From Bailout to Benchmark: Rethinking the Alfieri Procedure for Mitral Regurgitation in Barlow’s Disease

All articles of this category (opens in new window) Background: The treatment of mitral regurgitation (MR) due to Barlow’s disease remains a significant surgical challenge. Various repair techniques have been developed, with the Alfieri procedure gaining increasing popularity. Nevertheless, many surgeons continue to apply this technique mainly as a bailout strategy. We assessed the Alfieri edge-to-edge as a deliberate, reliable, and durable approach to mitral valve repair. Methods: From the institutional database, we conducted a retrospective analysis of patients undergoing surgical repair for severe Barlow-related MR (2007–2023). Patients were treated with either Alfieri or neochordal repair. The primary endpoints were long-term durability and safety, assessed by echocardiography and clinical follow-up (FU). Results: We screened a total of 322 patients with Barlow’s disease. To minimize biases, we exclusively analyzed patients with one specific semi-rigid annuloplasty ring. Cases with leaflet resection, concomitant CABG, or aortic valve procedures were excluded. The resulting cohort included 140 patients (Alfieri n = 47; neochordae n = 93). The baseline demographic and echocardiographic characteristics were comparable between groups. Perioperative mortality was 0% in both groups, and no significant differences were observed in complication rates (stroke, re-exploration for bleeding). Aortic cross-clamp time was significantly shorter ( p < 0.001) in the Alfieri group. No relevant transmitral gradient was detected postoperatively in either group, and no case of systolic anterior motion occurred. At a median FU of 4.7 years, only one patient in each cohort (Alfieri 2.1% vs. neochordae 1.1%) presented with more than moderate mitral regurgitation. At last FU, reoperation rates were equally low between neochordal ( n = 3) and Alfieri repair ( n = 1). Both cohorts demonstrated a low symptomatic burden (NYHA I–II) at last FU. Echocardiographic assessment showed left ventricular reverse remodeling without significant intergroup differences. Conclusion: Both the Alfieri and neochordae techniques provided uniformly favorable perioperative outcomes, with improved functional status alongside LV reverse remodeling. Clinical and echocardiographic results were comparable, demonstrating lower cross-clamp time in edge-to-edge repair without compromising clinical safety or long-term durability. These findings support the use of the Alfieri technique as an equivalent alternative to neochordae repair in complex mitral valve pathology. Publication History Article published online: 17 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany