Transapical Off-pump Mitral Valve Repair Research Articles

Feasibility of concomitant exclusion of left atrial appendage during novel transapical off-pump beating heart mitral valve repair.

The AtriClip device enables the safe and reproducible epicardial clipping of the left atrial appendage. Transapical off-pump beating heart mitral valve repair using NeoChord DS100 Artificial Chordae Delivery System has matured and become more standardized. We aim to evaluate the feasibility of combining NeoChord repair and left atrial appendage exclusion in a single procedure through the same minithoracotomy in patients with mitral valve prolapse and atrial fibrillation. From 2018 to 2019, seven patients with severe mitral regurgitation and atrial fibrillation underwent transesophageal echocardiography-guided transapical off-pump mitral valve repair with the novel NeoChord DS 1000 system and concomitant left atrial appendage exclusion using the AtriClip Pro II device. Both procedures were performed via left mini-thoracotomy. The AtriClip device was applied after the NeoChord repair was done. All seven patients had less than moderate mitral regurgitation after the NeoChord repair and successful left atrial appendage occlusion. There were no device or procedure-related complications. Clinical follow-up revealed significant symptomatic improvement, and no cardiovascular complications were reported. Transesophageal echocardiography at 6-12months post-procedure showed stable left atrial appendage occlusion with no residual flow between the left atrium and the left atrial appendage and a stump of less than 5mm. Beating heart epicardial clipping of the left atrial appendage using AtriClip concomitant with transapical mitral valve repair using Neochord DS 1000 system is a feasible and safe treatment option in mitral valve prolapse and atrial fibrillation in patients with limited indications. However, its safety needs to be confirmed in a larger series of patients.

Echocardiographic predictors of operative outcome for transapical off-pump mitral valve repair with neochord implantation

Abstract Introduction Transapical off-pump mitral valve repair with artificial neochord implantation (TOP-MINI) is safe and effective for the treatment of primary mitral regurgitation12, however, the current literature regarding echocardiographic criteria prior to the procedure is scarce. Objective To identify preoperative echocardiographic predictors of technical success after TOP-MINI for severe primary mitral regurgitation. Methods All consecutive patients who underwent TOP-MINI for severe primary mitral regurgitation from 2017 to 2022 were included. Preoperative echocardiographic evaluation included transthoracic and transesophageal echocardiography. Transesophageal evaluation included 2D measurements of mitral valve annulus, mitral leaflets, flail gap, and 3D mitral valve reconstruction among others, the leaflet-to-annulus index was estimated in all patients. Mitral valve morphology was classified as: Type A (Central posterior leaflet prolapse/flail) or non-Type A (Type B: posterior multisegment involvement; type C: anterior leaflet prolapse; type D: paracommissural or calcified leaflet). Technical success was defined according to the Mitral Valve Academic Research Consortium criteria. Independent echocardiographic predictors for the primary outcome were identified using a multivariate logistic regression model. Results Fifty-five patients were included. Mean age was 66.7 years (SD 12.9). Technical success with MR <2+ was achieved in 48 (87.27%) patients. Significant predictors for technical success were the leaflet-to-annulus index (OR 1.09; p=0.012; 95% CI: 1.02–1.15), with an optimal cutoff value of 1.26 (sensitivity 73.3%, specificity 85.7%); and a non-type A valve morphology (OR 0.04; p=0.024; 95% CI: 0.01–0.65). The model showed good discrimination (AUC = 0.92) and calibration (Hosmer-Lemeshov p=0.21). Conclusion A thorough preoperative echocardiographic evaluation is key to improve outcomes in TOP-MINI. In this study, a leaflet-to-annulus index >1.26 was associated with technical success, whether a non-type A valve morphology was associated with technical failure. These parameters could help to identify proper candidates for this technique. Funding Acknowledgement Type of funding sources: None.

Transapical off-pump mitral valve repair with NeoChord™ implantation: An early single-center Portuguese experience.

Transapical off-pump NeoChord DS1000™ implantation is a minimally invasive surgical mitral valve repair (MVr) procedure to treat degenerative mitral regurgitation (MR), which is performed using the NeoChord DS1000™ system with two and three-dimensional transesophageal echocardiographic guidance on a beating heart. It has been demonstrated to be safe and effective in carefully selected patients. The authors aim to analyze short-term clinical and echocardiographic results after mitral valve repair using the NeoChord™ system. All patients that underwent transapical off-pump mitral valve repair with NeoChord™ implantation at our center, between December 2017 and December 2019, were included. The procedure was performed by left minithoracotomy, under general anesthesia. All patients presented severe primary MR due to flail/prolapse of one leaflet (anterior or posterior). Eighteen patients were included in the analysis, the mean age was 65±15 years, 72% were male. The mean EuroSCORE II was 1.9±1.6. All patients had New York Heart Association (NYHA) class ≥ II. Mean effective regurgitant orifice area was 1.0±0.4 cm2, with a mean regurgitant volume 146±42 mL, and a mean leaflet-to-annulus index of 1.29±0.14. MR was due to leaflet prolapse in 50% (N=9), and flail leaflet in 50% (N=9). Anatomic type A (isolated P2 defect) was the predominant form in 66.5% (N=12). Successful repair, defined by none, trace or mild mitral regurgitation, by implantation of two to four neochordae, was achieved in all 18 patients. No major complications arose intra-procedurally. The median follow-up was 194 days. NYHA class was ≤II in 94.5% patients at six-month follow-up, which represented a significant improvement in symptomatic status (p=0.002). At follow-up, 72% of patients (N=13) had grade ≤2 MR. There was a significant reduction in mean indexed left atrium volume (63±7 mL/m2 vs. 45±6 mL/m2, p=0.038), mean indexed left ventricular end-diastolic volume (87±7 mL/m2 vs. 79±9 ml/m2, p=0.001), and pulmonary arterial systolic pressure (44±4 vs. 31±8 mmHg, p=0.002). The re-intervention rate was 11.1% (N=2, both patients underwent reintervention, either a re-do NeoChord™ or conventional MV repair on-pump surgery). No major adverse cardiac or cerebrovascular events were registered. In selected patients, minimally invasive MVr using the NeoChord™ system is safe, effective and reproducible. Early clinical and echocardiographic results suggest a significant symptomatic improvement, sustained MR grade decrease, and favorable left cardiac chamber remodeling, with low re-intervention rates. These results warrant further confirmation in larger cohorts, on longer period of follow-up.

Transapical off-pump mitral valve repair with NeoChord implantation: Is less better?

Transapical off-pump mitral valve repair with NeoChord implantation: Is less better?

Transapical off-pump mitral valve repair with NeoChord™ implantation: An early single-center Portuguese experience

IntroductionTransapical off-pump NeoChord DS1000™ implantation is a minimally invasive surgical mitral valve repair (MVr) procedure to treat degenerative mitral regurgitation (MR), which is performed using the NeoChord DS1000™ system with two and three-dimensional transesophageal echocardiographic guidance on a beating heart. It has been demonstrated to be safe and effective in carefully selected patients. ObjectiveThe authors aim to analyze short-term clinical and echocardiographic results after mitral valve repair using the NeoChord™ system. MethodsAll patients that underwent transapical off-pump mitral valve repair with NeoChord™ implantation at our center, between December 2017 and December 2019, were included. The procedure was performed by left minithoracotomy, under general anesthesia. All patients presented severe primary MR due to flail/prolapse of one leaflet (anterior or posterior). ResultsEighteen patients were included in the analysis, the mean age was 65±15 years, 72% were male. The mean EuroSCORE II was 1.9±1.6. All patients had New York Heart Association (NYHA) class ≥ II. Mean effective regurgitant orifice area was 1.0±0.4 cm2, with a mean regurgitant volume 146±42 mL, and a mean leaflet-to-annulus index of 1.29±0.14. MR was due to leaflet prolapse in 50% (N=9), and flail leaflet in 50% (N=9). Anatomic type A (isolated P2 defect) was the predominant form in 66.5% (N=12). Successful repair, defined by none, trace or mild mitral regurgitation, by implantation of two to four neochordae, was achieved in all 18 patients. No major complications arose intra-procedurally. The median follow-up was 194 days. NYHA class was ≤II in 94.5% patients at six-month follow-up, which represented a significant improvement in symptomatic status (p=0.002). At follow-up, 72% of patients (N=13) had grade ≤2 MR. There was a significant reduction in mean indexed left atrium volume (63±7 mL/m2 vs. 45±6 mL/m2, p=0.038), mean indexed left ventricular end-diastolic volume (87±7 mL/m2 vs. 79±9 ml/m2, p=0.001), and pulmonary arterial systolic pressure (44±4 vs. 31±8 mmHg, p=0.002). The re-intervention rate was 11.1% (N=2, both patients underwent reintervention, either a re-do NeoChord™ or conventional MV repair on-pump surgery). No major adverse cardiac or cerebrovascular events were registered. ConclusionsIn selected patients, minimally invasive MVr using the NeoChord™ system is safe, effective and reproducible. Early clinical and echocardiographic results suggest a significant symptomatic improvement, sustained MR grade decrease, and favorable left cardiac chamber remodeling, with low re-intervention rates. These results warrant further confirmation in larger cohorts, on longer period of follow-up.

Transapical off-pump mitral valve repair with NeoChord implantation: Is less better?

Transapical off-pump mitral valve repair with NeoChord implantation: Is less better?

Transapical Off-pump Mitral Valve Repair with NeoChord Implantation: Initial experience in Portugal

Objective: Transapical off-pump NeoChord repair is a minimally invasive surgical procedure, to treat degenerative mitral valve regurgitation, of increasing interest. The procedure is performed usin...

The neochord mitral valve repair procedure: Numerical simulation of different neochords tensioning protocols

Transapical off-pump mitral valve repair with neochord implantation is an established technique for minimally-invasive intervention on mitral valve prolapse/flail. The procedure involves the positioning of artificial chords, whose length/tension is adjusted intraoperatively, adopting different methods based on the experience of the surgeon. This unsystematic approach occasionally leads to complications such as leaflet rupture and excessive/insufficient load on the neochords. In this study, finite element models of a generalized prolapsing mitral valve are used to verify the effect of two alternative tensioning approaches (AT – All together and 1-by-1 – one by one sequences) on the coaptation area and valve biomechanics, comparing results with a corresponding healthy configuration. The total force of about 1 N is exerted by the chords in both strategies, but the maximum stress and coaptation area are closer to those of the healthy configuration in the 1-by-1 sequence. However, the analysis also provides an explanation for the chords unloading in the 1-by-1 strategy observed in the clinical practice, and suggests an optimum tensioning methodology for NeoChord procedures. The study also reveals the potential power of the implemented numerical approach to serve as a tool for procedural planning, supporting the identification of the most suitable ventricular access site and the most effective stitching points for the artificial chords.

A Treatise on The Surgical Management and A Suggested Amendment of Surgical Classification of Left Ventricular Rupture Following Mitral Valve Replacement

The present perspective is a synthesis of 108 published investigations in the setting of different types of left ventricular rupture following mitral valve replacement (MVR). We identified 109 investigations and reviewed the clinical presentation, diagnostic modalities, surgical techniques and outcomes. Clinical presentation, roentgenography, cross-sectional transthoracic/transesophageal echocardiography and computerized tomography provided the diagnostic information and defined the causative mechanism. Magnetic resonance imaging had been used for further clarification of the native ventricular anatomy in high-risk subset of patients, undergoing non-traditional transapical off-pump mitral valve repair with neochordal implantation. In this article, we have attempted to address several concerning issues and controversies with reference to the possible causative mechanisms, preventive measures, the issue of chordal preservation during MVR, the degree of decalcification required in cases of heavily calcified mitral annulus, selection of appropriate sized prosthetic valves, the surgical importance of a small left ventricle, various techniques of repair, role of cardiopulmonary bypass and cardioplegic arrest during the repair of left ventricular rupture, the role of biodegradable epicardial tissue sealants, to repair or not to repair the atrio-ventricular groove hematoma during mitral valve surgery, and the role of intra-aortic balloon counterpulsation in the perioperative period. Additionally, we have highlighted a new type of left ventricular rupture described in the literature located between the base of the papillary muscle and the apex, which can be categorized as a complication of new technologies of mitral valve repair such as NeoChord device artificial chordal implantation. We have classified this category as type IV ventricular rupture. Overall, this review attempts to address the guidelines for different surgical approaches and techniques of repair of different types of left ventricular rupture for a successful outcome. We submit that an increased appreciation of the causative mechanisms of different types of left ventricular rupture and its prevention may well contribute to improved surgical management.

Percutaneous interventions for mitral and tricuspid heart valve diseases.

Percutaneous mitral and tricuspid valve interventions are alternative treatment options for patients who are deemed to be at high surgical risk and/or inoperable. Transcatheter edge-to-edge mitral valve repair using the MitraClip and PASCAL system, which are designed to mimic the surgical Alfieri's stich, has changed the landscape for the treatment of symptomatic functional mitral regurgitation (MR). Previous studies have shown that the procedure can reduce symptoms and improve functional capacity with low rates of complication. Recently, two randomized controlled clinical trials have reported the effect of the MitraClip on outcomes for secondary MR. Next-generation devices, advanced techniques, and additional clinical data would further improve the outcomes following this procedure. Percutaneous direct annuloplasty using the Cardioband system is a relatively new technique that closely resembles surgical annuloplasty. Its role in treating secondary MR as well as its concomitant use with edge-to-edge mitral repair will continue to gain attention. The transapical off-pump mitral valve repair with neochord implantation, known as a NeoChord procedure, is also a new option to implant artificial chords in a minimally invasive manner in MR patients with leaflet prolapse or flail. Transcatheter mitral valve replacement is another emerging treatment option for selected patients. Although the development of transcatheter strategies for tricuspid regurgitation (TR) is still in the early stages, there is growing evidence to support the application of various approaches, including edge-to-edge repair and annuloplasty, to address unmet needs. In this review article, we will summarize the emerging minimally invasive interventions for mitral and tricuspid valves.

Transapical off-pump mitral valve repair

Transapical off-pump mitral valve repair

Corrigendum to: 'An early European experience with transapical off-pump mitral valve repair with NeoChord implantation [Eur J Cardiothorac Surg 2018;54:460-6

Corrigendum to: 'An early European experience with transapical off-pump mitral valve repair with NeoChord implantation [Eur J Cardiothorac Surg 2018;54:460-6

Mechanisms of recurrent regurgitation after transapical off-pump mitral valve repair with neochord implantation†.

The aim of this study was to describe possible mechanisms of recurrent mitral regurgitation (MR) in patients who have been treated with the NeoChord procedure. Patients presenting with recurrent severe or moderate MR were categorized as Not Expected Surgical-Like Result (NESLR)-Redo and NESLR-MR2 [NESLR reintervention or moderate MR (2+), respectively]. NESLR patients were stratified by onset (intraoperative, perioperative 24 h-30 days, or early 30 days to follow-up), by MR jet direction (central or eccentric) and by jet orientation (anterior or posterior). Specific mechanisms of NESLR were analysed. Fifty-two patients were identified with 13 (25%) categorized as NESLR-Redo, and 39 (75%) as NESLR-MR2. NESLR-Redo patient stratification included: intraoperative = 2 patients (1.2%), both eccentric anteriorly directed jets; perioperative = 7 patients (4.2%), all eccentric with 3 anteriorly and 4 posteriorly directed jets; and early = 4 patients (2.4%), 1 central, 3 eccentric, 2 posteriorly and 1 anteriorly directed jets. NESLR-MR2 patient stratification included: perioperative = 2 patients (5.1%), both eccentric, 1 anteriorly and 1 posteriorly directed jets; and early = 37 patients (94.9%), 4 central, 33 eccentric, 22 anteriorly and 11 posteriorly directed jets. Possible mechanisms of recurrent MR were identified as: patient selection (17.3%), technical issues (28.8%), progression of baseline disease (15.4%), left ventricle reverse remodelling (1.9%), excessive over-tensioning (35.8%) and PML curling (30.8%). The mechanisms of recurrent MR after the NeoChord procedure can be determined. Understanding recurrent MR mechanisms has led to improvements in procedural standardization and ad hoc prevention strategies that have been widely adopted since our initial clinical experience.

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.

Early echocardiographic results of transapical off-pump mitral valve repair with the NeoChord DS1000 device in patients with severe mitral regurgitation due to posterior leaflet prolapse: first experiences in Poland.

IntroductionMinimally invasive techniques of mitral valve (MV) repair have been increasingly used in recent years. Transapical implantation of artificial chordae on a beating heart under 2D/3D transesophageal echocardiographic guidance with the NeoChord DS1000 device is a new surgical treatment of degenerative mitral regurgitation (MR).AimTo evaluate early results of MV repair with the NeoChord DS1000 device in the first group of consecutive patients operated on in Poland.Material and methodsTwenty-one patients with severe MR due to posterior leaflet prolapse (81% male; mean age: 60.7 ±12.7 years) underwent MV repair with the NeoChord DS1000 system. There were 12 (57.1%) patients with type A (an isolated central prolapse/flail), 8 (38.1%) patients with type B (multisegment disease/flail) and 1 (4.8%) patient with type C (posterior/paracommisural area) MV prolapse. A flail leaflet was present in 12 (57.1%) patients. The median number of neochords was 3 (2–6). We assessed by echocardiography left-sided heart morphology and evaluated MR degree before and 6 months after chords implantation.ResultsEarly procedural success was achieved in 100% of patients. At the 6-month follow-up nonsignificant MR (trace and mild) was detected in 17 (81.0%) patients, while moderate MR was detected in 4 (19.0%) patients; mean values of left-sided heart dimensions and volumes, mitral E and E’ velocity of lateral MV annulus significantly decreased.ConclusionsA novel procedure with the NeoChord DS1000 device is feasible in properly selected patients, and results in a significant reduction of MR degree and left ventricle and left atrium reverse remodeling at the 6-month follow-up.

Transapical NeoChord mitral valve repair.

Transapical off-pump mitral valve repair (MVr) with NeoChord implantation has become widely applied in Europe for patients presenting with severe mitral regurgitation due to leaflet prolapse or flail. The procedure is performed under real-time 2D- and 3D-transesophageal echocardiography (TEE) for both implantation and neochordae tension adjustment allowing real-time monitoring of hemodynamic recovery. Preoperative anatomic and echocardiographic selection criteria, procedure refinement, as well as innovative ex-vivo surgical simulator training have been developed and strategically employed in the past few years, to generate a robust precision-based procedural framework with significantly enhanced operator use, patient safety and clinical outcomes. The procedure has evolved into a reproducibly successful and safe approach, which complements existing surgical treatment strategies available to eligible patients with chronic severe degenerative mitral regurgitation.

An early European experience with transapical off-pump mitral valve repair with NeoChord implantation.

Transapical off-pump NeoChord repair is a novel minimally invasive surgical procedure to treat degenerative mitral valve regurgitation. The aim was to evaluate 1-year clinical results of the NeoChord procedure in a consecutive cohort of patients. Between February 2013 and July 2016, 213 patients were enrolled in the NeoChord Independent International Registry. All patients presented severe mitral regurgitation due to flail/prolapse of 1 or both leaflets, and they all completed postoperative echocardiographic assessment up to 1 year. We identified the primary end point as composed of procedural success, freedom from mortality, stroke, reintervention, recurrence of severe mitral regurgitation, rehospitalization and decrease of at least 1 New York Heart Association functional class at 1-year follow-up. We also compared outcomes according to the anatomical classification (Type A: isolated central posterior leaflet disease; Type B: posterior multisegment disease; Type C: anterior, bileaflet, paracommissural disease with/without leaflet/annular calcifications). The median age was 68 years (interquartile range 56-77), and the median EuroSCORE II was 1.05% (interquartile range 0.67-1.76). The number of Type A, B and C patients was 82 (38.5%), 98 (46%) and 33 (15.5%), respectively. Procedural success was achieved in 206 (96.7%) patients. At 1-year follow-up, overall survival was 98 ± 1%. Composite end point was achieved in 84 ± 2.5% for the overall population and 94 ± 2.6%, 82.6 ± 3.8% and 63.6 ± 8.4% in Type A, Type B and Type C patients, respectively (P < 0.0001). These results demonstrate that the NeoChord procedure is safe, effective and reproducible. Clinical and echocardiographic efficacy is maintained up to 1 year with significant differences among the anatomical groups. Specific anatomical selection criteria are necessary to achieve stable results.

Acute intraoperative echocardiographic changes after transapical off-pump mitral valve repair with NeoChord implantation

ObjectivesOur aim is to investigate the acute intraoperative effects of the NeoChord repair procedure on mitral valve (MV) annular geometry and LV function and the impact of these changes on MR at 1-year follow-up. BackgroundRecently transapical off-pump mitral valve repair with NeoChord implantation has been demonstrated to be safe and effective in patients with degenerative mitral regurgitation (DMR). MethodsWe retrospectively analyzed baseline and early postoperative 3-dimensional transesophageal echocardiography of 66 patients who underwent NeoChord repair for isolated posterior leaflet MV disease using semiautomatic off-line analysis software. ResultsWe observed a significant acute reduction of indexed LV end diastolic volume (Δ% = 14, p < .001), LV ejection fraction (Δ = 5.7%, p = .002), indexed left atrial volume (Δ = 14.7%, p = .045), and pulmonary artery pressure (Δ = 2.1%, p = .026). Among MV geometric parameters, we observed a significant reduction of MV antero-posterior diameter (Δ = 7%, p < .001), sphericity index (Δ = 8%, p < .001), annulus circumference (Δ = 0.9%, p = .021), and annulus area (Δ = 2.7%, p = .018). At 1-year, 53 patients (85.5%) presented MR ≤ mild, while 9 patients (14.5%) had MR ≥ moderate. Reduction of AP diameter (OR = 0.14, CI −3.83; 0.08, p < .001), annulus circumference (OR = 0.27, CI −2.98; 0.37, p = .005), MV area (OR = 0.39, CI −2.46; 0.61, p = .04), aorto-mitral angle (OR = 0.38, CI −2.49; 0.54, p = .002) and iEDV (OR = 0.44, CI −2.44; 0.81, p = .001) were independent protective factors against recurrence of MR greater than mild at 1-year follow-up. ConclusionsTransapical NeoChord repair produces important acute intraoperative changes in MV anatomy in DMR patients. The acute changes observed were associated with procedure durability at 1-year FU.

TCT-53 Transapical Off-pump Echo-guided Mitral Valve Repair with Neochordae Implantation: 2-Years Results

Transapical off-pump mitral valve repair with neochordae implantation is a minimally invasive, safe and reproducible treatment for degenerative mitral valve regurgitation (MR). Aim of this study is to evaluate the 2 years clinical results according to morphological valve classifications. 152

Beating heart mitral valve repair with neochordae implantation: real-time monitoring of haemodynamic recovery

Transapical off-pump mitral valve repair with neochord implantation has been approved for patients presenting with severe mitral regurgitation due to leaflet prolapse or flail. The procedure is performed under real-time 2D and 3D transoesophageal echocardiography for both implantation and neochordae tension adjustment allowing real-time monitoring of haemodynamic recovery.