Mitral Valve Repair with Trans-Apical off-Pump Neochord Technique:
Hemodynamic Effects, Morbidity and Mortality

Background:

Mitral regurgitation (MR) is the most common valvular heart disease and an important cause of heart failure. The majority of patients with severe symptomatic degenerative MR are at high risk for surgical intervention because of multiple co-morbidities, advanced age and increased cardiovascular morbidity and mortality. Trans-apical off-pump Neochord implantation may be a better therapeutic option for these high-risk patients.

Objectives:

The aim of this study was to evaluate the clinical outcomes and hemodynamic changes in very high-risk patients who, due to severe degenerative MR with prolapse or flail leaflet, underwent trans-apical off-pump mitral valve repair (MVr) with Neochord implantation.

Methods:

Between March 2016 and October2017, 127 patients underwent MVr. Of them, 10(aged 82 ±6 years; 70% males) were at high-risk for conventional surgery, and were treated by using a trans-apical off-pump with a Neochord DS1000 system implantation. The surgical technique involved off-pump implantation of artificial chordae. The device was inserted into the left ventricle (LV) and directed to the diseased portion of the leaflet, which was perforated by a needle that released a chord that was fixed onto the atrial surface. The chord was then tensioned on the epicardial surface of the LV under guided 3D echocardiography.

Results:

Patients were followed for an average of 4±3 months. Very high-risk patients had reduced mobilization, a logistic Euroscore of 21±10, reoperations (40%), SPAP>60mmHg (40%), EF% 58±9, and NYHA III-IV (70%). Posterior MV flail was seen in 60%, anterior flail in 10%, and combined disease in 30% of patients. There was no in-hospital mortality. Postoperative major complications included acute kidney injury in only one patient, which was resolved during hospitalization. There was no peri-operative myocardial infarction, no permanent pacemaker implantation, and no stroke or bleeding events. After 7 days, one patient developed severe MR due to leaflet tear-associated fibroblastic deficiency, and successfully underwent MV replacement. Postoperative echocardiography was performed on all patients at 3±4months of follow-up (duration 1-11m): MR was trivial-mild in 80%, moderate in 10% and severe in one patient, who underwent MV replacement. None of the patients had SPAP>60mmHg. Mean EF% was 55±9, and postoperative NYHA had decreased to I-II in all patients.

Conclusion:

Trans-apical off-pump MVr with Neochord implantation can be performed with very good clinical and hemodynamic outcomes in a high-risk population with severe MR due to leaflet prolapse or flail. Further comparative investigation with a standard MVr approach is recommended.