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From the Divisions of *Cardiothoracic Anesthesia and Critical Care and Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
Address correspondence and reprints requests to Roman M. Sniecinski, MD, Department of Anesthesiology, Emory University Hospital, 1364 Cliftton Rd, NE, Atlanta, GA 30322. Address e-mail to roman.sniecinski{at}emoryhealthcare.org.
A 66-year-old man with a history of a large anteroapical myocardial infarction presented to the operating room for three-vessel coronary artery bypass grafting and left ventricular (LV) reconstructive surgery (Dor procedure). His baseline intraoperative transesophageal echocardiography demonstrated a dilated LV with an end diastolic diameter >7 cm and an ejection fraction <20%. A central jet of severe mitral regurgitation (MR) was present, causing systolic flow reversal in the pulmonary veins. The mechanism appeared to be dilation of the mitral valve (MV) annulus and tethering of both the anterior and posterior leaflets. A coaptation defect was clearly seen along the entire commissural line (Video clip 1, Please see video clip available at www.anesthesia-analgesia.org).
After initiation of cardiopulmonary bypass (CPB) and completion of the coronary artery bypass grafting, the LV was opened and a pericardial patch sewn into place to exclude the infarcted area of myocardium. Because of the high risk of the procedure and an already long bypass time (more than 2.5 h), the decision was made not to open another area of the heart to deal with the patient's severe MR. Instead, before closing the LV, an Alfieri stitch was placed, using the double-orifice technique (Fig. 1). This was done to increase the area of coaptation between the two leaflets. The patient was successfully weaned from CPB with inotropes and an intraaortic balloon pump. Transesophageal echocardiography examination after chest closure showed only mild MR (Video clip 2, Please see video clip available at www.anesthesia-analgesia.org). The combined area of the double-orifice MV was 3.2 cm2 by planimetry (Fig. 2).
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The edge-to-edge technique of MV repair was first reported in 1995 by Fucci et al. (1) and is now commonly referred to as simply the "Alfieri stitch." The procedure consists of sewing the free edge of a prolapsing leaflet segment to the corresponding segment on the opposing leaflet. When the middle sections are anchored together (i.e., A2 and P2), the term "double-orifice technique" applies. The Alfieri stitch is generally used for treatment of myxomatous disease. An annuloplasty ring is also usually placed, and results may be less than optimal without it (2). Experience in patients with dilated or ischemic cardiomyopathy, such as ours, is limited and controversial. One study suggested that up to 45% of patients undergoing combined Alfieri repair and LV reconstruction may have the return of moderate-to-severe MR within 2 yr (3). Nevertheless, given its ease of placement and an already long CPB time, we considered the Alfieri stitch a reasonable option in our patient.
Whatever the situation, the echocardiographer needs to be aware of the changes in MV morphology created by the double-orifice technique. The most obvious change, of course, is the formation of two openings into the LV, an anterolateral orifice and a posteromedial orifice. These can be visualized at the same time in either the transgastric basal short axis view, as seen in Fig. 1, or the midesophageal commissural view, which is useful for Doppler measurements. Leaflet mobility is reduced after placement of the Alfieri stitch. This is particularly evident in the midesophageal aortic valve long axis view, where the normal diastolic separation between P2 and A2 is no longer seen (Video clip 2).
The double-orifice technique results in a reduction in total MV orifice size, so the possibility of mitral stenosis should be evaluated. Pressure decreases across the valve are not influenced by the valve's configuration, and the simplified Bernoulli formula (
P = 4V2) has been validated for assessing the transvalvular gradient (4). Most patients will have a mean gradient of <5 mm Hg (5). However, gradients can be misleading in the immediate post-CPB period due to inotropic and mechanical support, changing loading conditions, and altered blood viscosity, so obtaining a valve area is suggested. This can usually be done by planimetry of the orifices during diastole in the transgastric basal short axis view (Fig. 2). It is important to ensure that the view is perpendicular to the tips of the MV when using this method. Several measurements should also be taken, using the smallest value obtained. We consider a combined valve area 
2.5 cm2 an acceptable result, which is much larger than a valve with even mild mitral stenosis. Calculating a valve area via the pressure half-time method (MV area = 220/pressure half-time) is not recommended in the immediate post-CPB period due to altered LV compliance.
Experience with and popularity of the Alfieri stitch are increasing. Percutaneous devices are also now available that can successfully create the double-orifice in settings outside of the operating room (6). As a result, the echocardiographer will likely encounter the double-orifice MV in a variety of clinical situations.
Footnotes
This article has supplementary material on the Web site: www.anesthesia-analgesia.org.
Accepted for publication July 9, 2007.
REFERENCES
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