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Transapical Off-pump Neochord Implantation For Posterior Mitral Leaflet Disease: Clinical And Echocardiographic Results

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Transapical Off-Pump Neochord Implantation of Posterior Mitral Leaflet Disease: Clinical and echocardiographic Results.

Andrea Colli, Erica Manzan, Fabio Zucchetta, Laura Besola, Eleonora Bizzotto, Demetrio Pittarello, Gino Gerosa.

Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy

Objectives

Transapical off-pump Neochord procedure for mitral valve repair (MVR) has been recently proposed as a new therapeutic option to treat patients with degenerative severe  mitral regurgitation (MR). This prospective study aimed to evaluate clinical and echocardiographic results of Neochord procedure. 

Methods

Thirty-six consecutive patients with severe symptomatic degenerative mitral regurgitation (MR > 3+/4; NYHA > III) due to posterior mitral leaflet prolapse or flail underwent Neochord procedure.

Mitral valve (MV) anatomy was assessed preoperatively with 3D transesophageal echocardiography.

According to MV morphology patients were divided in 2 groups: group A (isolated P2 prolapse/flail) and group B (multiple prolapsing segments, P1-P2 , P2-P3). Ten patients (27,8%) were included in group A and 26  patients  (72,2%) in group B.

Procedural success was defined as residual MR < 2+ after surgery.

Three months clinical and echocardiographic follow up was completed in 25 patients (69,4%).

Results

Twenty-three patients (63,9%) were in NYHA class III or IV. Median age was 67 years (IQR 54-76). Median Euroscore-I was 3% (IQR 0,9-7,4).

The procedure was successfully completed in all patients (100%). Three neochords were implanted in 12 patients (33,3%), 4 in 18 (50%), 5 in 6 (16,7%). Three month survival was 98%, one patient (2%) died after sudden cardiac arrest for right ventricular dysfunction with competent MV.

At 3 months echocardiographic follow up:

ØMV antero-posterior annular dimension reduced from 35,7 ± 6 mm to 32,1 ± 4,5 mm (p value 0,075), latero-lateral annulus dimension slightly reduced from 35,2 ± 5,4 mm to 33,8 ± 5,1 mm (p value 0,5).
ØLeft ventricle (LV) end-systolic volumes changed from 30,9 ± 14,2 ml/m2 to 30 ± 8,5 ml/m2 (p value 0,85). LV end-diastolic volumes reduced from 76 ± 22 ml/ m2  to 72 ± 15 ml/ m2  (p value 0,58). Left atrial volumes decreased from 49 ± 12 ml/m2 to 36 ± 15 ml/ m2 (p value 0,027).

 

At 3 months clinical and echocardiographic success was 100% (8/8) in group A and 88% (15/17) in group B. In group A, MR was absent in 6 patients (75%), mild in 1 (12,5%), moderate in 1 (12,5%). In group B, MR was absent in 6 patients (40%), mild in 6 (40%), moderate in 3 (20%). Clinical improvement (NYHA class I) was achieved in all treated patients, even when moderate residual MR was present.

Conclusions

Neochord procedure is a viable alternative to surgery for patients with a posterior leaflet disease. Clinical and echocardiographic benefits were observed in all patients. Preoperative MV anatomy is closely related to early Neochord procedural success.

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