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Echocardiographic Predictors of Clinical Outcomes after Transapical Off-Pump Mitral Valve Repair With Neochord Implantation

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Echocardiographic Predictors of Clinical Outcomes after Transapical Off-Pump Mitral Valve Repair With Neochord Implantation

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


The use of the transapical off-pump mitral valve repair with neochord implantation (TOP-MINI) is safe and effective. The impact of the absence of a concomitant annuloplasty on postoperative residual mitral regurgitation (MR) is unknown.

This study aimed to assess the echocardiographic results of the TOP-MINI procedure in degenerative MR due to posterior leaflet disease.


We analyzed a single center registry of patients treated with the TOP-MINI: patients underwent pre-operative and postoperative 3D transesophageal echocardiography.

In addition to standard echocardiographic measurements we evaluated:

v septolateral (SL) and intercommisural (IC) dimensions
v anterior (ALH) and posterior leaflet-height (PLH)
v coaptation depth (CD) and coaptation length (CL)
v flail gap (FG) and flail width (FW).

The ratio SL/ALH+PLH was considered as an index of anular-to-leaflet mismatch. The impact of all clinical and echocardiographic variables on the residual MR was evaluated.


A total of 31 patients were treated; median age was 73 years (range 31-90 years) and median Euroscore-I 6% (range 0.9-38.9%).

Twenty-eight patients (93.5%) presented a posterior leaflet disease.

Three neochordae were implanted in 8 patients (28.6%), 4 in 14 (50.0%), 5 in 5 (17.9%), 6 in 1 (3.5%). Acute procedural success was achieved in all patients.

MR at 30-days was absent in 14 patients (50.0%), grade 1+/4 in 9 patients (32.2%), grade 2+/4 in 3 patients (10.7%). Two patients (7.1%) presented a recurrence of MR >2+ after 30 days due to chordal rupture and underwent successful reintervention with conventional surgery.


v Pulmonary hypertension, age, coaptation length and SL/ALH+PLH (error rate of 20.96%) related significantly on prediction of residual MR.
v A cut-off of 5 mm of coaptation length showed significant relationship with recurrence of regurgitation (p=0.029). (Figure 1)
v A range of 0.5-0.7 of SL/ALH+PLH showed only a tendency to be significant (p=0.22). (Figure 2)


Clinical and echocardiographic variables associated with recurrence of MR were identified. In particular SL/ALH+PLH ratio could be useful to select patients for TOP-MINI procedure.

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