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Review
. 2018 Nov;7(6):812-820.
doi: 10.21037/acs.2018.11.04.

Transapical NeoChord mitral valve repair

Andrea Colli  1 , David Adams  2 , Alessandro Fiocco  1 , Nicola Pradegan  1 , Lorenzo Longinotti  1 , Matteo Nadali  1 , Dimosthenis Pandis  2 , Gino Gerosa  1
Affiliations
Review

Transapical NeoChord mitral valve repair

Andrea Colli et al. Ann Cardiothorac Surg. 2018 Nov.

Abstract

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.

Keywords: Mitral regurgitation; NeoChord; mitral insufficiency; mitral valve flail; mitral valve prolapse; mitral valve repair (MVr).

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Conflict of interest statement

Conflicts of Interest: A Colli, G Gerosa received travel grants from Neochord, Inc. D Adams is the Co-Principal Investigator of the Rechord Trial, which is supported by Neochord, Inc. The other authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1
Left anterolateral minithoracotomy in the 5th intercostal space.
Figure 2
Figure 2
Posterolateral LV access is prepared with two circumferential purse strings reinforced by pledgets. Ventriculotomy is performed and the device is introduced. LV, left ventricular.
Figure 3
Figure 3
The NeoChord device crosses the mitral valve under 2D transesophageal echocardiographic guidance.
Figure 4
Figure 4
The left ventricle can be divided into two areas, one apical called the chordal free zone limited by the tip of the papillary muscle and one called the chordal area below the leaflet and up to the upper part of the tip of the papillary muscle. The device should be moved anterioposteriorly or mediolaterally only once in the chordal free area in order to avoid entanglement of the subvalvular apparatus.
Figure 5
Figure 5
The device tip needs to point toward the dome of the posterior leaflet. Once the dome is reached a gentle downward movement of the handle moves the device tip towards free edge of the posterior leaflet allowing for smooth and safe progression of the device on the atrial surface of the anterior leaflet.
Figure 6
Figure 6
The long axis 3-chamber echocardiographic X-plane view allows visualization from two different angles at 90°. This is the key imaging modality for ventricular navigation and crossing of the mitral valve.
Figure 7
Figure 7
The NeoChord device is simultaneously viewed in both echocardiographic X-plane images allowing for a safe navigation and crossing of the mitral valve in its central area.
Figure 8
Figure 8
The NeoChord device is seen only in one screen because it is not positioned in the central portion of the mitral valve. Navigation and crossing of the mitral valve present a higher risk of leaflet and chordal damage because of misalignment. It is essential to not lose sight of the device in both echocardiographic images during LV navigation. LV, left ventricular.
Figure 9
Figure 9
The tip of the NeoChord device is placed over the diseased segment of the mitral leaflet to be treated using 3D echocardiographic guidance. The jaws of the device are opened.
Figure 10
Figure 10
The device is gently retrieved from the left atrium until the point that the inferior jaws load the leaflet. The confirmation monitor shows a lightning flash confirming the correct loading of the leaflet.
Figure 11
Figure 11
The jaws are closed; the leaflet is punctured and the Gore-Tex chord is passed through.
Figure 12
Figure 12
The NeoChord that has been passed is retrieved from the device together with the needle.
Figure 13
Figure 13
The NeoChord device is opened and retrieved from the left ventricle.
Figure 14
Figure 14
A girth hitch knot is performed.
Figure 15
Figure 15
The knot slides in the left ventricle up to the free margin of the treated leaflet fixing the implanted neochord.
Figure 16
Figure 16
Surgical view of the mitral valve showing three implanted NeoChords on the P2 segment.
See this image and copyright information in PMC

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References

    1. Baumgartner H, Falk V, Bax JJ, et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J 2017;38:2739-91. 10.1093/eurheartj/ehx391 - DOI - PubMed
    1. Perier P, Hohenberger W, Lakew F, et al. Toward a new paradigm for the reconstruction of posterior leaflet prolapse: midterm results of the “respect rather than resect” approach. Ann Thorac Surg 2008;86:718-25; discussion 718-25. 10.1016/j.athoracsur.2008.05.015 - DOI - PubMed
    1. Seeburger J, Rinaldi M, Nielsen SL, et al. Off-pump transapical implantation of artificial neo-chordae to correct mitral regurgitation: the TACT Trial (Transapical Artificial Chordae Tendinae) proof of concept. J Am Coll Cardiol 2014;63:914-9. 10.1016/j.jacc.2013.07.090 - DOI - PubMed
    1. Rucinskas K, Janusauskas V, Zakarkaite D, et al. Off-pump transapical implantation of artificial chordae to correct mitral regurgitation: early results of a single-center experience. J Thorac Cardiovasc Surg 2014;147:95-9. 10.1016/j.jtcvs.2013.08.012 - DOI - PubMed
    1. Colli A, Manzan E, Fabio FZ, et al. TEE-guided transapical beating-heart neochord implantation in mitral regurgitation. JACC Cardiovasc Imaging 2014;7:322-3. 10.1016/j.jcmg.2014.01.003 - DOI - PubMed