Midterm results of transventricular mitral valve repair: Single-center experience.

OBJECTIVE: The study objective was to evaluate the midterm outcomes of transventricular mitral valve repair and its association with the initial anatomy of the mitral valve. METHODS: This nonrandomized observational study included 88 patients (mean age, 60 years; 69% were men) who underwent transventricular mitral valve repair for severe degenerative mitral regurgitation between 2011 and 2017. Mitral valve function was assessed by echocardiography at 1 and 6 months and annually after the procedure. According to the location of mitral valve pathology, all patients were stratified into 4 anatomic types (A, B, C, and D). Results were assessed using Kaplan-Meier method, mixed-effects continuation ratio model, and multivariable Cox regression. RESULTS: Median follow-up of 42 months (interquartile range, 27-55) was complete for 83 patients (94.3%). There were 3 late deaths: 2 cardiac and 1 noncardiac. Recurrent mitral regurgitation greater than 2+ was observed in 29 patients (33%), and 18 patients (20.5%) underwent repeat surgery. Device success was 82% in type A at 6 months and thereafter; 87%, 85%, and 75% at 6, 12, and 36 months in type B, respectively; and 53% at 1 month and 20% at 24 months in type C. Probability of postoperative mitral regurgitation progression was higher in patients with greater preoperative left ventricular end-diastolic diameter, type B pathology, and type C pathology (P < .05). Risk factors of mitral regurgitation recurrence included increased left ventricle size (hazard ratio, 1.11; 95% confidence interval, 1.04-1.20; P = .001) and type C pathology (hazard ratio, 5.99; 95% confidence interval, 1.87-19.21; P = .003). CONCLUSIONS: Initial acceptable mitral regurgitation reduction after transventricular mitral valve repair of isolated P2 prolapse was possible but found durable in only 82% at 3 years. Higher risk of mitral regurgitation recurrence occurred with complex degenerative pathology.

Reoperative, transapical off-pump neochordae implantation for recurrent degenerative mitral regurgitation resulting from a newly ruptured native chord.

Transapical mitral valve repair with NeoChord implantation is effective and safe to replace ruptured chordae due to degenerative disease. Redo transapical neochordae implantation has never been reported in the literature. We present a case report of a 53-year-old man who underwent a reoperative neochord implantation for recurrent severe mitral regurgitation, resulting from degenerative disease progression with a new native chordal rupture. We report the midterm durability of reoperative Neochord repair.

Comparison of early postoperative results between conventional and transapical mitral valve repair.

INTRODUCTION: Conventional mitral valve repair (CMVR) is well-established, safe and effective treatment for degenerative mitral regurgitation (MR). Transapical off-pump implantation of artificial chordae (TA) has been introduced into practice and gained interest among surgeons. However, there are no publications comparing the results between TA and CMVR. AIM: To compare early postoperative outcomes of CMVR with TA in patients with degenerative MR. MATERIAL AND METHODS: This was a retrospective cohort study. A total of 169 patients who underwent mitral valve repair between 2011 and 2018 were included in this analysis. Patients were divided into two groups: the TA group, n = 78 and CMVR group, n = 91. The groups were compared for early postoperative outcomes. RESULTS: Patients in the TA group were younger, 54.2 ±11.1 vs. 59.5 ±12.8 years (p = 0.005). Patients in the CMVR group had more complicated postoperative course with higher incidence of blood transfusion (42.9% vs. 7.8%, p = 0.001), atrial fibrillation (25.3% vs. 11.7%, p = 0.031), renal insufficiency (15.4% vs. 2.6%, p = 0.007) and stroke (2.1% vs. 0%). In the early postoperative period, one patient died in the TA group, and there were no deaths in the CMVR group (p = 0.277). Residual moderate to severe mitral regurgitation was present in nine (11.5%) TA patients, while none of the patients in the CMVR group had moderate or a higher degree of residual regurgitation (p = 0.001). CONCLUSIONS: Off-pump transapical MV repair is a feasible and safe procedure with low postoperative morbidity rates. Higher rates of mitral regurgitation reoccurrence would require a careful and thorough selection of the patients suitable for the TA approach.

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

OBJECTIVES: 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. METHODS: 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). RESULTS: 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). CONCLUSIONS: 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.

Anesthetic Management and Procedural Outcomes of Patients Undergoing Off-Pump Transapical Implantation of Artificial Chordae to Correct Mitral Regurgitation: Case Series of 76 Patients.

BACKGROUND: Transapical implantation of artificial chordae using the NeoChord system (NeoChord Inc, Minneapolis, MN) is an emerging beating-heart technique for correction of mitral regurgitation (MR) through a minimally invasive left minithoracotomy. The purpose of the study was to describe the anesthetic management and procedural success of patients undergoing this procedure. METHODS: All patients (n = 76) who underwent mitral valve repair with the NeoChord system in our institution from December 2011 to December 2016 were included in this observational prospective study. Balanced anesthesia with a combination of fentanyl, propofol, and sevoflurane was used in all patients. Each patient's core temperature was maintained at >36°C whenever possible. Two- and 3-dimensional transesophageal echocardiography was used in all patients to navigate the device to the posterior mitral valve leaflet (68 of 76 patients), anterior mitral valve leaflet (3 of 76 patients), or both leaflets (5 of 76 patients). After effective leaflet capture, the artificial chordae were deployed. Position and function of the artificial chordae were assessed by evaluating the degree of MR when the neochordae were tensed. After surgery, all patients were transferred to the intensive care unit. RESULTS: The mean age of the patients was 60 ± 13 years (range, 33-87 years), and the male/female ratio was 52/24. Most patients had severe MR (grade 4+ in 25 [33%] patients, grade 3+ in 51 [67%] patients). The average preoperative EuroSCORE II was 1.23% ± 1.16% (range, 0.46%-4.23%). The median duration of the procedure was 120 minutes (interquartile range [IQR] 115-145 minutes). After the procedure, 42 (56%) patients had trivial MR, 27 (36%) had grade 1+ MR, 4 (5%) had grade 2+ MR, and 2 (3%) had >2+ MR. One patient underwent conversion to conventional mitral valve repair due to perforation of the posterior mitral valve leaflet. The whole procedure was well tolerated by the patients, with hemodynamics remaining stable in the majority of the cases. Only 20 (26%) patients needed low-dose inotropic support perioperatively. All patients had an uneventful postoperative course. The median time to extubation was 4 hours (IQR, 2.6-6), and the length of intensive care unit stay was 22 hours (IQR, 21-24). Five (6.6%) patients required allogeneic blood products. CONCLUSIONS: Anesthesia for transapical NeoChord implantation can be safely performed under beating-heart conditions, with low perioperative morbidity and rare blood transfusions. Transesophageal echocardiography is crucial for the guidance, safety, and effectiveness of the procedure.

The dynamic cardiac biosimulator: A method for training physicians in beating-heart mitral valve repair procedures.

OBJECTIVE: Previously, cardiac surgeons and cardiologists learned to operate new clinical devices for the first time in the operating room or catheterization laboratory. We describe a biosimulator that recapitulates normal heart valve physiology with associated real-time hemodynamic performance. METHODS: To highlight the advantages of this simulation platform, transventricular extruded polytetrafluoroethylene artificial chordae were attached to repair flail or prolapsing mitral valve leaflets. Guidance for key repair steps was by 2-dimensional/3-dimensional echocardiography and simultaneous intracardiac videoscopy. RESULTS: Multiple surgeons have assessed the use of this biosimulator during artificial chordae implantations. This simulation platform recapitulates normal and pathologic mitral valve function with associated hemodynamic changes. Clinical situations were replicated in the simulator and echocardiography was used for navigation, followed by videoscopic confirmation. CONCLUSIONS: This beating heart biosimulator reproduces prolapsing mitral leaflet pathology. It may be the ideal platform for surgeon and cardiologist training on many transcatheter and beating heart procedures.

Hybrid approach for transcatheter paravalvular leak closure of mitral prosthesis in high-risk patients through transapical access.

OBJECTIVES: To report "hybrid" procedure feasibility and the clinical success of transcatheter paravalvular leak closure through apical access. METHODS: Seven patients (73.6±6.1 years; 4 men) with severe mitral prosthesis paravalvular leak were selected. All patients were at high risk for open surgery because of severe comorbidities and heart failure (New York Heart Association class III-IV). RESULTS: The defect size was 25±7.8 mm in the long axis and 9.3±2 mm in the short axis. Two defects were detected in 2 patients. The transapical procedure was performed in a "hybrid" surgery room using minithoracotomy and general anesthesia. Three-dimensional transesophageal echocardiography and fluoroscopy were used for imaging. A total of 19 Amplatzer Vascular Plug III devices (St Jude Medical) were implanted in 7 patients, 2.7/patient and 1 to 3/fistula. The procedure time was 150.7±66.8 minutes. In 6 of 7 patients (85.7%), the paravalvular leak was successfully closed, resulting in no or mild residual regurgitation. One patient had moderate regurgitation despite deployment of 3 Amplatzer Vascular Plug III devices. Two patients required blood transfusion related to procedural blood loss. The patients were discharged at 15.3±6.5 days and followed up at 215.7±138.6 days. All but 1 patient reported symptomatic improvement by ≥1 New York Heart Association class at follow-up. One patient died 216 days postoperatively. CONCLUSIONS: A "hybrid approach" for transcatheter paravalvular leak closure of mitral prosthesis from the apical route is effective in reducing the regurgitation grade and improving functional capacity in high-risk patients. Complete closure of the defect was maintained at follow-up in most patients.