Complex Mitral Valve Case

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TTEIntraOpAP4CV2D
Short case presentation
78 y.o. caucasian male presents for a redo CABG w/ECC /EVH and a mitral valve repair/replacement.  He has a history ov a CABG 20 years ago.  The LIMA -> LAD and RIMA -> D1 are OK.  The OM and PDA are diseased.  He has a hx of atrial fribrillation, MR, HTN and asthma.  He is on Amiodarone, Coumadin, and Albuterol.  His CP and SOB have recently worsened.  A preop echo and an intraop echo were performed.  The preop echo had a MV ERO of 0.23 cm2 and a regurgitant volume of 34 mls with a RVSP of 101 mmHg.  The MR jet was eccentric.  He has LAE (LA diameter 4.9 cm and 108 mls LA volume) and LVE (LVIDd 5.02) and a LVEF of 36%.  The LVI Evmax was 157 cm/sec.  The pulmonary venous Doppler showed severe blunting of the systolic wave.

What is your assessment of the severity of the mitral regurgitation?
What is your assessment of the mechanism of mitral regurgitation?
What is your recommendation for repair of the mitral valve?
Would you recommend an Alfieri stitch if residual MR was present after a repair?
What is your recommendation for treatment of the atrial fribrillation?