Transesophageal echocardiography in NeoChord procedure

Abstract

Background: Transapical off-pump mitral valve intervention with neochord implantation for degenerative mitral valve disease have been recently introduced in the surgical practice. The procedure is performed under 2D-3D transesophageal echocardiography guidance.

Methods: The use of 3D real-time transesophageal echocardiography provides more accurate information than 2D echocardiography only in all the steps of the procedure. In particular 3D echocardiography is mandatory for preoperative assessment of the morphology of the valve, for correct positioning of the neochord on the diseased segment , for the final tensioning of the chordae and for the final evaluation of the surgical result.

Result and conclusion: This article is to outline the technical aspects of the transesophageal echocardiography guidance of the NeoChord procedure showing that the procedure can be performed only with a close and continuous interaction between the anesthesiologist and the cardiac surgeon.

Figure 1

NeoChord device for the transapical implantation of neochord. The NeoChord DS1000 device which contains a handle for steering purpose, the needle, which is advanced through the mitral valve leaflet tissue, and a long shaft with the grasping mechanism on the tip (a). The associated device monitor, which contains four fiber optic monitor lights changing from red to white when the effective leaflet is captured (b)

Figure 2

Two-dimensional transesophageal echocardiography long-axis view of mitral valve. On the left side showed prolapse of posterior lefleat (arrow). In the right side with color flow Doppler the mitral regurgitation

Figure 3

Zoomed three-dimensional transesophageal echocardiographic image for the assessment of mitral valve prolapse in P2 segment (arrow). AML: Anterior mitral lefleat, PML: Posterior mitral lefleat

Figure 4

Multi-plane imaging (X-plane) of mitral valve (MV). The use of a dual screen is useful to simultaneously display two real-time images. In the left side the image is typically a reference view of MV at 120–130°, while on the right side the image that is inverted right-left (anterior in the right side and posterior in the left side), or “ateral plane” represents a plane rotated at 90° from the reference plane. This plane allows the MV to be seen in two planes in real-time and to visualize the position of the device during the insertion (arrow)

Figure 5

Three-dimensional transesophageal echocardiography of mitral valve (MV) with the NeoChord device (arrow) within the MV orifice. The grasping mechanism, which can be identified as the accentuation on the tip, is facing the P2 segment where there is the prolapse. Three-dimensional echocardiography imaging is especially valuable for identification of the prolapsing segment of the MV as well as for intraoperative navigation of the device. AML: Anterior mitral leaflet, PML: Posterior mitral leaflet

Figure 6

Three-dimensional transesophageal echocardiography of mitral valve (MV) at the end of the procedure. The prolapse of the posterior lefleat as we have seen previously disappeared. Tension and securing of NeoChords is controlled by three-dimensional transesophageal echocardiography and two-dimensional to achieve maximal competence of the MV. AML: Anterior mitral leaflet; PML: Posterior mitral leaflet

Figure 7

Two-dimensional transesophageal echocardiography showed no residual regurgitation after NeoChord implantation