Triple-orifice valve repair in severe Barlow disease with multiple-jet mitral regurgitation: Report of mid-term experience Carlo Fucci a, ⁎, Pompilio Faggiano b , Matilde Nardi b , Antonio D'Aloia b , Giuseppe Coletti a , Giuseppe De Cicco a , Leonardo Latini a , Enrico Vizzardi b , Roberto Lorusso a a Cardiac Surgery Unit, Cardiology Unit, Civic Hospital, Brescia, Italy b Echocardiography Laboratory, Cardiology Unit, Civic Hospital, Brescia, Italy abstract article info Article history: Received 5 April 2012 Received in revised form 22 June 2012 Accepted 23 June 2012 Available online xxxx Keywords: Mitral valve repair Barlow syndrome Mitral regurgitation Stress echocardiography Edge-to-edge technique Objectives: Barlow disease represents a surgical challenge for mitral valve repair (MR) in the presence of mi- tral insufficiency (MI) with multiple regurgitant jets. We hereby present our mid-term experience using a modified edge-to-edge technique to address this peculiar MI. Methods: From March 2003 till December 2010, 25 consecutive patients (mean age 54 ± 7 years, 14 males) affected by severe Barlow disease with multiple regurgitant jets were submitted to MR. Preoperative transesophageal echo (TEE) in all the cases showed at least 2 regurgitant jets, involving one or both leaflets in more than one segment. In all the patients, a triple orifice valve (TOV) repair with annuloplasty was performed. Intra-operative TEE and post- operative transthoracic echocardiography (TTE) were carried out to evaluate results of the TOV repair. Results: There was no in-hospital death and one late death (non-cardiac related). At intra-operative TEE, the three orifices showed a mean total valve area of 2.9 ± 0.1 cm 2 (range 2.5–3.3 cm 2 ) with no residual regurgitation (2 cases of trivial MI) and no sign of valve stenosis (mean transvalvular gradient 4.6±1.5 mm Hg). At follow up (mean 38 ± 22 months), TTE showed favourable MR and no recurrence of significant MI (6 cases of trivial and 1 of mild MI). Stress TTE was performed in 5 cases showing persistent effective valve function (2 cases of trivial MI at peak exercise). All the patients showed significant NYHA functional class improvement. Conclusions: This report indicates that the TOV technique is effective in correcting complex Barlow mitral valves with multiple jets. Further studies are required to confirm long-term applicability and durability in more numer- ous clinical cases. © 2012 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Myxomatous degeneration of the mitral valve (MV) is the leading cause of valvular insufficiency in the western world. Barlow disease, or “floppy valve”, is the most frequent condition with an evident valve ab- normality in which excessive mucopolysaccharide-based content variably leads to redundant valvular tissue, valve structure weakness, chordal elongation or rupture, leaflet prolapse or flail usually involving the mid portion of both leaflets, and annular dilatation [1]. Structural and func- tional mitral insufficiency (MI) patterns, however, may vary a great deal, involving more than one portion of one leaflet or both MV leaflets at several sites often generating a multiple-jet regurgitation requiring complex and time-consuming mitral valve repair (MR) techniques. Even if well standardised and intra-operatively effective surgical tech- niques are applied in this setting unpredictable postoperative results and MI recurrence are often observed [2–5]. Novel approaches have been proposed providing simple, reproducible, and effective repair procedures, or to improve postoperative results although more consis- tent information about long-term results is still required [6–9]. Besides implantation of artificial chordae, procedure characterised by several technical constraints, no other technique, to our knowledge, have reli- ably addressed the challenging multiple-jet MI to achieve durable and effective MR. In an attempt to provide an additional tool in this MR set- ting, we have recently described a procedure [10] derived from the pre- viously proposed edge-to-edge (E2E) technique [6,7] to address this peculiar MV dysfunction. We hereby describe our preliminary clinical experience using the modified E2E technique consisting of identifying and grading the regurgitant jets, doubling the bow-tie stitch at the level of the 2 main predominant MV leaks, finally leading to a triple or- ifice valve (TOV). Postoperative assessment of MR by echocardiography was performed according to a prospective postoperative schedule and also during stressful hemodynamic conditions. 2. Material and methods 2.1. Patients From March 2003 to December 2010, 209 consecutive patients affected by Barlow disease were submitted to MR (94%) or mitral valve replacement (MVR) (6%). In a International Journal of Cardiology xxx (2012) xxx–xxx ⁎ Corresponding author at: Cardiac Surgery Unit, Civic Hospital, Piazzale Spedali Civili, 1, 25125 Brescia, Italy. Tel.: +39 030 3995692; fax: +39 030 3995004. E-mail address: carlofucci@libero.it (C. Fucci). IJCA-15058; No of Pages 7 0167-5273/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2012.06.101 Contents lists available at SciVerse ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard Please cite this article as: Fucci C, et al, Triple-orifice valve repair in severe Barlow disease with multiple-jet mitral regurgitation: Report of mid-term experience, Int J Cardiol (2012), doi:10.1016/j.ijcard.2012.06.101