Is transapical off-pump neochord implantation a safe and effective procedure for mitral valve repair?

Abstract

Is trans-apical off-pump neochord implantation a safe and effective procedure for mitral valve repair? Objective: Trans-apical off-pump mitral valve repair is a new minimally invasive surgical technique for the correction of mitral regurgitation caused by mitral leaflet prolapse. The purpose of this study is to evaluate, using clinical and echocardiographic follow-up data, the mid-term results of patients undergoing this procedure. Methods: A total of 26 patients diagnosed with severe mitral regurgitation underwent mitral valve repair with trans-apical off-pump neochord implantation using the NeoChord device at our hospital from July 2015 to July 2017. All patients were examined by transthoracic and transesophageal echocardiography. Eighteen (69.2%) patients had type A anatomy, 4 (15.4%) had type B anatomy, and 4 (15.4%) had type C anatomy. Preoperative, intraoperative, and postoperative demographic, echocardiographic, and clinical data were collected. Results: The patients' age ranged from 33 to 76 years (mean: 56±10.1 years). The average preoperative EuroSCORE II was 1.04%±0.7%. Acute procedural success was achieved in 25 (96.15%) patients. There was only 1 early death (30-day mortality rate: 3.8%) due to postoperative low cardiac output syndrome. Transthoracic echocardiography examinations revealed trivial/mild mitral regurgitation in 87.5% of the patients and moderate regurgitation in 12.5% of the patients. During the follow-up period, transthoracic echocardiography examinations revealed trivial/mild mitral regurgitation (MR) in 14 (58.3%) patients. Six (25%) patients presented with moderate MR and 4 (16.7%) patients had severe MR. At the 30-month follow-up, freedom from residual severe MR was 78.8%±10.3% and freedom from reoperation was 87.5%±6.8%. Conclusion: Trans-apical off-pump mitral valve repair with neochord implantation may be a suitable treatment option in patients with isolated posterior mitral valve leaflet prolapse.

Microinvasive mitral valve repair with transapical mitral neochordae implantation

“…At 1 year, the actuarial rate of patients meeting the composite primary endpoint of this study [APS and freedom from death, stroke, structural or functional failure of the MV repair, unplanned intervention related to the procedure, cardiacrelated hospitalization, or worsening of the New York Heart Association (NYHA) class] was 84% (DS 2.5%) (9). There are several other studies and reviews that report good clinical and echocardiographic results (3,23) such as Ahmed et al with an operative success of 96.8% in 249 patients (24) or in a study by Salihi et al where APS was achieved in 96.15% of patients; at a 30-month follow-up, freedom from residual severe MR was 78.8% (DS 10.3%) and freedom from reoperation was 87.5% (DS 6.8%) (14).…”

“…Exclusion criteria for NC implantation through a transapical approach are previous left chest surgery, pleural disease (7), active endocarditis, secondary mitral regurgitation, unfavorable anatomy (i.e., heavily calcified valves, significant leaflet tethering, presence of multiple or complex color Doppler jets, significant tricuspid or aortic valvular disease, leaflet perforation, and less than 5 mm flail overlap of the diseased leaflet with respect to the normal one) (3), and severe left ventricular dysfunction (14). Table 1 summarizes the preoperative factors that need to be evaluated during the screening process and that may predict ideal, good, possible, or unsuitable candidates for NC.…”

Actual perspective on off‐pump transapical artificial chord implantation

“…Published results of transapical chordal implantation show significant percentages of more than mild residual mitral regurgitation. 5,6,8,11,38,39 Gammie et al 23 introducing Harpoon results in their series of more than 60 patients show at 30 days 13% of moderate MR and 2% of severe MR. At 1 year, these percentages increase up to 23% and 2% for moderate and severe MR, respectively; 13% of the patients required reoperations. Lozos et al, 10 publishing the results of the first experience in Greece with Neochord DS1000, presented a 16% and 7% of moderate and severe residual MR, respectively.…”

“…Citing Ilir Hysi and Olivier Fabre 37 in their commentary to the 1‐year results of Harpoon published by Gammie et al, 23 “Where do we set the limit” for mitral valve repair? Published results of transapical chordal implantation show significant percentages of more than mild residual mitral regurgitation 5,6,8,11,38,39 . Gammie et al 23 introducing Harpoon results in their series of more than 60 patients show at 30 days 13% of moderate MR and 2% of severe MR. At 1 year, these percentages increase up to 23% and 2% for moderate and severe MR, respectively; 13% of the patients required reoperations.…”

“…This relatively new device, 1 follows the footsteps of Neochord (Neochord, Inc.) and Harpoon (Edwards Lifesciences) and permits the positioning of polytetrafluoroethylene (ePTFE) artificial chordae through a transapical off‐pump ventricular access. The efficacy and safety of this solution have already been demonstrated mainly thanks to the worldwide expansion of the Neochord experience 2–26 …”