Direct Beating Heart NeoChord Mitral Valve Re-Repair

Procedure
A small left anterolateral thoracotomy was performed through the fifth intercostal space to access the left ventricular apex with a 5 cm skin incision. Pericardiotomy and exposure of the left ventricle was followed by the application of two purse-string 2-0 prolene sutures with large Teflon pledgets around the site of the access on the posterolateral LV wall. The exact entry site between the origin of the papillary muscles was confirmed by TEE imaging using a digital punch.

The NeoChord DS1000 system cartridge assembly is prepared by folding the end of a 120 cm 4/O ePTFE suture that is passed through the cartridge groove, and at the tip the two halves of the sutures are separated and the loop drawn over the head of the clamp. The cartridge assembly is slid into the handle and advanced until two audible snaps are heard, and then the needle is loaded into the cartridge.

A Seldinger technique with progressive dilators was used to access the LV through the pre-chosen site. The NeoChord device was directed towards the mitral valve plane using 2D-TEE guidance (X-plane with ME LAX and MC views). It must be pointed out that the NeoChord device must always be kept the native chordae-free zone of the LV below the level of the papillary muscle tips. The device tip is advanced and after the MV annular plane was crossed, the TEE imaging mode was switched from 2D to 3D imaging using the surgical view of the mitral valve. This way, the device tip was detected on the target mitral leaflet segment. The jaws of the NeoChord device were opened and the leaflet edge was gently grasped by withdrawing the device slowly away from the left atrium. Confirmation of correct leaflet capture was obtained when all four light indicators on the fiber optic display monitor turned from red to white, after the closure of the jaws of the device on the leaflet tissue. Once the leaflet capture was confirmed, the needle was gently pushed forward and through the target-leaflet and then retracted with a smooth continuous motion in order to pull out the loop of the suture through the proximal tip of the handle of the instrument, and the NeoChord device was retracted from the ventricle with its jaws open. Then, the two ends of the suture were detected and placed through the suture loop to form a girth hitch knot that was advanced to the free edge of the captured leaflet. In the authors’ case, three neochordae were necessary for the achievement of a satisfactory result.

Once all the neochordae were placed, the apical purse-strings were secured and tied, and the sutures were passed through a small, 2 cm x 2 cm triple layer “button” that was then created using knitted polyester fabric (Bard® Sauvage®) around a piece of Teflon pledget. The final adjustment of the length of the NeoChord was performed with the assistance of tourniquets, and when this has been achieved, each new cord is securely tied on the epicardial patch. The final result was evaluated using 2D and 3D transesophageal echocardiographic imaging which showed complete correction of the flail P2 segment and no evidence of residual regurgitation.

References

1. Fiocco A, Nadali M, Speziali G, Colli A. Transcatheter mitral valve chordal repair: current indications and future perspectives. Front Cardiovasc Med. 2019 Sep 4;6:128.
2. Caballero A, Mao W, McKay R, Sun W. Transapical mitral valve repair with neochordae implantation: FSI analysis of neochordae number and complexity of leaflet prolapse. Int J Numer Method Biomed Eng. 2020 Mar;36(3):e3297.
3. Colli A, Manzan E, Aidietis A, Rucinskas K, Bizzotto E, Besola L, et al. Corrigendum to: 'An early European experience with transapical off-pump mitral valve repair with NeoChord implantation [Eur J Cardiothorac Surg 2018;54:460-6]. Eur J Cardiothorac Surg. 2019 Jun 1;55(6):1240.
4. Colli A, Besola L, Bizzotto E, Fiocco A, Denas G, Bellu R, et al. Mechanisms of recurrent regurgitation after transapical off-pump mitral valve repair with neochord implantation. Eur J Cardiothorac Surg. 2019 Sep 1;56(3):479-487.

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