Microinvasive mitral valve repair with transapical mitral neochordae implantation

Microinvasive cardiac surgery includes procedures performed off-pump, on the beating heart, with limited or absent skin incision, and those that rely on live imaging techniques. Transapical off-pump beating heart neochordae implantation allows the repair of severe mitral valve regurgitation due to leaflet prolapse or flail with live three-dimensional echo guidance. This procedure has shown good results for up to 5 years and can be considered as a valid alternative to conventional surgery in selected patients with high prediction of success based on clinical and anatomical considerations. The aim of this review is to describe the devices, indications, patient screening process, clinical and echocardiographic results, and future perspectives of this procedure.

Outcomes of transapical mitral valve repair with neochordae implantation

OBJECTIVE

Transapical off-pump beating-heart neochord implantation (NC) has shown encouraging early results in patients with degenerative mitral regurgitation. The aim of this study was to evaluate clinical and echocardiographic 5-year outcomes of patients who underwent NC.

METHODS

All patients who underwent NC at our institution from November 2013 to March 2016 were included. Indications were severe symptomatic degenerative mitral regurgitation due to leaflet prolapse/flail. Patients were classified as having favorable anatomy (FA) and unfavorable anatomy (UA) on the basis of the extent and severity of mitral valve disease. All patients underwent clinical and echocardiographic follow-up at 1, 3, 6, and 12 months, and annually thereafter. Data were prospectively collected and retrospectively analyzed. Outcomes were on the basis of the Mitral Valve Academic Research Consortium guidelines.

RESULTS

One hundred consecutive patients were included in the analysis (FA: 81%; UA: 19%). Median age was 66 years (interquartile range, 58-76) and median European System for Cardiac Operative Risk Evaluation (EuroSCORE) II was 1.4% (interquartile range, 0.7-2.3). Technical and procedural success were 98% and 94%, respectively. Thirty-day mortality was 2%. Device success was 94%, 92%, and 78%, at 30 days, 1-year, and 5 years, respectively. Patient success at 1 year was 92%. Median follow-up was 5.1 years. At 5 years, overall survival was 83% with no difference between FA and UA patients. Cumulative incidence of severe mitral regurgitation recurrence at 5 years was 14% (95% CI, 6.5%-22.8%) in FA patients and 63% (95% CI, 39.7%-86.2%) in UA patients, respectively (P < .001). Patients with FA compared with UA had a lower incidence of reintervention (14.7% vs 43.4%; P < .001).

CONCLUSIONS

Transapical off-pump beating heart NC might represent an acceptable option in patients with degenerative mitral valve disease and FA.