Clinically significant mitral regurgitation (MR) often coexists with severe aortic valve pathology, especially in patients presenting with aortic valve stenosis or aortic root disease. While double valve surgery remains a standard option for managing concomitant mitral and aortic valve disease, it is consistently associated with increased perioperative morbidity and mortality, especially in high-risk individuals [1]. In patients where the risks of a double valve procedure outweigh the potential benefits, an alternative strategy is the combination of isolated aortic valve replacement (AVR) with a transaortic mitral valve edge-to-edge repair.

The edge-to-edge (E-to-E) technique was introduced in the early 1990s and has provided a useful contribution to the surgical armamentarium of mitral valve repair. The free edges of the mitral leaflets have to be approximated in correspondence of the site of the regurgitant jet in such a way that mitral regurgitation is corrected without producing stenosis. [2]

The Alfieri edge-to-edge repair, initially described by Maisano et al., achieves mitral competence by suturing the anterior and posterior mitral leaflets at their middle scallops (A2–P2), creating a double-orifice valve [3]. Performing this repair transaortically during AVR eliminates the need for separate left atriotomy and mitral annuloplasty, thus minimizing additional surgical trauma and potentially reducing operative time. Early studies and case reports have demonstrated the safety, feasibility, and efficacy of this approach in appropriately selected high-risk patients, with promising reductions in MR severity and maintenance of left ventricular function [4].

Despite these encouraging reports, most existing data come from small case series with limited long-term follow-up. There remains a need to further elucidate the outcomes of this combined strategy, particularly in populations with complex or mixed aortic pathologies.The present study aims to describe our single-center experience with transaortic mitral repair performed concomitantly with AVR or aortic root procedures.

This case series included seven patients with mixed aortic pathologies and associated mitral regurgitation who underwent aortic valve surgery combined with transaortic edge-to-edge (Alfieri) mitral valve repair. The patients presented with conditions such as aortic dissection, ascending aortic aneurysm, severe aortic stenosis, severe aortic regurgitation, and mixed aortic valve disease, along with moderate-to-severe mitral regurgitation.

Case 1: A 34-year-old male, weighing 64 kg with a height of 180 cm, presented with Type A chronic aortic dissection associated with severe aortic regurgitation and severe mitral regurgitation. He was in NYHA Class III preoperatively. Echocardiography showed a left atrial size of 41.4 mm, ejection fraction of 60%, and an aortic valve gradient of 20 mmHg. The patient underwent aortic surgery with transaortic Alfieri edge-to-edge mitral valve repair. Postoperatively, mitral regurgitation was reduced to mild, and NYHA class improved to I. Left atrial dimension showed slight reduction. Postoperative ejection fraction remained stable at 60%, and the valve gradient improved to 5 mmHg. The recovery was uneventful.

Case 2: A 25-year-old female, weighing 36.5 kg and measuring 148 cm in height, had an ascending aortic aneurysm (Stanford Type B) with severe aortic regurgitation and moderate-to-severe mitral regurgitation. She was NYHA Class III preoperatively. Echocardiography revealed left atrial size 50 mm, ejection fraction 50%, and aortic valve gradient 24 mmHg. She underwent aortic root surgery with transaortic mitral valve repair. Postoperatively, mitral regurgitation was reduced to mild, and NYHA class improved to I. Left atrial dimensions normalized modestly. Ejection fraction improved to 60%, and the aortic valve gradient reduced to 8 mmHg. The postoperative course was uneventful.

Case 3: A 45-year-old male, weighing 61 kg and measuring 162 cm in height, presented with aortic root dilatation, severe aortic regurgitation, and moderate-to-severe mitral regurgitation. He was in NYHA Class II. Echocardiography showed left atrial size 34 mm, ejection fraction 35%, and aortic valve gradient 24 mmHg. He underwent aortic root surgery with Alfieri mitral repair. Postoperative mitral regurgitation was reduced to trivial. NYHA class improved to I, ejection fraction increased to 50%. The postoperative gradient was 4 mmHg, and recovery was uncomplicated.

Case 4: A 65-year-old male, weighing 61.5 kg and 170 cm tall, presented with Type A aortic dissection, severe aortic regurgitation, and moderate mitral regurgitation. He was NYHA Class III. Echocardiography showed left atrial size 40.8 mm, ejection fraction 60%, and valve gradient 20 mmHg. He underwent surgical repair of aortic dissection and Alfieri mitral repair. Postoperatively, mitral regurgitation was reduced to mild, and NYHA improved to I. However, this patient succumbed postoperatively despite stable echocardiographic findings with preserved ejection fraction and improved gradient to 8 mmHg.

Case 5: A 72-year-old male, weighing 64.5 kg and 171 cm tall, had severe aortic stenosis, moderate aortic regurgitation, and moderate mitral regurgitation. He was in NYHA Class III. Echocardiography showed left atrial size 39 mm, ejection fraction 60%, and aortic valve gradient 28 mmHg. He underwent aortic valve replacement and transaortic Alfieri mitral repair. Postoperatively, mitral regurgitation reduced to trivial, NYHA improved to I, ejection fraction remained at 60%, and gradient reduced to 6 mmHg. Recovery was uneventful.

Case 6: A 50-year-old male, weighing 53.5 kg and 163 cm tall, presented with an ascending aortic aneurysm, severe aortic regurgitation, and moderate mitral regurgitation. He was NYHA Class II. Echocardiography showed left atrial size 40 mm, ejection fraction 45%, and valve gradient 30 mmHg. He underwent aortic surgery with Alfieri repair. Mitral regurgitation reduced to trivial, NYHA improved to I, ejection fraction improved to 50%. Postoperative gradient decreased to 4 mmHg. Recovery was smooth.

Case 7: A 48-year-old male, weighing 48 kg and 160 cm tall, presented with severe calcific aortic stenosis, severe aortic regurgitation, and moderate mitral regurgitation. He was NYHA Class II. Echocardiography revealed left atrial size 33 mm, ejection fraction 55-60%, and valve gradient 20 mmHg. He underwent aortic valve replacement with Alfieri mitral repair. Postoperatively, mitral regurgitation was reduced to mild. NYHA improved to I; ejection fraction remained at 60%, and gradient reduced to 5 mmHg. Recovery was uneventful.

All patients had preoperative NYHA functional class II–III and showed significant mitral regurgitation ranging from moderate to severe. Preoperative left ventricular ejection fraction varied from 35% to 60%, with some patients showing dilated left atrial  dimensions.Postoperatively, mitral regurgitation was reduced to trivial or mild in all cases. NYHA class improved to I in six out of seven patients, indicating marked symptomatic relief. Left ventricular function (EF) was preserved or showed improvement in most cases. Left atrial dimensions stabilized or showed mild reduction. Aortic valve gradients improved significantly post-surgery.There was one mortality in a patient who underwent repair for Type A aortic dissection; the remaining six patients had an uneventful postoperative course with no evidence of mitral stenosis or need for reintervention.

Overall, this case series demonstrates that transaortic Alfieri repair is a safe and effective adjunct during aortic valve surgery for reducing mitral regurgitation in high-risk patients with complex aortic pathologies, with favourable short-term outcomes in terms of symptoms, ventricular function, and hemodynamics.

In this case series of seven high-risk patients undergoing aortic valve or root surgery combined with transaortic Alfieri mitral valve repair, we observed that this approach is feasible and effective for addressing moderate-to-severe mitral regurgitation (MR). Across all patients, MR severity decreased to trivial or mild following surgery. Six of the seven patients demonstrated clear symptomatic improvement to NYHA Class I status. Left ventricular function was either preserved or improved in the majority of cases, and there were no instances of new-onset mitral stenosis or the need for re-intervention during the short-term follow-up. One mortality occurred in a patient undergoing emergency surgery for Type A aortic dissection, which aligns with the expected high risk of mortality in this subset of patients.

These findings are consistent with existing literature. In a larger cohort of 55 high-risk patients with a mean age of 78 years, Mihos et al. reported a 7% 30-day mortality rate and a significant reduction in MR severity from 3+ to 0–1+ at a median follow-up of 6.5 months [5]. Similar to our findings, their study demonstrated that MR reduction was durable and associated with preserved left ventricular function. Furthermore, they reported no cases of postoperative mitral stenosis, confirming the safety of the edge-to-edge technique when performed via a transaortic approach. Mihos and Lamelas also described in a subgroup of patients undergoing minimally invasive surgery that MR resolution was maintained at 12–18 months of follow-up, reinforcing the reliability of this technique for selected patients [6]. These reports align well with the outcomes we observed, especially in terms of operative risk, MR reduction, and early functional recovery.

Our findings also complement the more recent work by Papadopoulos et al., who described a modified transventricular and transaortic approach that mimicked the MitraClip overcorrection method. Their technique incorporated additional reinforcement of the mitral leaflets to enhance durability, and their mid-term outcomes showed this approach to be safe and effective for managing functional MR in patients undergoing complex cardiac surgery[7]. While our series used the standard Alfieri stitch without reinforcement, our outcomes were similarly favorable. In particular, our results suggest that even without modification, the basic Alfieri technique provides consistent and effective MR reduction, preserved ventricular function, and symptomatic improvement, especially in younger patients with mixed aortic pathologies.

Experience with edge-to-edge repair of the mitral valve through the transaortic approach remains limited in published literature. To date, there are only two case reports and three small case series describing this technique [8-12]. In the largest such series of 13 patients, MR was significantly reduced from a median qualitative angiographic grade of 3 preoperatively to 1 postoperatively (P < 0.0001) [12]. Importantly, no mitral stenosis attributable to the edge-to-edge repair was identified on postoperative transesophageal echocardiography. At a mean follow-up of 12.5 months, no worsening of MR was observed compared to the immediate postoperative findings. Although the sample size was small, this series demonstrated the procedure’s safety, feasibility, and sustained efficacy during mid-term follow-up. These findings closely align with our observations, providing additional support for the transaortic approach as a valid and durable solution for selected patients with concomitant aortic and mitral valve disease.

The long-term durability of the Alfieri repair via the transaortic approach has been well documented. In an extended follow-up study over 13 years, Mihos et al. demonstrated sustained MR reduction from 3+ to 1+, improved mean ejection fraction from 34% to 41%, favorable ventricular remodeling, and survival rates of 82% at one year and 65% at 4.5 years [13]. Although our follow-up period was shorter, we observed comparable trends in functional recovery and improvements in ejection fraction in some patients, such as an increase from 35% to 50%. This supports the notion that early ventricular remodeling benefits may be anticipated with this surgical technique.

Patient selection remains critical for optimizing outcomes. As noted by Mihos et al., ideal candidates for this approach typically exhibit MR jets localized to the A2–P2 segments, minimal annular calcification, and the absence of fibrotic remodeling of the valve [5]. These criteria were reflected in our patient selection, contributing to the absence of recurrent MR and mitral stenosis postoperatively. Additionally, similar to prior reports, none of our patients required a mitral annuloplasty ring, further simplifying the surgical procedure.

The strengths of our study include its demonstration of the applicability of this technique in a younger patient cohort with complex mixed aortic pathologies, uniform improvement in hemodynamics and ventricular function, and the feasibility of performing a straightforward, minimally invasive edge-to-edge stitch without increasing surgical complexity. However, limitations include the small sample size, retrospective design, and the inherent bias of a single-center experience. The short-term nature of follow-up, while comparable to existing studies, underscores the need for longer-term data to fully validate the durability of outcomes. The single postoperative mortality, though unrelated directly to the mitral repair, highlights the inherent risks of emergent aortic surgery, particularly in patients presenting with acute dissection, as also reported in previous studies.

In our case series, transaortic edge-to-edge (Alfieri) mitral valve repair combined with aortic surgery effectively reduced mitral regurgitation to mild or trivial levels, preserved ventricular function, and improved symptoms in high-risk patients. There were no cases of mitral stenosis or reintervention during short-term follow-up. Our findings support this technique as a safe and practical option in selected patients with complex aortic pathology.

Comparative Overview of Transaortic EdgetoEdge Mitral Repair Studies

LA view of mitral valve

LV view of mitral valve through aorta

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