Minimally Invasive Off-Pump Mitral Valve Repair with the NeoChord DS1000 System

This video presents minimally invasive, off-pump mitral valve repair with the NeoChord DS1000 system. This is an innovative device that implants multiple sets of Gortex PTFE neochords onto the prolapsing segment of the posterior mitral valve leaflet. This hybrid operation was performed under TEE guidance and beating heart conditions.

The patient in this video is a seventy-five-year-old man who previously had minimally invasive mitral valve repair with a 36 mm annuloplasty ring and four Gortex neochords. On follow-up echocardiograms, he had recurrent severe mitral regurgitation due to prolapsing of P2 and P1 segments.

The operation was performed in a hybrid operating room, which allowed for projection of echocardiogram images made easily visible to the entire surgical team. The patient was placed under general anesthesia and positioned supine. A 3 to 4 cm incision was made at the fifth intercostal space in the anterior axillary line after identifying the location of left ventricular apex via transthoracic ultrasound. Soft tissues and ribs were retracted. A transesophageal echocardiogram (TEE) was used to appropriately guide left ventricle (LV) apical access. Prolene pledgetted sutures were placed around the apical access site for future snaring.

Meanwhile, the NeoChord DS1000 device was prepared with loaded Gortex sutures. The NeoChord DS system was then inserted through the LV apex and positioned across the mitral valve and into the left atrium, which was confirmed on echo. The prolapsing or flail posterior leaflet segment was grasped. This was evident on 2D and 3D echo images. The position of the grasper was confirmed using fiber optic feedback contained within the NeoChord system. The sensors demonstrated adequate tissue in the grasper when four lights illuminated white. When the device was deployed, the needle passed through the leaflet. The ends of the inserted neochord were retracted out through the LV apex with the device. These ends were then pulled taught and a loop formed on the free margin of the leaflet where the needle was inserted. 

Subsequent chordal insertions were performed as required to alleviate residual mitral regurgitation. Chordal tightening was performed under full loading conditions of the beating heart and with real time echo guidance. The chordal tightening resulted in the retraction of the posterior leaflet towards the apex, moving the point of coaptation posteriorly. The chords were then fixated on the epicardial surface of the apex with one large single felt pledget and tied. A postoperative TEE showed trivial residual mitral regurgitation.

Following removal of soft tissue retraction, one chest tube was inserted into the pericardial space and the thoracotomy was subsequently closed in the standard fashion.
 

References

1. Hassanabad AF, Kent WDT, Adams C. Review of transapical off-pump mitral valve intervention with NeoChord implantation. Curr Opin Cardiol (2021) 36:130-140. doi:10.1097/HCO.0000000000000825

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