Combined off-pump minimally invasive coronary artery bypass grafting and mitral valve repair with NeoChord via a left anterolateral small thoracotomy

Combined off-pump minimally invasive coronary artery bypass grafting and mitral valve repair with... Abstract Off-pump direct coronary artery bypass grafting through a left anterior small thoracotomy is widely utilized for minimally invasive myocardial revascularization. More recently, a novel technique for transapical off-pump mitral valve repair with the NeoChord device is demonstrating its efficacy. This report describes a case of an 84-year-old male patient with coronary artery disease involving the left anterior descending coronary artery and acute severe mitral regurgitation secondary to posterior leaflet flail who underwent both off-pump coronary artery bypass and mitral valve repair with the transapical implantation of artificial chordae using the NeoChord DS 1000 system through the same anterolateral small thoracotomy. Coronary artery bypass, Off-pump, Minimally invasive cardiac surgery, Mitral regurgitation, Mitral valve repair INTRODUCTION Minimally invasive coronary artery bypass grafting through a left anterior small thoracotomy was first described by Calafiore et al. [1] in 1996, more recently another off-pump technique for mitral valve (MV) repair using the NeoChord DS1000 system (NeoChord DS1000, St Louis Park, MN, USA) has been introduced [2]. CASE STUDY An 84-year-old man without a previous medical history was admitted to our hospital with acute pulmonary oedema. Baseline transthoracic and 3D transoesophageal echocardiography showed a severe mitral regurgitation due to posterior leaflet flail secondary to chordae tendineae rupture (Fig. 1A). The preoperative coronary angiography showed a severe calcified stenosis of the proximal left anterior descending coronary artery, deemed unsuitable for a percutaneous coronary intervention at our hospital Heart Team meeting a combined procedure of surgical myocardial revascularization and MV repair was scheduled. The MV features, Type ‘A’ according to the anatomical stratification introduced by Colli et al. [3] (Fig. 1A, C and D), were favourable for a NeoChord procedure, and we opted to combine this off-pump technique with a left anterior small thoracotomy coronary artery bypass using the same small thoracotomy access. Figure 1 View largeDownload slide (A) 3D transoesophageal echocardiography (TEE) image of the mitral valve (MV) with the broken chordae tendineae and P2 flail: ‘the surgical view’. (B) The NeoChord DS 1000 device grasping the prolapsing leaflet. (C) 2D TEE image showing the overlap of P2 over A2 and the absence of annular dilatation, i.e. 2 of the main parameters for assessing the suitability of performing MV repair with the NeoChord technique. (D) 2D TEE image showing the eccentric regurgitation jet that constitutes, together with a good LVEF, the other 2 parameters for determining the feasibility of an off-pump MV repair. (E) The final result with a completely restored mitral valve competence and an optimal coaptation height. LVEF: left ventricular ejection fraction. Figure 1 View largeDownload slide (A) 3D transoesophageal echocardiography (TEE) image of the mitral valve (MV) with the broken chordae tendineae and P2 flail: ‘the surgical view’. (B) The NeoChord DS 1000 device grasping the prolapsing leaflet. (C) 2D TEE image showing the overlap of P2 over A2 and the absence of annular dilatation, i.e. 2 of the main parameters for assessing the suitability of performing MV repair with the NeoChord technique. (D) 2D TEE image showing the eccentric regurgitation jet that constitutes, together with a good LVEF, the other 2 parameters for determining the feasibility of an off-pump MV repair. (E) The final result with a completely restored mitral valve competence and an optimal coaptation height. LVEF: left ventricular ejection fraction. The operation was performed under conventional general anaesthesia with selective bronchial intubation. A 5-cm incision was made at a point 3 cm more laterally with respect to the conventional left anterior small thoracotomy procedure, and the chest was opened at the 5th intercostal space. The left internal thoracic artery was identified and harvested, the pericardium was opened longitudinally and, after full heparinization, the left internal thoracic artery was anastomosed to the left anterior descending coronary artery. After coronary artery bypass grafting, the pericardial incision was extended laterally in the shape of a ‘T’ up to 1 cm above the phrenic nerve, suspension stitches were placed at the edges of the pericardium to rotate anteriorly the heart apex and the NeoChord DS 1000 device was introduced into the anterolateral wall of the left ventricle through a small ventriculotomy (Fig. 2). Once the valve was crossed, the flailing scallop of the posterior leaflet was grasped with the NeoChord instrument under 3D transoesophageal echocardiography guidance (Fig. 1B), and 4 Gore-Tex CV-4 sutures (Gore-Tex; W.L. Gore & Associates, Inc, Flagstaff, AZ, USA) were deployed to the free edge of P2. The artificial chordae were passed through the left ventricle wall and the length and tension assessed under transoesophageal echocardiography obtaining a full mitral competence restoration. The patient was extubated in the intensive care unit 6 h later. The postoperative period was regular, and the patient was discharged on the 8th postoperative day. At the 2-month follow-up control at the outpatient clinic, the patient was doing well, and the transthoracic echocardiography showed no residual mitral regurgitation. Figure 2 View largeDownload slide Intraoperative image of the surgical field showing the LITA grafted to LAD coronary artery, the purse strings on the entry point and the Neochord DS1000 instrument introduced into the anterolateral wall of the left ventricle. LAD: left anterior descending; LITA: left internal thoracic artery. Figure 2 View largeDownload slide Intraoperative image of the surgical field showing the LITA grafted to LAD coronary artery, the purse strings on the entry point and the Neochord DS1000 instrument introduced into the anterolateral wall of the left ventricle. LAD: left anterior descending; LITA: left internal thoracic artery. DISCUSSION Combined off-pump coronary artery bypass and MV repair through a small thoracotomy are feasible, and both procedures can be performed through the same access with minimal technical changes. The associated MV repair with the NeoChord technique is suitable, however, only in selected patients with specific MV features. We believe that, by avoiding full sternotomy, cardiopulmonary bypass, cardiac arrest and open-heart surgery, the risk of a complex cardiac procedure in an elderly patient, such as described here in this report, can be significantly reduced. The possibility of combining off-pump coronary artery bypass and MV repair represents a further step forward in minimally invasive cardiac surgery. Conflict of interest: Alberto Albertini receives consulting and lecture honoraria from NeoChord Inc. and Medtronic Inc. Other authors has no conflicts of interest. REFERENCES 1 Calafiore AM, Giammarco GD, Teodori G, Bosco G, D’Annunzio E, Barsotti A et al.   Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg  1996; 61: 1658– 63. Google Scholar CrossRef Search ADS PubMed  2 Rucinskas K, Janusauskas V, Zakarkaite D, Aidietiene S, Samalavicius R, Speziali G et al.   Off-pump transapical implantation of artificial chordae to correct mitral regurgitation: early results of a single-center experience. J Thorac Cardiovasc Surg  2014; 147: 95– 9. Google Scholar CrossRef Search ADS PubMed  3 Colli A, Manzan E, Zucchetta F, Bizzotto E, Besola L, Bagozzi L et al.   Transapical off-pump mitral valve repair with Neochord implantation: early clinical results. Int J Cardiol  2016; 204: 23– 8. Google Scholar CrossRef Search ADS PubMed  © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Interactive CardioVascular and Thoracic Surgery Oxford University Press

Combined off-pump minimally invasive coronary artery bypass grafting and mitral valve repair with NeoChord via a left anterolateral small thoracotomy

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Oxford University Press
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© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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1569-9293
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Abstract

Abstract Off-pump direct coronary artery bypass grafting through a left anterior small thoracotomy is widely utilized for minimally invasive myocardial revascularization. More recently, a novel technique for transapical off-pump mitral valve repair with the NeoChord device is demonstrating its efficacy. This report describes a case of an 84-year-old male patient with coronary artery disease involving the left anterior descending coronary artery and acute severe mitral regurgitation secondary to posterior leaflet flail who underwent both off-pump coronary artery bypass and mitral valve repair with the transapical implantation of artificial chordae using the NeoChord DS 1000 system through the same anterolateral small thoracotomy. Coronary artery bypass, Off-pump, Minimally invasive cardiac surgery, Mitral regurgitation, Mitral valve repair INTRODUCTION Minimally invasive coronary artery bypass grafting through a left anterior small thoracotomy was first described by Calafiore et al. [1] in 1996, more recently another off-pump technique for mitral valve (MV) repair using the NeoChord DS1000 system (NeoChord DS1000, St Louis Park, MN, USA) has been introduced [2]. CASE STUDY An 84-year-old man without a previous medical history was admitted to our hospital with acute pulmonary oedema. Baseline transthoracic and 3D transoesophageal echocardiography showed a severe mitral regurgitation due to posterior leaflet flail secondary to chordae tendineae rupture (Fig. 1A). The preoperative coronary angiography showed a severe calcified stenosis of the proximal left anterior descending coronary artery, deemed unsuitable for a percutaneous coronary intervention at our hospital Heart Team meeting a combined procedure of surgical myocardial revascularization and MV repair was scheduled. The MV features, Type ‘A’ according to the anatomical stratification introduced by Colli et al. [3] (Fig. 1A, C and D), were favourable for a NeoChord procedure, and we opted to combine this off-pump technique with a left anterior small thoracotomy coronary artery bypass using the same small thoracotomy access. Figure 1 View largeDownload slide (A) 3D transoesophageal echocardiography (TEE) image of the mitral valve (MV) with the broken chordae tendineae and P2 flail: ‘the surgical view’. (B) The NeoChord DS 1000 device grasping the prolapsing leaflet. (C) 2D TEE image showing the overlap of P2 over A2 and the absence of annular dilatation, i.e. 2 of the main parameters for assessing the suitability of performing MV repair with the NeoChord technique. (D) 2D TEE image showing the eccentric regurgitation jet that constitutes, together with a good LVEF, the other 2 parameters for determining the feasibility of an off-pump MV repair. (E) The final result with a completely restored mitral valve competence and an optimal coaptation height. LVEF: left ventricular ejection fraction. Figure 1 View largeDownload slide (A) 3D transoesophageal echocardiography (TEE) image of the mitral valve (MV) with the broken chordae tendineae and P2 flail: ‘the surgical view’. (B) The NeoChord DS 1000 device grasping the prolapsing leaflet. (C) 2D TEE image showing the overlap of P2 over A2 and the absence of annular dilatation, i.e. 2 of the main parameters for assessing the suitability of performing MV repair with the NeoChord technique. (D) 2D TEE image showing the eccentric regurgitation jet that constitutes, together with a good LVEF, the other 2 parameters for determining the feasibility of an off-pump MV repair. (E) The final result with a completely restored mitral valve competence and an optimal coaptation height. LVEF: left ventricular ejection fraction. The operation was performed under conventional general anaesthesia with selective bronchial intubation. A 5-cm incision was made at a point 3 cm more laterally with respect to the conventional left anterior small thoracotomy procedure, and the chest was opened at the 5th intercostal space. The left internal thoracic artery was identified and harvested, the pericardium was opened longitudinally and, after full heparinization, the left internal thoracic artery was anastomosed to the left anterior descending coronary artery. After coronary artery bypass grafting, the pericardial incision was extended laterally in the shape of a ‘T’ up to 1 cm above the phrenic nerve, suspension stitches were placed at the edges of the pericardium to rotate anteriorly the heart apex and the NeoChord DS 1000 device was introduced into the anterolateral wall of the left ventricle through a small ventriculotomy (Fig. 2). Once the valve was crossed, the flailing scallop of the posterior leaflet was grasped with the NeoChord instrument under 3D transoesophageal echocardiography guidance (Fig. 1B), and 4 Gore-Tex CV-4 sutures (Gore-Tex; W.L. Gore & Associates, Inc, Flagstaff, AZ, USA) were deployed to the free edge of P2. The artificial chordae were passed through the left ventricle wall and the length and tension assessed under transoesophageal echocardiography obtaining a full mitral competence restoration. The patient was extubated in the intensive care unit 6 h later. The postoperative period was regular, and the patient was discharged on the 8th postoperative day. At the 2-month follow-up control at the outpatient clinic, the patient was doing well, and the transthoracic echocardiography showed no residual mitral regurgitation. Figure 2 View largeDownload slide Intraoperative image of the surgical field showing the LITA grafted to LAD coronary artery, the purse strings on the entry point and the Neochord DS1000 instrument introduced into the anterolateral wall of the left ventricle. LAD: left anterior descending; LITA: left internal thoracic artery. Figure 2 View largeDownload slide Intraoperative image of the surgical field showing the LITA grafted to LAD coronary artery, the purse strings on the entry point and the Neochord DS1000 instrument introduced into the anterolateral wall of the left ventricle. LAD: left anterior descending; LITA: left internal thoracic artery. DISCUSSION Combined off-pump coronary artery bypass and MV repair through a small thoracotomy are feasible, and both procedures can be performed through the same access with minimal technical changes. The associated MV repair with the NeoChord technique is suitable, however, only in selected patients with specific MV features. We believe that, by avoiding full sternotomy, cardiopulmonary bypass, cardiac arrest and open-heart surgery, the risk of a complex cardiac procedure in an elderly patient, such as described here in this report, can be significantly reduced. The possibility of combining off-pump coronary artery bypass and MV repair represents a further step forward in minimally invasive cardiac surgery. Conflict of interest: Alberto Albertini receives consulting and lecture honoraria from NeoChord Inc. and Medtronic Inc. Other authors has no conflicts of interest. REFERENCES 1 Calafiore AM, Giammarco GD, Teodori G, Bosco G, D’Annunzio E, Barsotti A et al.   Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg  1996; 61: 1658– 63. Google Scholar CrossRef Search ADS PubMed  2 Rucinskas K, Janusauskas V, Zakarkaite D, Aidietiene S, Samalavicius R, Speziali G et al.   Off-pump transapical implantation of artificial chordae to correct mitral regurgitation: early results of a single-center experience. J Thorac Cardiovasc Surg  2014; 147: 95– 9. Google Scholar CrossRef Search ADS PubMed  3 Colli A, Manzan E, Zucchetta F, Bizzotto E, Besola L, Bagozzi L et al.   Transapical off-pump mitral valve repair with Neochord implantation: early clinical results. Int J Cardiol  2016; 204: 23– 8. Google Scholar CrossRef Search ADS PubMed  © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Journal

Interactive CardioVascular and Thoracic SurgeryOxford University Press

Published: Mar 1, 2018

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