Transcatheter mitral valve chord repair

Abstract

The field of mitral valve disease diagnosis and management is rapidly evolving. New understanding of pathophysiology and improvements in the adoption of sophisticated multimodality imaging modalities have led to early diagnosis and to more complex treatment. The most common cause of mitral regurgitation (MR) in the western world is in the primary alteration of the valve, which leads to degenerative leaflet prolapse due to chordal elongation or rupture and annular dilatation. Untreated, significant MR has a negative impact prognosis, leading to reduction of survival. In the setting of degenerative MR, surgical repair currently represents the standard of care. Treatment of asymptomatic patients with severe MR in the Valve Center of Excellence, in which successful repair reaches more than 95% and surgical mortality less than 1%, symbolizes the direction for the next years. Transcatheter mitral valve repair with different devices, more recently the chordal replacement ones, is providing good outcomes and became a therapeutic option in high-risk patients with degenerative MR. In the future, more advances are expected from further development of interventional techniques, careful evaluation and better patient selection. This review will focus on long-term surgical outcomes of mitral valve repair with artificial chordae and on the emerging transcatheter chordal repair devices as therapeutic options for degenerative MR patients.

Keywords: Mitral valve (MV); chordal repair; mitral regurgitation (MR); transcatheter.

Figure 1

Echo view of a prolapse without flail of the posterior mitral leaflet (central segment). The three panels show, from top to bottom, the morphologic transoesophageal 2D echo aspect of a posterior prolapse, the color-Doppler analysis showing an eccentric jet causing severe regurgitation and a 3D en face view from the left atrium of the mitral leaflet (with the prolapse of P2).

Figure 2

Transesophageal echo view of a prolapse with flail of the posterior mitral leaflet due to chordal rupture. The four-panel image depicts, from the top to the bottom and from left to right, the transoesophageal echo of the two mitral leaflets. Morphologic 2D with color-Doppler analysis show severe mitral regurgitation, with an eccentric jet. The 3D echo, en face view of the mitral leaflets, depicts the chordal rupture which is moving free in the left atrium during the systole. Last, the prolapse flail with bulging of the posterior leaflet in the central and medial segment can be appreciated in the 2D echo intercommissural morphologic view.

Figure 3

The NeoChord DS 1000 System_ Courtesy of NeoChord (NeoChord, USA).

Figure 4

The Harpoon TSD-5 System_ Courtesy of Harpoon (Edwards Lifescience, USA).

Figure 5

The Harpoon TSD-5 System during the different phases of the chordal implantation_ Courtesy of Harpoon (Edwards Lifescience, USA).

Figure 6

Intraprocedural guidance with multimodality fusion imaging during preclinical experience with Chordart device, using the EchoNavigator^®-system (Philips Healthcare, Best, The Netherlands) side-by-side with the HeartNavigator^®-system (Philips Healthcare), which enables CT planning and CT-fluoroscopy overlay. Using the HeartNavigator, the optimal trajectory of the device from the tip of the target papillary muscles through the corresponding MV leaflet, to define the coaxial entry point into the left atrium, was assessed (A). Grasping of P2 segment with HeartNavigator (B), EchoNavigator (C) and TEE guidance in real-time. Finally, Chordart implant with HeartNavigator (D) and EchoNavigator (E) guidance [F; Leaflet side of Chordart (*) papillary muscle side of Chordart (**)]. MV, mitral valve; CT, computed tomography; TEE, transesophageal echocardiography.

Figure 7

Leaflet-to-Annulus Index <1.4, defined as the ratio between the sum of anterior leaflet length and posterior leaflet length over antero-posterior length, can be used as reliable predictor to identify patients without annular dilatation. Courtesy of NeoChord (NeoChord, USA) (30,31). AML, anterior mitral leaflet; PML, posterior mitral leaflet; AP, antero-posterior diameter.

Video

Transcatheter mitral valve chord repair.