Professor Alfieri, let's start with the mitral valve regurgitation surgical treatment options. Thirty years ago, you developed a specific method of mitral valve repair. It's called the Edge-to-edge technique. Now it's known as the Alfieri technique of mitral valve repair. Could you please tell us about your method of mitral valve repair? How did Alfieri method of mitral valve repair come about, and how to select the patients appropriately for your particular method and technique of mitral valve repair?

Okay, the Edge-to-edge technique approximates the free edges of the mitral valve leaflets exactly at the point of mitral regurgitation. It is done in such a way that mitral regurgitation is eliminated. We introduced that technique back in 1991. So as you said, exactly 30 years ago, at that time, the repair of the mitral valve was not very much developed. It was not spread out among the surgeons, and only a few people were performing mitral valve repair. The rest of the surgeons around the world were invariably replacing the mitral valve for mitral regurgitation. With mitral valve repair, there are particular subsets of anatomy which are very good for repair. They are associated with excellent long-term results.

On the other hand, there are also some subsets of patients that present with anatomy which were not ideal for mitral valve repair, and the mitral valve repair in those cases was associated with the suboptimal results. So, the technique was invented with the idea of making a repair possible with good results. It is used in those patients who could not have good results with the conventional methods of mitral valve repair at the time, specifically, patients who had anterior leaflet prolapse. So, patients with the anterior leaflet prolapse did not have good results with the techniques of mitral valve repair. On the other hand, with the technique of the edge-to-edge mitral valve repair we could eliminate anterior leaflet prolapse. We could repair bi-leaflet mitral valve prolapse. These were incremental factors for suboptimal surgical operation results. There were other situations where the edge-to-edge mitral valve repair technique was really convenient. For instance, mitral valve prolapse at the site of the mitral valve commissure was also another very difficult entity to be treated with the mitral valve repair. And that became very easy with the edge-to-edge technique. Also, for functional mitral regurgitation, the edge-to-edge technique was very convenient. This mitral valve repair also worked well for situations that are occurring occasionally, where you don't know exactly what is the mechanism responsible for mitral valve regurgitation. Then in those cases, the edge-to-edge mitral valve repair takes care of the problem.

And usually, when you mentioned that the HDH repair would be good and functional mitral valve prolapse, so functional, meaningful people with heart failure, as opposed to just structural How do you differentiate between the functional and structural organic mitral valve regurgitation?

As you said, in organic mitral valve regurgitation, there is an intrinsic abnormality and anatomic normality of the valve. On the other hand, in functional mitral regurgitation, the valve is intrinsically normal. The regurgitation of the mitral valve is only due to dilatation and dysfunction of the left ventricle. So, this is the difference.

A patient is being considered for surgical treatment of mitral valve repair. They are discussing with their surgeon how a surgeon would approach the mitral valve treatment. A patient might have heard the edge-to-edge technique of mitral valve repair. Should a patient ask their surgeon, what about using the edge-to-edge technique of mitral valve repair? What would be the characteristics of a patient that would make it particularly well suited for the edge-to-edge mitral valve repair technique?

The ideal patient for the Alfieri technique is the patient who has a localized mitral insufficiency. So when you can identify exactly where the regurgitation jet is located, you can put a surgical stitch exactly at that point. You can create a double orifice mitral valve. This will, of course, eliminate the mitral valve insufficiency.

So, among the most common types of mitral regurgitation, what percentage of patients roughly would be amenable to the edge-to-edge Alfieri technique of mitral valve repair?

You can extend the use of the edge-to-edge mitral valve repair method to many patients. But, of course, we also have other mitral valve repair techniques, which can have very good results. These heart valve repair methods can be used alternatively to the edge-to-edge Alfieri technique. Certainly, the isolated anterior leaflet prolapse is an excellent indication of the Alfieri technique. As well as Barlow's disease with the bi-leaflet mitral valve prolapse. As I also said, the prolapse corresponding to the commissure of the mitral valve can be treated very conveniently with the Alfieri technique.