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Anesthetic Management and Procedural Outcomes of Patients Undergoing Off-Pump Transapical Implantation of Artificial Chordae to Correct Mitral Regurgitation: Case Series of 76 Patients

Samalavicius, Robertas, Stasys, MD, PhD*; Norkiene, Ieva, MD, PhD; Drasutiene, Agne, MD; Lipnevicius, Arturas, MD; Janusauskas, Vilius, MD, PhD; Urbonas, Karolis, MD*; Zakarkaite, Diana, MD, PhD; Aidietis, Audrius, MD, PhD; Rucinskas, Kestutis, MD, PhD

doi: 10.1213/ANE.0000000000002767
Perioperative Echocardiography and Cardiovascular Education: Original Clinical Research Report

BACKGROUND: Transapical implantation of artificial chordae using the NeoChord system (NeoChord Inc, Minneapolis, MN) is an emerging beating-heart technique for correction of mitral regurgitation (MR) through a minimally invasive left minithoracotomy. The purpose of the study was to describe the anesthetic management and procedural success of patients undergoing this procedure.

METHODS: All patients (n = 76) who underwent mitral valve repair with the NeoChord system in our institution from December 2011 to December 2016 were included in this observational prospective study. Balanced anesthesia with a combination of fentanyl, propofol, and sevoflurane was used in all patients. Each patient’s core temperature was maintained at >36°C whenever possible. Two- and 3-dimensional transesophageal echocardiography was used in all patients to navigate the device to the posterior mitral valve leaflet (68 of 76 patients), anterior mitral valve leaflet (3 of 76 patients), or both leaflets (5 of 76 patients). After effective leaflet capture, the artificial chordae were deployed. Position and function of the artificial chordae were assessed by evaluating the degree of MR when the neochordae were tensed. After surgery, all patients were transferred to the intensive care unit.

RESULTS: The mean age of the patients was 60 ± 13 years (range, 33–87 years), and the male/female ratio was 52/24. Most patients had severe MR (grade 4+ in 25 [33%] patients, grade 3+ in 51 [67%] patients). The average preoperative EuroSCORE II was 1.23% ± 1.16% (range, 0.46%–4.23%). The median duration of the procedure was 120 minutes (interquartile range [IQR] 115–145 minutes). After the procedure, 42 (56%) patients had trivial MR, 27 (36%) had grade 1+ MR, 4 (5%) had grade 2+ MR, and 2 (3%) had >2+ MR. One patient underwent conversion to conventional mitral valve repair due to perforation of the posterior mitral valve leaflet. The whole procedure was well tolerated by the patients, with hemodynamics remaining stable in the majority of the cases. Only 20 (26%) patients needed low-dose inotropic support perioperatively. All patients had an uneventful postoperative course. The median time to extubation was 4 hours (IQR, 2.6–6), and the length of intensive care unit stay was 22 hours (IQR, 21–24). Five (6.6%) patients required allogeneic blood products.

CONCLUSIONS: Anesthesia for transapical NeoChord implantation can be safely performed under beating-heart conditions, with low perioperative morbidity and rare blood transfusions. Transesophageal echocardiography is crucial for the guidance, safety, and effectiveness of the procedure.

From the *II Department of Anesthesia, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania

Clinic of Anaesthesiology and Reanimatology

Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.

Published ahead of print December 26, 2017.

Accepted for publication November 13, 2017.

Funding: None.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

Institutional review board: Vilnius Regional Bioethics Committee, M. K. Ciurlionio St 21/27, LT 03101, Vilnius, Lithuania. E-mail:

Reprints will not be available from the authors.

Address correspondence to Arturas Lipnevicius, MD, Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, Santariskiu 2, Vilnius, LT 08661 Lithuania. Address e-mail to

© 2018 International Anesthesia Research Society
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