Transapical mitral valve repair procedures: Primetime for microinvasive mitral valve surgery

Abstract

Introduction: Nowadays micro-invasive-procedures (off-pump, beating-heart) for mitral valve repair (MVRe) are abruptly expanding with the potential to be adopted as a valuable alternative to surgery. In the present manuscript, the authors review the available technologies intended to treat mitral regurgitation (MR) through transapical approach, including annuloplasty and chordal-repair options.

Annuloplasty: To date, Valcare Amend is the only transapical MV ring to have been implanted in patients. The device allows for stabilization of the annulus through a complete semirigid d-shaped ring. The first-in-human successful procedure was performed in 2016 by our Group and subsequent clinical experience included a total of 14 implanted patients. Currently, the technology is under clinical trial evaluation to validate the efficacy and safety profile of the device.

Chordal repair: Beating-heart chordal implantation via transapical approach is a current feasible, safe and reproducible option. Neochord DS1000 is the most widely used technology in the field, with a solid procedural experience and good results in well-selected patients. Its clinical use has been validated in Europe since 2012, while it is still under clinical investigation in the United States. Harpoon MVRe system is a novel technology, recently CE-mark approved for clinical use.

Discussion and conclusions: Transapical micro-invasive technologies are current viable therapies to treat MR in selected patients. Although there are still several limitations that preclude an extensive use of such procedures, their results are promising in well-selected patients. Embracing transcatheter MVRe therapies should guide the cardiac surgeon through the new revolution of micro-invasive MV tailored repair.

Keywords: clinical review; valve repair/replacement.

Figure 1

The AMEND ring. Courtesy of Valcare Medical

Figure 2

The AMEND ring; fluoroscopic images summarizing procedural steps. (A) Ventriculography demonstrating guidewire crossing of the mitral valve and landing in superior pulmonary vein with the tip of the delivery system on the ventricular apex. (B) The ring is partially unsheathed in the left atrium. (C) The ring is fully unsheathed with closed D shape. (D) The stabilizing tool is unsheathed and the ring is positioned anatomically. (E) Posterior anchors have been deployed. (F) Final appearance of the Amend ring with all anchors deployed. Adapted from Gerosa et al.

Figure 3

Neochord transcatheter mitral valve repair. (A) The Neochord system. (B) The Neochord system inserted in the left ventricle. (C) Once the tip has crossed the valve, the jaws of are opened and the leaflet edge is grasped by withdrawing the device from the left atrium. (D and E) The leaflet is pierced through a needle and a loop of the suture is deployed. (F and G) The device is retrieved, exteriorizing the chordal loop; a girth hitch knot is be formed. (H) The length of each neo‐chordae is set until adequate coaptation is reached, under real‐time transesophageal echocardiogram; each of the neo‐chordae is fixed to an epicardial Teflon pledget. Courtesy of Neochord Inc.

Figure 4

The Harpoon Mitral Valve Repair System and procedure. A small anterolateral thoracotomy is performed in the fourth or fifth intercostal space. The valved introducer is inserted into the ventricle through a purse‐string suture in a location that is 3–4 cm basal from the apex and lateral to the left anterior descending coronary artery. The TSD‐5 is steered to the belly of the prolapsed leaflet at the targeted location, and once leaflet stabilization is achieved, the device is actuated, piercing the leaflet and deploying a chordal with a double‐helix knot‐anchored on the atrial surface. The introducer is retrieved; and the chords are tensioned till the adequate coaptation is achieved, and then fixed on an epicardial Teflon pledget. Adapted from Sharma et al.