Transapical neochord implantation - Multimedia Manual Cardio ...

doi:10.1510/mmcts.2010.004606
Transapical neochord implantation
Joerg Seeburger*, Michael Winkfein, Michael Hoebartner, Thilo Noack, Philipp Kiefer,
Marcel Vollroth, Sergej Leontjev, Friedrich Wilhelm Mohr
Heart Center, Leipzig University, Struempelstrasse 39, 04289 Leipzig, Germany
The NeoChord procedure has recently been introduced to facilitate chordal replacement for
mitral valve repair using a transapical beating heart off-pump approach. We herein elucidate
on the concept, the technique, the operative approach and the procedure in a ‘how-to-doit’
manner.
Keywords: Beating heart; Chordal replacement; Mitral valve repair; Transapical
Introduction
Degenerative mitral valve (MV) disease may lead to
chordae rupture with subsequent leaflet prolapse and
mitral regurgitation (MR) w1, 2x. Current standard of
care for MV prolapse with severe MR is surgical MV
repair w1, 2x. Implantation of neo-chordae with the use
of expanded polytetrafluoroethylene (ePTFE) sutures
(Gore Associates, Flagstaff, AZ, USA) has since its
introduction into clinical practice by Frater et al. proven
to be a valuable technique for contemporary MV
repair w3–6x. Chordal replacement enables preservation
of native valve anatomy, physiological leaflet
motion and creation of large mitral orifice area w6, 7x.
Furthermore, it has contributed to the reparability
independent of valve complexity w4, 8x.
Recent developments led to the concept of transapical
beating heart MV repair with implantation of
neo-chordae using the NeoChord DS1000 device
(NeoChord Inc, Minnetonka, MN, USA; Photos 1 and
2) w9x. This approach has initially been evaluated in
acute and chronic animal studies w9x. Subsequently,
first successful transapical beating heart off-pump MV
repair in man has been reported w10x. In order to present
procedural details and technical aspects of this
new operative technique this article aims to depict the
NeoChord procedure in a ‘how-to-do-it’ manner.
* Corresponding author. Tel.: q49-341-8651421; fax: q49-341-
8651452.
E-mail: seej@med.uni-leipzig.de
� 2011 European Association for Cardio-thoracic Surgery
The NeoChord procedure
The NeoChord procedure has been developed to treat
severe MR due to posterior mitral leaflet prolapse
caused by chordae rupture (Video 1A and B). In the
NeoChord procedure, the heart is accessed through
a left lateral mini-thoracotomy (Videos 2 and 3). The
left ventricle (LV) apex is accessed via a standard
purse string ventriculotomy and the device is inserted
(Video 4). The instrument is then advanced towards
the MV (Video 5). It has expandable jaws used to capture
and control the prolapsing leaflet segment where
the NeoChords will be deployed. Optimal intra-cardiac
orientation is achieved with 2D and/or 3D echocardiographic
guidance (Video 6). Leaflet grasping is
performed with movement of the jaws towards the flail
segment of the leaflet (Video 7). Effective leaflet capture
is confirmed by observing the four fiber optic
monitor lights changing from red (blood pool) to white
(leaflet tissue; Photo 2). Next the leaflet is penetrated
with the needle with subsequent retrieval of the
Photo 1. The NeoChord DS 1000 device for transapical off-pump
mitral valve repair.
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J. Seeburger et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2010.004606
Photo 2. The NeoChord device monitor for confirmation of successful
(poor) mitral valve leaflet grasp.
Video 1. Mitral regurgitation.
Severe mitral regurgitation due to chordae rupture and posterior
mitral leaflet prolapse assessed with chest-wall (Video 1A) and
three-dimensional transesophageal echocardiography (Video 1B).
Video 2. Principle of the NeoChord procedure.
Schematics of the NeoChord procedure are depicted in an animation
video (with courtesy from NeoChord Inc, Minnetonka, MN,
USA).
NeoChord ePTFE suture (Video 8). Once the suture is
retrieved and fully accessed free of the instrument
after complete retraction of the NeoChord device (Video
9), a girth hitch knot is secured to the leaflet (Video
10). In case of insufficient result the NeoChord can be
retrieved using an additional retraction suture. Then
the procedure as shown in Videos 3–9 is repeatedly
performed to re-suspend the complete prolapsing
segment if necessary. After implantation of the necessary
number of NeoChords final assessment of the
operative result is achieved using echocardiography
Video 3. Surgical access.
A standard transapical access is used to expose the left ventricle
of the heart via a small left lateral mini-thoracotomy.
Video 4. Transapical introduction of the NeoChord device.
Two purse string sutures with felt pledgets are sewn on the apex.
A wire is inserted into the left ventricle and the access is dilated
(Video 4A). This pre-dilated access is used to advance the Neo-
Chord device into the left ventricle (Video 4B).
Video 5. Advancing the NeoChord device to the mitral valve.
Under constant echocardiographic guidance the device is further
advanced through the mitral valve into the left atrium.
Video 6. 3D echo guidance.
Three-dimensional echocardiography allows for optimal orientation
with regards to the prolapsing segment of the posterior leaflet.
While performing the procedure the surgeon has to follow the echocardiography
image to ‘find’ the prolapse – not vice versa.
(Video 11). The final step of the procedure is to manually
secure the properly tensioned NeoChords to the
LV apex using a French-eye needle, additional felt
pledgets and simple knots (Video 12). The operative
result with elimination of MV prolapse and no evidence
of MR is assessed with transesophageal echocardiography
(Video 13A). At discharge of the patient

J. Seeburger et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2010.004606
Video 7. Leaflet grasping.
When appropriate positioning has been achieved the two jaws on
the tip of the device are opened facing towards the prolapsing segment.
In practice the lower jaw can be used to ‘upload’ the posterior
leaflet and thus minimize leaflet motion. For final grasping the surgeon
needs to close the jaws while actively retracting the upper jaw
(Video 7A and B). Confirmation of sufficient tissue grasp is derived
from the numbers and color of the fiber optics on the device leaflet
capture display (Photo 2).
Video 8. Deployment of NeoChord.
After successful grasping and confirmation the needle is fully
advanced to puncture the leaflet segment and to ‘hook on’ to the
ePTFE suture which is pre-loaded within the device. The needle is
then completely retracted and the loop of the ePTFE suture is pulled
outside the device. The needle is then put aside.
Video 9. Retraction of the device.
Once the NeoChord has been pulled through the tissue of the prolapsing
segment and retracted, the grasping mechanism is relaxed
to relief the leaflet. The device is then fully retracted and pulled
outside the apex of the heart. The purse string sutures are then
tightened to prevent loss of blood.
chest wall echocardiography confirms no prolapse
and no MR (Video 13B).
Comment
Chordal replacement for MV repair with the use of
ePTFE sutures has shown to reach excellent results
in large clinical series w4–8x. Over the last decade, it
has gained a high-popularity even comparable to the
classical technique of leaflet resection w6, 7, 11x. The
rational of the NeoChord procedure, however, is to re-
Video 10. Girth hitch knot.
In this state of the procedure the loop of the ePTFE suture as well
as both ends of the suture are outside of the chest while the ePTFE
is led through the prolapsing segment of the leaflet. A girth hitch
knot is tied by leading the two ends through the free loop of the
suture. Subsequently, the knot is moved upwards to the mitral leaflet
by gently pulling on both ends of the suture. Confirmation of this
step is derived from reduction of leaflet motion and mitral regurgitation
using echocardiography.
Video 11. NeoChord in place.
As previously indicated the NeoChord is easily visible on echocardiography
and assessment of functionality can be achieved by pulling
or relaxing on the NeoChord. In case of too much tension
restriction of the posterior leaflet with induction of mitral regurgitation
occurs. Depending on the operative result after implantation of
the first NeoChord additional NeoChords are implanted by repeating
the procedure as illustrated in Videos 4–10.
Video 12. Fixation to apex.
After completion of NeoChord implantation to the prolapsing segment
a critical valve analysis using echocardiography is performed.
Proper tensioning as well as proper distribution of NeoChords on
the prolapsing segment with complete elimination of both prolapse
and MR has to be achieved. If adequate, the NeoChords have to
be anchored to the apex of the heart while securing perfect length
and proper tensioning. Therefore, a French eye needle is used to
lead the remaining two ends of the ePTFE suture through the myocardium
exteriorly from the apical access and is finally fixed over
an additional felt pledget (Video 12A and Photo 3). This step is
repeated for each NeoChord separately (Photo 3). Under constant
echocardiographic guidance and functional assessment the Neo-
Chords are secured on the apex of the heart to achieve the final
result (Video 12B).
suspend the prolapsing leaflet segment while abandoning
cardiopulmonary bypass and cardiac arrest.
This in combination with the transapical direct access
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J. Seeburger et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2010.004606
Photo 3. Schematics for apical fixation of NeoChords over additional
felt pledgets.
Video 13. Final result.
After completion of the procedure, complete elimination of the mitral
valve prolapse and mitral regurgitation is achieved (Video 13A). At
discharge chest wall echocardiography control shows the Neo-
Chord in place with no evidence of prolapse and no mitral regurgitation
(Video 13B).
to the MV is the main characteristic as well as apparent
uniqueness of the NeoChord procedure. Since the
NeoChord procedure represents a completely new
operative technique it has yet to prove repeat clinical
applicability. Nevertheless, feasibility of the procedure
with first successful in man application has been
demonstrated: complete elimination of MV prolapse
and MR was achieved in a patient with severe MR due
to chordae rupture w10x. The NeoChord procedure is
currently being investigated in the multicenter clinical
TransApical Chordae Tendinae (TACT) trial with
regards to safety and efficacy. Therefore, the presented
clinical experience is very preliminary and the
procedure is still considered to be experimental.
Despite the simplicity of the NeoChord concept and
its applicability as illustrated in this article the Neo-
Chord procedure includes several crucial steps which
need to be conducted with a high accuracy. Those
are: (1) sufficient leaflet grasp of the prolapsing segment;
(2) secure fixation of NeoChords to the MV leaflet
edge; (3) sufficient distribution of NeoChords over
the complete prolapsing segment; (4) proper tensioning
and length adjustment of NeoChords; (5) assessment
of functional result using echocardiography; and
(6) echocardiographic guidance throughout the complete
procedure.
Conclusion
In conclusion transapical beating heart off-pump implantation
of neo-chordae for MV repair is feasible.
Further clinical experience, however, is inevitable.
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