Trans-apical Off-pump Mitral Valve Repair with the Neochord Ds 1000 Device in Patients Refused for Conventional Cardiac Surgery
Reinhard Moidl, Marieluise Harrer, Stephanie Wallner, Andreas Strouhal, Georg Delle Karth, Martin Grabenwoeger.
General Hospital Hietzing, Vienna, Austria.
Introduction: Due to comorbidities and pulmonary hypertension, older patients with severe mitral incompetence (MI) have limited perioperative survival after conventional cardiac surgery. With the new NeoChord device, mitral valve prolapse repair through trans-apical approach, is feasible without the need of cardiopulmonary bypass.
Method: We report our first clinical experience in eight patients refused for conventional mitral valve repair who underwent implantation of expanded neo-chordae (polytetrafluoroethylene ePTFE) with the NeoChord DS 1000 device since 2016 (mean age 86, range 78-93 years). The left ventricular apex is accessed via standard triple purse string ventriculotomy through a left “TAVI” mini-thoracotomy. The device is inserted towards the mitral valve into the left atrium. Intra-cardiac orientation is achieved with both 2D and 3D echocardiographic guidance. With expandable jaws, the prolapse is captured and its effectiveness confirmed by observing the four fiber optic monitor lights changing from red (blood) to white (leaflet). Now the leaflet is penetrated with a needle with subsequent retrieval of the NeoChord ePTFE suture. After implantation of the necessary number of sutures, final assessment of the operative results is achieved using echocardiography. Now the properly tensioned NeoChords are secured to the left ventricular apex with pledgets and knots.
Results: With the use of ePTFE sutures (mean 2.4 per patient), competent valves were achieved in 6 patients with PII-prolapse. One patient with anterior prolapse AII and AIII (st.p CABP, st.p. TAVI) was discharged with MI grade II+ but in significantly better NYHA classification and stable MI at 2 year follow-up. One 87 year old lady with acute chordal rupture was operated in cardiogenic shock and lung edema. PII-prolapse could be corrected but still moderate MI from PIII-prolapse could not be corrected. This patient died on postoperative day 7 from pneumonia and lung edema (perioperative mortality=12.5%).
Conclusions: NeoChord implantation without cardiopulmonary bypass via trans-apical approach is feasible even in patients refused for conventional cardiac surgery with acceptable perioperative results. It leads to significant reduction of MI in patients with mitral valve prolapse. All patients have stable MI at follow-up (mean 17, range 5-34 month) and significant improvement in NYHA classification and life quality.
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