Alfieri Stitch in Minithoracotomy Repair of Degenerative Mitral Regurgitation: Potential Role and Outcomes

Objective: The Alfieri stitch is a mitral repair technique that can easily be applied in less invasive approaches to the mitral valve. However, the Alfieri stitch is seldom used and has raised concerns about producing mitral stenosis or recurrent regurgitation. Methods: A total of 1,134 consecutive patients undergoing repair of degenerative mitral regurgitation via right minithoracotomy from 1997 to 2019 were examined from a prospectively maintained database. Propensity score matching was performed on patients with and without Alfieri stitch. Results: The Alfieri stitch was used in 697 of 1,134 patients (53%) with annuloplasty in all patients. Patients receiving the Alfieri stitch had more flail leaflet (P = 0.001), larger rings (P < 0.001), more chordal replacement (P < 0.001), and more cleft closure (P < 0.001). In 201 matched patient pairs, Alfieri patients did not differ significantly in baseline characteristics or procedure performed other than the Alfieri stitch. Matched patients with Alfieri stitch had similar clamp and pump times and no difference in postoperative course. Matched patients with Alfieri stitch had only slightly higher mean postoperative gradient (4.0 +/- 1.5 vs 3.2 +/- 1.3 mm Hg, P < 0.001). At 10 years, matched patients with Alfieri stitch showed nonsignificant differences in survival (P = 0.5), cumulative incidence of severe mitral regurgitation (5% +/- 3% vs 3% +/- 3%, P = 0.3), and moderate or more mitral regurgitation (17% +/- 4% vs 12% +/- 4%, P = 0.8) but more mitral reoperation at 10 years (6% +/- 3% vs 1% +/- 1%, P = 0.02). Conclusions: The Alfieri stitch can be applied via right minithoracotomy to repair a wide variety of degenerative mitral pathology with minimally higher mitral gradient and a late trend toward increased mitral reoperation at 10 years.