Mitral valve repair using adjustable posterior leaflet neochords

Central MessageWe report on a novel technique for implantation of neochordae to the posterior leaflet and demonstrate excellent safety and efficacy in a series of 22 patients.See Commentaries on pages 55, 56, and 58. We report on a novel technique for implantation of neochordae to the posterior leaflet and demonstrate excellent safety and efficacy in a series of 22 patients. See Commentaries on pages 55, 56, and 58. Mitral valve regurgitation (MR) is a common disorder1Freed L.A. Levy D. Levine R.A. Larson M.G. Evans J.C. Fuller D.L. et al.Prevalence and clinical outcome of mitral-valve prolapse.N Engl J Med. 1999; 341: 1-7Crossref PubMed Scopus (698) Google Scholar that has been found to be a powerful predictor of serious morbidity and mortality.2Enriquez-Sarano M. Avierinos J.-F. Messika-Zeitoun D. Detaint D. Capps M. Nkomo V. et al.Quantitative determinants of the outcome of asymptomatic mitral regurgitation.N Engl J Med. 2005; 352: 875-883Crossref PubMed Scopus (577) Google Scholar As such, the management of MR has evolved over time and has trended toward a more aggressive surgical approach to mitral valve pathology.3Suri R.M. Schaff H.V. Enriquez-Sarano M. Mitral valve repair in asymptomatic patients with severe mitral regurgitation: pushing past the tipping point.Semin Thorac Cardiovasc Surg. 2014; 26: 95-101Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar,4Goldstone A.B. Patrick W.L. Cohen J.E. Aribeana C.N. Popat R. Woo Y.J. Early surgical intervention or watchful waiting for the management of asymptomatic mitral regurgitation: a systematic review and meta-analysis.Ann Cardiothorac Surg. 2015; 4: 220-229PubMed Google Scholar This trend is likely a product of the appreciation of the risks associated with untreated MR but also partly attributable to the tremendous progress that has been made with operative mitral valve repair.5Castillo J.G. Anyanwu A.C. Fuster V. Adams D.H. A near 100% repair rate for mitral valve prolapse is achievable in a reference center: implications for future guidelines.J Thorac Cardiovasc Surg. 2012; 144: 308-312Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar,6Goldstone A.B. Cohen J.E. Howard J.L. Edwards B.B. Acker A.L. Hiesinger W. et al.A “repair-all” strategy for degenerative mitral valve disease safely minimizes unnecessary replacement.Ann Thorac Surg. 2015; 99: 1983-1991Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar Minimally invasive approaches7Cao C. Gupta S. Chandrakumar D. Nienaber T.A. Indraratna P. Ang S.C. et al.A meta-analysis of minimally invasive versus conventional mitral valve repair for patients with degenerative mitral disease.Ann Cardiothorac Surg. 2013; 2: 693-703PubMed Google Scholar and robotic mitral surgery8Gillinov A.M. Mihaljevic T. Javadikasgari H. Suri R.M. Mick S.L. Navia J.L. et al.Early results of robotically assisted mitral valve surgery: analysis of the first 1000 cases.J Thorac Cardiovasc Surg. 2018; 155: 82-91.e2Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar have entered the mainstream and continue to grow in popularity.9Gammie J.S. Zhao Y. Peterson E.D. O'Brien S.M. Rankin J.S. Griffith B.P. Less-invasive mitral valve operations: trends and outcomes from the society of thoracic surgeons adult cardiac surgery database.Ann Thorac Surg. 2010; 90: 1401-1408Abstract Full Text Full Text PDF PubMed Scopus (245) Google Scholar Concurrently, leaflet remodeling techniques continue to evolve and nonresectional approaches10Woo Y.J. MacArthur J.W. Simplified nonresectional leaflet remodeling mitral valve repair for degenerative mitral regurgitation.J Thorac Cardiovasc Surg. 2012; 143: 749-752Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar,11Cevasco M. Myers P.O. Elbardissi A.W. Cohn L.H. Foldoplasty: a new and simplified technique for mitral valve repair that produces excellent medium-term outcomes.Ann Thorac Surg. 2011; 92: 1634-1638Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar have gained favor as a means to reduce posterior leaflet height without compromising posterior leaflet mobility while maximizing a smooth coaptation zone between the mitral leaflets. Although it is evident that a physiologic approach to mitral valve repair yields superior long-term results, it is less clear how to safely and reliably apply these techniques in a minimally invasive platform. As such, we sought to develop a method for posterior mitral valve leaflet remodeling that has been optimized for thoracoscopic surgery and report our experience on 22 patients treated with a novel adjustable neochord method. From December 2016 through August 2018, 22 patients underwent mitral valve repair utilizing the adjustable posterior neochord technique at Yale New Haven Hospital. During the same time period, a total of 106 mitral valve surgeries were performed by the senior author. The decision to place adjustable posterior neochords was at the discretion of the operative surgeon at the time of surgery on the basis of anatomic suitability. All patients included in the study had preoperative, intraoperative, and postoperative echocardiographic assessment of the mitral valve. Demographic and other patient-related data were obtained from the Yale New Haven Hospital medical records. Follow-up information was obtained from data collected at postoperative clinic visits and via written correspondence from local physicians. The study was approved by the Yale Institutional Review Board and individual consent was waived for aggregate data. A minimally invasive approach was used in the majority of patients included in the study. Cardiopulmonary bypass was initiated through access to the femoral artery and vein. The chest was accessed through a thoracotomy incision in the right fourth intercostal space. Myocardial arrest was achieved through combination of antegrade and retrograde cardioplegia. The left atrium was then entered through the interatrial groove and exposure of the valvular apparatus was obtained using the Estech Atrial Lift System (Atricure, Mason Ohio) and the Collar papillary muscle exposure device (Miami Instruments, Miami, Fla). After identification of the prolapsing segment(s) each arm of a CV-5 Gore-Tex (W. L. Gore and Associates, Flagstaff, Ariz) suture was inserted into the leaflet edge and brought down to the corresponding papillary muscle belly in a single pass and then brought behind the posterior leaflet through the base of the annulus and temporarily secured on the atrial side of the annulus. A single suture was thereby looped from leaflet edge, to papillary muscle twice, and then through the annulus twice. Depending on the level or width of prolapsed segment additional neochords were placed in similar fashion. After placement of the neochords, annuloplasty sutures were placed and the annuloplasty secured using a Core-knot device (LSI Solutions, Victor, NY). With the annuloplasty ring in place, the valve is tested for competency by pressurizing the left ventricle with saline with the mitral annulus engaged. A suture placed through the annuloplasty ring and gentle traction is applied to restore ventricular geometry with the ventricle pressurized. The valve is visually inspected for regurgitation and the neochordae are dynamically adjusted to address residual prolapse or to correct restriction. The neochords are then secured using the TIE Intracorporeal Knot Placement Assist Device (Miami Instruments, Miami, Fla). The atrium is closed in a standard fashion and the patient weaned from bypass (Video 1). The patients' preoperative and echocardiographic characteristics are shown in Table 1. Seventy-seven percent of procedures were performed through a minimally invasive approach where full sternotomy was reserved for patients with a contraindication to peripheral cardiopulmonary bypass or in those who required concomitant procedures. A total of 36 procedures were performed on 22 patients included in the cohort (listed in Table 1). Average cardiopulmonary bypass time for the cohort was 119 minutes with an average crossclamp time of 103 minutes.Table 1Demographic, preoperative, and operative characteristics for patients included in the cohortCharacteristicDemographic No. of patients22226 Male gender15 (72) Age62 ± 12 (29-80) Coronary artery disease5 (24) Atrial fibrillation9 (29) Chronic renal insufficiency2 (9) Diabetes2 (9) CVA1 (4.5) Prior cardiothoracic surgery2 (9) Bileaflet prolapse/Barlow2 (9) Posterior leaflet prolapse/flail20 (91)EchocardiogramPrePost6 mo EF58.2 ± 8.953.8 ± 11.560.6 ± 3.04 MR6.9 ± 0.30.35 ± 1.350.33 ± 0.51None to trace16 (72)6 (100)Mild6 (27)ModerateSevere22 (100) MV gradient4.1 ± 1.542.7 ± 0.67Operative Minimally invasive approach17 (77.2) CBP (min)119 ± 33 Crossclamp (min)103 ± 31 Ring size31.55 mm (28-34) Mode 30 No. of posterior neochords2.29 ± 1, 2 (1-6) No. of anterior neochords0.48 ± 1 Quadrangular resection (n)1 Folding plasty (n)1 Annular advancement (n)4 Cleft closure (n)10 Ring typeCarpentier-Edwards Physio III∗Edwards Lifesciences LLC, Irvine, Calif.11 (50)Simulus Semi-Rigid Ring†Medtronic, Inc, Minneapolis, Minn.9 (41)Medtronic Profile 3D†Medtronic, Inc, Minneapolis, Minn.1 (4.5)Cosgrove-Edwards Band∗Edwards Lifesciences LLC, Irvine, Calif.1 (4.5) Concurrent procedures‡Thirty-six total procedures in 22 patients.CABG2 (9)TVR3 (14)Left atrial appendage ligation4 (18)Maze5 (22)Perioperative ICU length of stay (d)2.54 ± 1.47 (1-7) Hospital length of stay (d)6.63 ± 4.9 (3-26) 30-d readmission3 (14) Death0 Stroke0 MI0 Re-exploration0 Access site complication1 (4.5) Atrial fibrillation7 (31) Pleural effusion2 (9) PPM placement1 (4.5)Values are presented as mean ± standard error of the mean (interquartile range), n (%), or median (range). CVA, Cerebrovascular accident; EF, ejection fraction; MR, mitral regurgitation; CBP, cardiopulmonary bypass; CABG, coronary artery bypass grafting; TVR, tricuspid valve repair; ICU, intensive care unit; MI, myocardial infarction; PPM, permanent pacemaker.∗ Edwards Lifesciences LLC, Irvine, Calif.† Medtronic, Inc, Minneapolis, Minn.‡ Thirty-six total procedures in 22 patients. Open table in a new tab Values are presented as mean ± standard error of the mean (interquartile range), n (%), or median (range). CVA, Cerebrovascular accident; EF, ejection fraction; MR, mitral regurgitation; CBP, cardiopulmonary bypass; CABG, coronary artery bypass grafting; TVR, tricuspid valve repair; ICU, intensive care unit; MI, myocardial infarction; PPM, permanent pacemaker. All attempts at mitral valve repair were successful and several adjunctive techniques used in addition to the placement of neochords to the posterior leaflet. A median of 2 posterior adjustable neochords were placed in each patient with a range of 1 to 6 and were most commonly placed to P2. Our strategy for valve repair utilizes a variety of adjunctive techniques that are selectively employed to accommodate patient specific variations in the mitral pathology. Several techniques were performed in addition to neochordae to the posterior leaflet with the most common being suture closure of a residual cleft between the posterior leaflet segments. Four patients required an annular advancement, or a mattress suture placed between the posterior annulus and the body of the posterior leaflet to decrease the height of the posterior leaflet. One patient required partial resection of P2 due to persistent prolapse that was not amenable to neochord implantation. Prolapse of the anterior leaflet was typically managed with placement of simple neochordae to the prolapsing segment and was performed in a total of 5 patients. Postprocedurally, 72% of patients had no detectable MR on echocardiography and the remaining 27% of patients had a grade of trace or mild. Six-month echocardiographic follow-up data were available in 6 patients and at this time point 100% of patients had undetectable or trace MR. No patients required reintervention on the mitral valve during the study period and there were no cases of systolic anterior motion noted postoperatively. Patients were routinely extubated within 4 hours of admission to the intensive care unit and the average length of stay in the intensive care unit was 2 days with a range of 2 to 7 days. The average hospital length of stay was 7 days with a range of 3 to 27 days. The most common complication noted during the immediate perioperative period was new-onset atrial fibrillation observed in 31% of patients followed by development of pleural effusion seen in 9% of patients. There were no deaths during the study period and no major complications were observed, including renal failure, cerebrovascular accident, or myocardial infarction. One patient in the cohort required reoperation for a femoral access site complication. Degenerative MV is a common condition that is estimated to affect as many as 6 million patients in the United States alone.1Freed L.A. Levy D. Levine R.A. Larson M.G. Evans J.C. Fuller D.L. et al.Prevalence and clinical outcome of mitral-valve prolapse.N Engl J Med. 1999; 341: 1-7Crossref PubMed Scopus (698) Google Scholar The long-term risks associated with untreated severe mitral regurgitation have been well documented2Enriquez-Sarano M. Avierinos J.-F. Messika-Zeitoun D. Detaint D. Capps M. Nkomo V. et al.Quantitative determinants of the outcome of asymptomatic mitral regurgitation.N Engl J Med. 2005; 352: 875-883Crossref PubMed Scopus (577) Google Scholar and earlier intervention is being recommended on account of a growing body of literature to suggest improved clinical outcomes with surgical repair before the development of class I triggers.4Goldstone A.B. Patrick W.L. Cohen J.E. Aribeana C.N. Popat R. Woo Y.J. Early surgical intervention or watchful waiting for the management of asymptomatic mitral regurgitation: a systematic review and meta-analysis.Ann Cardiothorac Surg. 2015; 4: 220-229PubMed Google Scholar,12Suri R.M. Vanoverschelde J.L. Grigioni F. Schaff H.V. Tribouilloy C. Avierinos J.F. et al.Association between early surgical intervention vs watchful waiting and outcomes for mitral regurgitation due to flail mitral valve leaflets.JAMA. 2013; 310: 609-616Crossref PubMed Scopus (217) Google Scholar,13Kang D.H. Park S.J. Sun B.J. Cho E.J. Kim D.H. Yun S.C. et al.Early surgery versus conventional treatment for asymptomatic severe mitral regurgitation: a propensity analysis.J Am Coll Cardiol. 2014; 63: 2398-2407Crossref PubMed Scopus (59) Google Scholar At the same time, there is a great deal of evidence demonstrating the safety and long-term durability of modern mitral valve repair14Vassileva C.M. Mishkel G. McNeely C. Boley T. Markwell S. Scaife S. et al.Long-term survival of patients undergoing mitral valve repair and replacement: a longitudinal analysis of medicare fee-for-service beneficiaries.Circulation. 2013; 127: 1870-1876Crossref PubMed Scopus (91) Google Scholar owing to the rapid advances in both technique and technology. A variety of methods for valve repair have been proposed and as of yet there is no definitive evidence to support any single approach over another—although all appear to outperform valve replacement and as such a repair first strategy has been recommended by most professional societies. The well-known quadrangular resection for mitral valve repair was first popularized by Carpentier in the now classic report given at the American Association for Thoracic Surgery meeting in 198315Carpentier A. Cardiac valve surgery—the “French correction”.J Thorac Cardiovasc Surg. 1983; 86: 323-337Abstract Full Text PDF PubMed Google Scholar and consists of a partial or complete resection of P2 with subsequent reconstruction as a means to address P2 prolapse. Excellent long-term results have been described using this technique,16Correia P.M. Coutinho G.F. Branco C. Garcia A. Antunes M.J. Surgical treatment of posterior mitral valve prolapse: towards 100% repair.J Heart Valve Dis. 2015; 24: 752-759PubMed Google Scholar including 98% freedom from reoperation over a 14-year follow-up.17Kasegawa H. Shimokawa T. Horai T. Takeuchi S. Nishimura K. Ozawa N. et al.Long-term echocardiography results of mitral valve repair for mitral valve prolapse.J Heart Valve Dis. 2008; 17: 162-167PubMed Google Scholar Despite excellent efficacy and apparent interoperator reproducibility, several concerns regarding the physiologic and hemodynamic implications of resectional techniques. In experimental models posterior leaflet resection has been shown to decrease posterior leaflet mobility18Padala M. Powell S.N. Croft L.R. Thourani V.H. Yoganathan A.P. Adams D.H. Mitral valve hemodynamics after repair of acute posterior leaflet prolapse: quadrangular resection versus triangular resection versus neochordoplasty.J Thorac Cardiovasc Surg. 2009; 138: 309-315Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar in vivo and to increase posterior leaflet stress19Morgan A.E. Pantoja J.L. Grossi E.A. Ge L. Weinsaft J.W. Ratcliffe M.B. Neochord placement versus triangular resection in mitral valve repair: a finite element model.J Surg Res. 2016; 206: 98-105Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar in silico when compared with neochord placement. A recent meta-analysis20Mazine A. Friedrich J.O. Nedadur R. Verma S. Ouzounian M. Jüni P. et al.Systematic review and meta-analysis of chordal replacement versus leaflet resection for posterior mitral leaflet prolapse.J Thorac Cardiovasc Surg. 2018; 155: 120-128.e10Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar partially corroborates experimental data and suggests a long-term benefit to left ventricular function with neochord implantation, although this finding did not reach statistical significance in the single randomized control study21Falk V. Seeburger J. Czesla M. Borger M.A. Willige J. How does the use of polytetrafluoroethylene neochordae for posterior mitral valve prolapse (loop technique) compare with leaflet resection? A prospective randomized trial Volkmar.J Thorac Cardiovasc Surg. 2008; 135: 344-346Google Scholar comparing both methods of repair. Higher rates of reoperation for systolic anterior motion have also been reported with the resectional repair,22Mihaljevic T. Pattakos G. Gillinov A.M. Bajwa G. Planinc M. Williams S.J. et al.Robotic posterior mitral leaflet repair: neochordal versus resectional techniques.Ann Thorac Surg. 2013; 95: 787-794Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar,23Seeburger J. Falk V. Borger M.A. Passage J. Walther T. Doll N. et al.Chordae replacement versus resection for repair of isolated posterior mitral leaflet prolapse: à ègalité.Ann Thorac Surg. 2009; Full Text Full Text PDF PubMed Scopus Google Scholar although this to be to utilizing a minimally invasive approach and has not been reported where a sternotomy is H. Shimokawa T. Horai T. Takeuchi S. Nishimura K. Ozawa N. et al.Long-term echocardiography results of mitral valve repair for mitral valve prolapse.J Heart Valve Dis. 2008; 17: 162-167PubMed Google A.M. M. A.L. A. S. et and techniques for posterior mitral leaflet prolapse.J Surg. 2011; 26: PubMed Scopus Google Scholar these data suggest that degenerative mitral valve prolapse be using any of several neochordae over leaflet resection in a minimally invasive There are to implantation of neochordae that be when an approach to valve repair. is the for the length of the the length is on the length of the as well as on the leaflet and then it that in an or address this we an method for the implantation of neochords and report excellent safety and efficacy in a series of 22 patients. The novel element of our method is that the looped neochord is secured behind the annulus and on the atrial that several over techniques. The traction on the neochord as it behind the annulus the surgeon to place the the annuloplasty and the valve without to the As such, the neochord be tested at several the surgeon to length to of prolapse and regurgitation as in 1. Mitral valve repair using the technique is a and method that to long-term over techniques. we report on a novel technique for implantation of neochordae to the posterior leaflet and demonstrate excellent echocardiographic and clinical results in a series of 22 patients treated at the