.

Dr Schaefers : One other question. The gradient with Carpentier's type I found somewhat high. We see lower gradients. Is it maybe that the ring that was taken was relatively small for the individual patients? What size rings were used?

Dr Frapier : We choose the ring size for Carpentier's repair with the usual guidelines. We didn’t try to oversize the annulus.

Dr Schaefers : But you have data on which diameters, what sizes of rings were used?

Dr Frapier : I guess the vast majority of patients should have, maybe 70%, a 34 and maybe 30% a 32. Quite surprisingly, and you will see it in the paper, when you analyze the increase of mitral gradient between gradient at rest and at peak exercise for a patient with an annulus, the augmentation is higher in group C with classical repair than in group A, maybe because valvular excursion is more physiological and there is no immobilization of the posterior leaflet like in a classical repair.

Dr Schaefers : Your data showed that?

Dr Frapier : Yes.


   Acknowledgments
 
We greatly thank Christine Defez MD, Medical Statistic Department, CHU Arnaud de Villeneuve for help in reviewing the statistical analysis.


   Footnotes
 
{star} Presented at the joint 19th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 13th Annual Meeting of the European Society of Thoracic Surgeons, Barcelona, Spain, September 25–28, 2005.


   References
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
 5. Conclusions
 Appendix A
 References
 

  1. Gillinov AM, Cosgrove DM. Mitral valve repair for degenerative disease. J Heart Valve Dis 2002;11(Suppl. 1):S15-S20.
  2. Alfieri O, Maisano F, De Bonis M, Stefano PL, Torracca L, Oppizzi M, La Canna G. The double-orifice technique in mitral valve repair: a simple solution for complex problems. J Thorac Cardiovasc Surg 2001;122:674-681.[Abstract/Free Full Text]
  3. Borghetti V, Campana M, Scotti C, Parrinello G, Lorusso R. Preliminary observations on haemodynamics during physiological stress conditions following "double-orifice" mitral valve repair. Eur J Cardiothorac Surg 2001;20:262-269.[Abstract/Free Full Text]
  4. Tribouilloy C, Shen WF, Rey JL, Adam MC, Lesbre JP. Mitral to aortic velocity–time integral ratio. A non-geometric pulsed-Doppler regurgitant index in isolated pure mitral regurgitation. Eur Heart J 1994;15:1335-1339.[Abstract/Free Full Text]
  5. Becassis P, Hayot M, Frapier JM, Leclercq F, Beck L, Brunet J, Arnaud E, Prefaut C, Chaptal PA, Davy JM, Messner-Pellenc P, Grolleau R. Postoperative exercise tolerance after aortic valve replacement by small-size prosthesis: functional consequence of small-size aortic prosthesis. J Am Coll Cardiol 2000;36:871-877.[Abstract/Free Full Text]
  6. Messner-Pellenc P, Ximenes C, Brasileiro CF, Mercier J, Grolleau R, Prefaut CG. Cardiopulmonary exercise testing. Determinant of dyspnea due to cardiac or pulmonary limitation. Chest 1994;106:354-360.[Abstract/Free Full Text]
  7. Maisano F, Torracca L, Oppizzi M, Stefano PL, D’Addario G, La Canna G, Zogno M, Alfieri O. The edge-to-edge technique: a simplified method to correct mitral insufficiency. Eur J Cardiothorac Surg 1998;13:240-246.[Abstract/Free Full Text]
  8. Bhudia SK, McCarthy PM, Smedira NG, Lam BK, Rajeswaran J, Blackstone EH. Edge-to-edge (Alfieri) mitral repair: results in diverse clinical settings. Ann Thorac Surg 2004;77:1598-1606.[Abstract/Free Full Text]
  9. Timek TA, Nielsen SL, Lai DT, Tibayan FA, Liang D, Rodriguez F, Daughters GT, Ingels Jr. NB, Miller DC. Edge-to-edge mitral valve repair without ring annuloplasty for acute ischemic mitral regurgitation. Circulation 2003;108(Suppl. 1):II122-II127.
  10. De Bonis M, Lapena E, Alfieri O. The"edge to edge" technique in mitral valve repairs. Heart Views 2002;3:164-169.
  11. Maisano F, Schreuder JJ, Oppizzi M, Fiorani B, Fino C, Alfieri O. The double-orifice technique as a standardized approach to treat mitral regurgitation due to severe myxomatous disease: surgical technique. Eur J Cardiothorac Surg 2000;17:201-205.[Abstract/Free Full Text]
  12. Maisano F, Caldarola A, Blasio A, De Bonis M, La Canna G, Alfieri O. Midterm results of edge-to-edge mitral valve repair without annuloplasty. J Thorac Cardiovasc Surg 2003;126:1987-1997.[Abstract/Free Full Text]
  13. Timek TA, Nielsen SL, Lai DT, Tibayan F, Liang D, Daughters GT, Beineke P, Hastie T, Ingels Jr. NB, Miller DC. Mitral annular size predicts Alfieri stitch tension in mitral edge-to-edge repair. J Heart Valve Dis 2004;13:165-173.[Medline]
  14. Umana JP, Salehizadeh B, DeRose Jr. JJ, Nahar T, Lotvin A, Homma S, Oz MC. "Bow-tie" mitral valve repair: an adjuvant technique for ischemic mitral regurgitation. Ann Thorac Surg 1998;66:1640-1646.[Abstract/Free Full Text]
  15. Agricola E, Maisano F, Oppizzi M, De Bonis M, Torracca L, La Canna G, Alfieri O. Mitral valve reserve in double-orifice technique: an exercise echocardiographic study. J Heart Valve Dis 2002;11:637-643.[Medline]
  16. Sakamoto Y, Hashimoto K, Okuyama H, Ishii S, Hanai M, Inoue T, Shinohara G, Morita K, Kurosawa H. Long-term assessment of mitral valve reconstruction with resection of the leaflets: triangular and quadrangular resection. Ann Thorac Surg 2005;79:475-479.[Abstract/Free Full Text]
  17. Kurosawa H, Nakano M, Kawase M, Kasegawa H, Nakano K, Eishi K. Mitral valve repair by Carpentier-Edwards physio annuloplasty ring. Jpn J Thorac Cardiovasc Surg 1999;47:355-360.[Medline]
  18. Poh KK, Hong EC, Yang H, Lim YT, Yeo TC. Transesophageal echocardiography during mitral valve repair underestimates mitral valve area by pressure half-time calculation. Int J Cardiol May 20 2005 [Epub ahead of print]..
  19. Carpentier AF, Lessana A, Relland JY, Belli E, Mihaileanu S, Berrebi AJ, Palsky E, Loulmet DF. The "physio-ring": an advanced concept in mitral valve annuloplasty. Ann Thorac Surg 1995;60:1177-1186.[Abstract/Free Full Text]
  20. Jawad IA, Ghali MH, Brown RL, Sohn YH. Pressure-flow relations across the normal mitral valve. Am J Cardiol 1987;59:915-918.[Medline]
  21. ACC/AHA guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association. Task Force on Practice Guidelines (Committee on Management of Patients with Valvular Heart Disease). J Am Coll Cardiol 1998;32:1486–588..
  22. Kim HJ, Ahn SJ, Park SW, Cho BR, Sung J, Hong SH, Park PW, Hong KP. Cardiopulmonary exercise testing before and one year after mitral valve repair for severe mitral regurgitation. Am J Cardiol 2004;93:1187-1189.[CrossRef][Medline]
  23. Le Tourneau T, de Groote P, Millaire A, Foucher C, Savoye C, Pigny P, Prat A, Warembourg H, Lablanche JM. Effect of mitral valve surgery on exercise capacity, ventricular ejection fraction and neurohormonal activation in patients with severe mitral regurgitation. J Am Coll Cardiol 2000;36:2263-2269.[Abstract/Free Full Text]




This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Jean-Marc Frapier
Bernard Albat
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Frapier, J.-M.
Right arrow Articles by Albat, B.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Frapier, J.-M.
Right arrow Articles by Albat, B.
Related Collections
Right arrow Valve disease

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS