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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

The traditional method of access when performing mitral valve (MV) surgery is a full median sternotomy. MV repair techniques have undergone continuous evolution during the past 50 years and a shift to less invasive techniques has been noted. Partial sternotomies and limited-access thoracotomies are performed more frequently, and percutaneous techniques for correction of valvular lesions have been introduced. Robotic MV repair has been shown to have excellent surgical outcomes and reduced morbidity.1 Percutaneous transapical MV replacement has been reported,2 and good short- and long-term outcomes of transcatheter MV repair have been described.3 A new technique for less invasive MV repair was introduced—transapical off-pump implantation of artificial chordae using NeoChord DS1000 system (NeoChord Inc, Minneapolis, MN).4 This system was designed for transesophageal echocardiography (TEE)–guided delivery of artificial chordae to the prolapsing leaflet under beating-heart conditions. Anesthetic management of patients undergoing off-pump transapical NeoChord implantation has been reported in 1 group of patients to date.5 The purpose of this study was to describe our initial experience with the anesthetic management and procedural success of patients who underwent transapical deployment of artificial chordae in our institution.

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This observational prospective study was approved by the local Regional Bioethics Committee. Patients of this study were also included in 2 registered multicenter trials: the prospective Transapical Artificial Chordae Tendinae (TACT) trial ( ID: NCT01777815) and the NeoChord TACT Post-Market Surveillance Registry ( ID: NCT01784055). NeoChord DS1000 system is not yet approved by the Food and Drug Administration and is undergoing an Food and Drug Administration trial “Randomized trial of the NeoChord DS1000 system versus open surgical repair (ReChord)” ( ID: NCT02803957).

Transthoracic echocardiography and TEE were used to select patients for the procedure. Mitral regurgitation (MR) severity was graded as mild, moderate, or severe based on qualitative and quantitative indicators of MR, as recommended by guidelines.6,7

After providing written informed consent, patients with severe MR (grade ≥3+) who were candidates for surgical MV repair and had a left ventricular (LV) ejection fraction of >25% were considered for transapical implantation of artificial chordae. Patients with functional or ischemic MR or severe LV dysfunction (LV ejection fraction of <25% or LV end-systolic diameter of >55 mm), infective endocarditis, inflammatory valve disorders (rheumatic valve disease, cancer-related endocarditis, autoimmune endocarditis, hypereosinophilic syndrome), leaflet perforation, or heavily calcified valves were excluded from the study. All patients who underwent MV repair using the NeoChord system in our institution from December 2011 to December 2016 were included in the study.

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NeoChord Implantation Procedure

The NeoChord implantation procedure was performed with the patient under general anesthesia in an ordinary cardiac surgery operating room. The patient was placed in the supine position, and access to the LV apex was achieved through a left lateral thoracotomy (5–6 cm) in the fifth intercostal space. Two standard purse-string sutures were placed at the entry site, which was determined by echocardiographic guidance. After ventriculotomy, a NeoChord DS1000 device loaded with single CV-4 suture (Gore-Tex; W. L. Gore & Associates, Inc, Flagstaff, AZ) was inserted into the LV and advanced to the left atrium. Artificial chordae were deployed to the diseased MV segment under 2-dimensional (2D) and 3-dimensional (3D) TEE guidance.

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Anesthesia Techniques

Standard monitoring during the NeoChord procedure was performed by electrocardiography (leads II and V), pulse oximetry, capnography, use of an oropharyngeal temperature probe, left radial arterial line for arterial pressure monitoring, and insertion of a central venous catheter along with cerebral oximetry and TEE to guide the NeoChord implantation procedure and perform hemodynamic evaluation. A pulmonary artery catheter was not used in this group of patients.

Anesthesia was induced with fentanyl/propofol and maintained with sevoflurane and intravenous infusion of fentanyl. After induction, the patients were intubated with a single-lumen endotracheal tube. Two self-adhesive external defibrillation pads were applied to the patient before surgical drape placement. The patient was kept warm during surgery by increasing the operating room temperature, using the warming blanket under the patient, and warming the intravenous fluids. Targeted heart rate was 60–90 beats/min throughout the procedure. β-Blockers and amiodarone were used to control tachycardia if deepening of anesthesia was not effective. None of our patients had bradycardia during the procedure, however, in that case, dopamine infusion would have been started to increase the heart rate. Dose of volatile anesthetic was increased and propofol bolus (if needed) was given to maintain systolic blood pressure <90 mm Hg during ventriculotomy and insertion of the NeoChord device into the LV to reduce the risk of excessive bleeding. Otherwise the target systolic arterial blood pressure was kept between 90 and 120 mm Hg. If systolic blood pressure decreased <90 mm Hg (mean: <60 mm Hg), no response to fluid challenge was observed (central venous pressure >12 mm Hg) and no changes in ventricular contractility evaluated by TEE, infusion of vasopressor agent (norepinephrine) was started. In cases of observed decreased LV function (assessed on TEE) dobutamine infusion was used.

Bilateral cerebral oxygen saturation was monitored in all patients as a first alert indication of adverse event during the procedure.8,9

Before insertion of the NeoChord DS1000, a single dose of heparin (150 U/kg) was administered, aiming for an activated clotting time of 250–300 seconds measured using a Hemochron 401 (Accriva Diagnostics, San Diego, CA). The activated clotting time was checked every 30 minutes. If needed, an additional bolus of 5000 U of heparin was administered to maintain an activated clotting time of >250 seconds. After NeoChord implantation, the heparin was reversed with protamine in a 1:1 ratio.

A cell saver system was used to salvage blood in all patients. The system was set up before surgery, and all blood during surgery was collected into a cardiotomy reservoir. If the amount of blood was substantial for the processing cycle, the salvaged blood was processed and transfused. The threshold for the red blood cells transfusion was a hemoglobin concentration of <8 g/dL.

After surgery, no attempts were made to tracheally extubate the patients in the operating room. All patients were transferred to the intensive care unit (ICU), where they stayed at least overnight according to institutional guidelines. They were mechanically ventilated for 2 hours and observed for signs of increased bleeding or hemodynamic instability; they were extubated when standard extubation criteria were met.

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Intraoperative TEE

All procedures were performed with 2D and 3D TEE guidance and color-flow Doppler imaging.

After exposure of the LV apex, the entry site was identified by gently pushing the myocardium with a finger. The intended ventriculotomy site was at an area 2–4 cm from the apex toward the posterolateral LV wall and between the papillary muscles base. The NeoChordae were anchored to this area to assume a physiologic orientation of the chordae and help to avoid potential interference or entanglement with the native MV chordae.

Two-dimensional and 3D TEE guidance was used for the selection of the ventriculotomy site. Two-dimensional TEE was performed using 2 orthogonal planes displayed simultaneously: a midesophageal long-axis view at 120°–130° and an orthogonal view from the reference plane. The ideal long-axis view intersects the aortic valve and the A2 and P2 segments of the MV. In addition, volumetric 3D images were used for selection of entry site with respect to both papillary muscles and subvalvular apparatus and depict the whole volumetric view of LV apex in a single 3D real-time perspective (Figure 1; Supplemental Digital Content 1, Video 1,

Figure 1.

Figure 1.

After placing purse-string sutures and insertion of the device into the LV, the device was navigated toward the MV under TEE guidance with the same 2D midesophageal long-axis view (simultaneous orthogonal multiplane mode was used). The two 2D midesophageal long-axis views minimized probe manipulations and allowed for easier navigation of the device. The device was kept in a central position within the LV cavity on both images while passing the subvalvular apparatus and MV plane to prevent MV damage (Supplemental Digital Content 2, Video 2,

The surgeon pushed the device toward the left atrium. If the device pushed one of the mitral leaflets up, it was retracted to avoid leaflet perforation and redirected to the central axis of the mitral plane.

When the device passed the MV annular plane and entered the left atrium, the real-time 3D zoom modality was used. The live 3D view was obtained from the midesophageal long-axis view with the zoomed sector including the mitral annulus and both leaflets without surrounding structures.

The 3D view was then rotated to obtain the surgeon’s view of the MV from the left atrial perspective with the aorta at the 12-o’clock position. This view was used for device positioning according to the prolapsing segment, as well as rotation of the opened device and leaflet grasping guidance (Figure 2; Supplemental Digital Content 3, Video 3,

Figure 2.

Figure 2.

The jaws of the device were opened while in the left atrium, and the flailing/prolapsing segment was captured. The NeoChord DS1000 device includes fiber optic technology with a monitor, allowing for confirmation of successful leaflet grasping. Effective leaflet capture was confirmed by observing a change in the fiber optic monitor lights from red (blood pooling) to white (leaflet tissue). Capture was considered effective when all 4 fiber optic monitor lights changed from red to white. When capture had been confirmed, a needle in the device was pushed forward to penetrate the leaflet and implant the NeoChord. The device was removed from the heart after that.

Optimal placement of each NeoChord was evaluated by placing the NeoChord under tension and observing disappearance or reduction of the prolapse on Live 3D zoom MV “surgeon’s” view. Two-dimensional color-flow Doppler was used to evaluate reduction of the MR. If MR was effectively reduced, the NeoChord position was considered adequate and the NeoChord was left attached to the MV leaflet. These maneuvers were repeated after implantation of each new artificial chord (usually 3 or 4 times) until the desired effect was reached (Figure 3; Supplemental Digital Content 4 and 5, Video 4,, and Video 5, If the placement point on the leaflet was either inappropriate or ineffective, a retrieval suture was used to remove the deployed suture.

Figure 3.

Figure 3.

Live 3D TEE zoom modality with MV en-face view was used to visualize the deployed NeoChordae and determine the desired position on the selected scallop. Depending on the width of the prolapsing segment, the NeoChordae were planned to be placed at equal intervals (about <1 cm) on the prolapsing segment. If the implanted NeoChordae were unequally distributed (spaced apart >1 cm) or significant eccentric residual MR was present due to remaining prolapse, an additional NeoChord was implanted. The deployed NeoChordae were anchored to the surface of the LV by suturing them to the pledget adjacent to the ventriculotomy with a standard surgical knot. Tension and securing of the NeoChordae were controlled by TEE to achieve maximal competence of the MV.

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From December 2011 to December 2016, 76 patients underwent off-pump MV repair with the NeoChord system in our institution. The preoperative patient data showed a low-risk profile for patients with an average preoperative EuroSCORE II of 1.23% ± 1.16%. Twenty-eight (37%) patients had New York Heart Association class III and IV heart failure. The patients’ preoperative demographic data and comorbidities are presented in Table 1. All patients had severe MR with a mean LV ejection fraction of 57% ± 5%. The results of the preoperative echocardiographic evaluation are presented in Table 2.

Table 1.

Table 1.

Table 2.

Table 2.

All but the first patient underwent successful MV repair using NeoChordae. The first patient underwent conversion to conventional MV repair because of leaflet damage induced by the device. After unsuccessful chordae deployment during the same procedure, a median sternotomy was performed and the patient underwent uneventful conventional MV repair. Fragile leaflet tissue was observed during the on-pump surgery; this might have contributed to the inability to deploy the NeoChordae and the damage of the leaflet.

One patient had an episode of ventricular fibrillation during opening of the pericardium and was successfully defibrillated. The median duration of the procedure was 120 minutes (interquartile range [IQR], 115–145). The typical NeoChord deployment time was <5 minutes per chord, with tensioning and anchoring requiring about 10 minutes per chord. An average of 3.3 ± 1.2 (range, 1–7) NeoChordae were implanted per patient. However, not all attempts to implant the NeoChordae were successful because of failure to grasp the leaflet or improper positioning during grasping. Therefore, the average number of attempts to deploy the NeoChordae was 4.4 ± 1.8 (range, 1–9) per patient or 1.26 attempts per successfully implanted NeoChord. Intraoperative TEE after the procedure revealed trivial MR in 42 (56%) patients, grade 1+ MR in 27 (36%), grade 2+ MR in 4 (5%), and >2+ MR in 2 (3%).

Median blood loss during surgery was 500 mL (IQR, 350–700 mL). Forty-six (61%) of our patients needed autotransfusion, and a median of 250 mL (IQR, 180–395 mL) of washed erythrocytes were transfused. In 10 (13%) cases, intraoperative blood loss exceeded 1000 mL. Significant reduction in median blood loss was observed while comparing first 25 patients and last 25 patients of our series: 700 mL (IQR, 500–1000 mL) versus 500 mL (IQR, 350–550 mL); P = .004. However, transfusion rate remained the same: 2 patients in each of the groups.

Twenty patients required inotropic support in the perioperative period, mainly norepinephrine infusion (Table 3). The median time to extubation was 4 hours (IQR, 2.6–6). Five (6.6%) patients required allogeneic blood products. None of our patients had atrial fibrillation (AF) intraoperatively and 9 (12%) patients had developed AF within 30 days after the procedure.

Table 3.

Table 3.

Reexploration for bleeding was performed in 2 patients of our group. Two patients underwent permanent pacemaker implantation for the preoperatively known sick sinus syndrome. Two patients developed acute postoperative kidney failure with a creatinine elevation of >150% from baseline, but none of the patients needed hemofiltration. No patients developed stroke, myocardial infarction, wound infection, or in-hospital mortality.

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MV repair is associated with better long-term survival10 compared with MV replacement and is considered to be the gold standard for treatment of severe MR in patients with degenerative MV disease.11–13 During the past 2 decades, less invasive approaches have become more popular, aiming to decrease the morbidity of MV surgery.14 Compared with conventional surgery, minimally invasive MV surgery has shown excellent results in terms of mortality, morbidity, and decreased postoperative pain, providing a shorter hospital stay and faster recovery; this translates into less use of rehabilitation resources and lower health care costs.15–22 Current spectrum of minimally invasive MV surgery includes surgical (right thoracotomy with or without video assistance), robotic, and percutaneous approaches.3,14,17,18,20,22–25 The on-pump MV repair can be performed with cardioplegia or fibrillatory cardiac arrest.26 Recently developed off-pump techniques allow to implant artificial chordae through the left thoracotomy on beating heart.27–29

Our group of 76 patients underwent transapical off-pump MV repair, thus avoiding complications related to cardiopulmonary bypass (CPB). The main limitations of our study are those inherent to nonrandomized single-center observational studies with limited numbers of patients, selection bias, and lack of a concurrent comparator group.

Hemodynamic stability and avoidance of increased blood pressure to reduce the blood loss are the main objectives of the anesthetic management. The whole procedure is well tolerated by the patient. Lower pressure during ventriculotomy and normal or slightly lower blood pressure throughout the case potentially might limit the blood loss. Blood pressure must be allowed to return to normal during tensioning and anchoring of implanted NeoChordae to check MR in more physiologic condition. We have not seen severe hemodynamic deterioration, which Kavakli et al5 reported as a common condition during the procedure. Even in the first case, which was converted to conventional on-pump repair, patient remained in stable condition.

The main limitation of the transapical NeoChord implantation is that this technique can only be used to repair prolapsing or flail MV segments; therefore, careful patient selection is needed based on the valve regurgitation mechanism. However, our study demonstrated a significant reduction in MR combined with a low rate of postoperative complications, rare blood product transfusions, and no mortality.

The most common adverse events associated with minimally invasive MV surgery include conversions to sternotomy, reexploration for bleeding, stroke, acute renal failure, myocardial infarction, postoperative AF, septic complications, respiratory failure, and pacemaker implantation.15,18,20,21

Recent studies showed that less invasive MV surgery through right minithoracotomy is associated with 1.4%–2.1% rate of conversion to sternotomy17,20 and 4.9%–7% rate of reexploration for bleeding.12,15,17,18,20 The very first patient in our group required conversion due to mitral leaflet perforation. The NeoChord implantation procedure was successful for the following 75 patients. The reexploration rate of <3% in the present study confirms the safety of this procedure in terms of postoperative bleeding.

Transfusion of allogeneic red blood cells is recognized as a risk factor for adverse outcomes after cardiac surgery.30,31 A recent study published by Gammie et al32 showed higher use of perioperative red blood cells in the conventional MV repair group: 52.6% vs 41.0% in the less invasive MV surgery group.31 Stevens et al33 recently observed a significant difference in the blood transfusion requirement among conventional, videoscopic (right minithoracotomy), and robotic MV surgery groups—63%, 43%, and 18%, respectively.31 The Mayo Clinic reported even better results of robotic MV repair: a 6% transfusion rate as described by Rodrigues et al.1 The authors emphasized that avoidance of sternotomy, effective patient selection, and short CPB times played important roles in achieving this result.1

Evolving percutaneous MV repair procedures have allowed for the performance of mitral surgery without CPB. The Endovascular Valve Edge-to-Edge REpair Study (EVEREST) II trial demonstrated a transfusion rate of 13% in patients who underwent percutaneous MV repair.25 The MV repair procedures in the present study were performed without CPB, and only 5 patients (6.6%) required any allogeneic blood products. It demonstrates a clear reduction in the use of blood products among patients who underwent minimally invasive off-pump MV repair.

Nevertheless, blood loss might be substantial during NeoChordae implantation due to the transapical LV access, design of the device, and multiple reinsertions of the instrument for deployment of the chordae. In 10 (13%) cases, intraoperative blood loss exceeded 1000 mL; therefore, intraoperative cell salvage and autotransfusion were important in the perioperative management of these patients.

Both conventional and minimally invasive MV repair techniques are associated with a risk of stroke. Different studies have reported a 1.3%–2.8% rate of postoperative neurologic events.12,18,20,23 Two recent meta-analyses showed no significant difference between MV repair through right small thoracotomy and conventional sternotomy.15,18 Stroke is often related to CPB and aortic cross-clamping. There were no neurological complications in the present study.

None of our patients developed postoperative acute renal failure requiring hemofiltration; however, 2 (3%) patients developed a creatinine elevation of >150% above baseline. Previously reported rates of postoperative renal failure after minimally invasive MV surgery (including right small thoracotomy, lower hemisternotomy, and robotic techniques) range from 1.3% to 4.3%,20,21,34 and according to various meta-analyses, these rates are similar to those after sternotomy.17,20,35

Recent data showed that postoperative AF is less frequent after right minithoracotomy than after sternotomy because of the less traumatic approach.18 Gammie et al32 showed a decreased incidence of postoperative AF (20.1% in the conventional sternotomy group and 15.9% in the less invasive group).31 Our data show a 12% incidence of postoperative AF and support the idea that a less invasive approach has a positive impact on postoperative arrhythmias. Permanent pacemakers were implanted in 2 (2.6%) of our patients postoperatively for the preoperatively known sick sinus syndrome.

The reported rate of myocardial infarction after less invasive MV surgery procedures is 0.6%–1.4%.17,20,36 Myocardial infarction is usually related to intraoperative coronary artery injury or thrombosis.18 During transapical implantation of NeoChordae, all manipulations are performed through the LV apex, away from the main coronaries; therefore, none of our patients had this complication.

Single-lung ventilation is often necessary for robotic MV procedures.1 It can also be used during transapical implantation of NeoChordae; however, we routinely use a single-lumen endotracheal tube without causing any technical issues for the surgeons.

Rodrigues et al1 demonstrated that tracheal extubation in the operating room was associated with reductions in the ICU and hospital stay.1 According to our center’s policy, all our patients were extubated in the ICU. Early extubation is a subject for further discussion.

The recently published TACT study included similar patients and showed that the efficacy and safety of NeoChord implantation were comparable with those in the present study.4

Recent publication about anesthetic management of patients undergoing off-pump transapical NeoChord implantation by Kavakli et al5 demonstrated slightly higher intraoperative blood loss (660 vs 500 mL) and higher rate of blood product transfusion compared to our study. However, it showed shorter ventilation time and length of ICU and hospital stay—2.6 vs 4 hours, 19.8 vs 22 hours, and 5 vs 8 days, respectively.

The other known options for treatment of degenerative MR include the MitraClip (Abbott Vascular, Santa Clara, CA), transcatheter MV implantation, and a preformed expanded polytetrafluoroethylene knot implantation device (Harpoon TSD-5; Harpoon Medical, Baltimore, MD).29

The MitraClip was approved for treatment of degenerative MR. Application of this therapy requires a patient to be deemed at high risk for MV surgery and to have a specific anatomy, which includes a relatively central MR jet origin and cooptation gap of <15 mm. Treatment of MR arising from the commissures is very difficult when using the MitraClip, and large flail segments with an excess coaptation gap have a high rate of failure. Neither transapical NeoChordae implantation nor use of the MitraClip is applicable to paracommissural MR, but patients with flail or prolapsing central parts of the leaflet can be treated using transapical NeoChordae implantation. The preoperative risk was not considered to be a selection criterion for transapical off-pump NeoChordae implantation. Consequently, our patients were younger and had fewer comorbidities than patients in the EVEREST II study.25

MitraClip implantation was associated with a 1% rate of postoperative mortality and stroke, postprocedural renal failure was noted in <1% of patients, and transfusion of ≥2 units of red blood cells was needed in 13% of patients.25

Off-label placement of a variety of transcatheter valve types has been reported in approximately 180 cases during the past 5 years, although no specific prosthesis has been approved for this indication. Specific requirements for the MV and LV anatomy are needed for different types of valve prostheses.37 And again, this is a different patient group; usually, only very high-risk patients are selected for transcatheter valve implantation.38

Patients enrolled in a recent trial of the authors’ initial experience with a preformed expanded polytetrafluoroethylene knot implantation device (Harpoon TSD-5) were very similar to our patients in terms of age and MV pathology.29 Their initial group of 11 patients showed a 100% procedural success rate, and no patients required intraoperative inotropic support. There was no perioperative mortality, stroke, renal failure, postoperative AF, or myocardial infarction. None of the patients required blood transfusions. Two patients underwent evacuation of pericardial effusion within the first 2 weeks postoperatively. The authors of the report concluded that the transapical off-pump MV repair procedure was safe and effective.

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Although anesthesia for transapical NeoChord implantation can be safely performed under beating-heart conditions, with a relatively short procedural time, low perioperative morbidity and rare blood transfusions, the risk of significant intraoperative blood loss and conversion to conventional MV surgery still exists; therefore, the team should be prepared for blood salvage and initiation of CPB. TEE is crucial for the guidance of the procedure and prevention of injury to the MV.

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Name: Robertas Stasys Samalavicius, MD, PhD.

Contribution: This author helped conduct the study, collect and analyze the data, and prepare the manuscript.

Name: Ieva Norkiene, MD, PhD.

Contribution: This author helped collect and analyze the data and prepare the manuscript.

Name: Agne Drasutiene, MD.

Contribution: This author helped conduct the study, collect and analyze the data, and prepare the manuscript.

Name: Arturas Lipnevicius, MD.

Contribution: This author helped conduct the study, collect and analyze the data, and prepare the manuscript.

Name: Vilius Janusauskas, MD, PhD.

Contribution: This author helped conduct the study, collect and analyze the data, and prepare the manuscript.

Name: Karolis Urbonas, MD.

Contribution: This author helped conduct the study and prepare the manuscript.

Name: Diana Zakarkaite, MD, PhD.

Contribution: This author helped conduct the study and prepare the manuscript.

Name: Audrius Aidietis, MD, PhD.

Contribution: This author helped conduct the study and prepare the manuscript.

Name: Kestutis Rucinskas, MD, PhD.

Contribution: This author helped design and conduct the study and collect and analyze the data.

This manuscript was handled by: Nikolaos J. Skubas, MD, DSc, FACC, FASE.

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1. Rodrigues ES, Lynch JJ, Suri RM, et al. Robotic mitral valve repair: a review of anesthetic management of the first 200 patients. J Cardiothorac Vasc Anesth. 2014;28:64–68.
2. Mukherjee C, Holzhey D, Mende M, Linke A, Kaisers UX, Ender J. Initial experience with a percutaneous approach to redo mitral valve surgery: management and procedural success. J Cardiothorac Vasc Anesth. 2015;29:889–897.
3. Puls M, Lubos E, Boekstegers P, et al. One-year outcomes and predictors of mortality after MitraClip therapy in contemporary clinical practice: results from the German transcatheter mitral valve interventions registry. Eur Heart J. 2016;37:703–712.
4. Seeburger J, Rinaldi M, Nielsen SL, et al. Off-pump transapical implantation of artificial neo-chordae to correct mitral regurgitation: the TACT Trial (Transapical Artificial Chordae Tendinae) proof of concept. J Am Coll Cardiol. 2014;63:914–919.
5. Kavakli AS, Ozturk NK, Ayoglu RU, et al. Anesthetic management of transapical off-pump mitral valve repair with NeoChord implantation. J Cardiothorac Vasc Anesth. 2016;30:1587–1593.
6. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Thorac Cardiovasc Surg. 2014;148:e1–e132.
7. Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management of valvular heart disease (version 2012): the Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur J Cardiothorac Surg. 2012;42:S1–S44.
8. Maldonado Y, Singh S, Taylor MA. Cerebral near-infrared spectroscopy in perioperative management of left ventricular assist device and extracorporeal membrane oxygenation patients. Curr Opin Anaesthesiol. 2014;27:81–88.
9. Murkin JM, Adams SJ, Novick RJ, et al. Monitoring brain oxygen saturation during coronary bypass surgery: a randomized, prospective study. Anesth Analg. 2007;104:51–58.
10. Daneshmand MA, Milano CA, Rankin JS, et al. Mitral valve repair for degenerative disease: a 20-year experience. Ann Thorac Surg. 2009;88:1828–1837.
11. Braunberger E, Deloche A, Berrebi A, et al. Very long-term results (more than 20 years) of valve repair with carpentier’s techniques in nonrheumatic mitral valve insufficiency. Circulation. 2001;104(12 Suppl 1):I8–I11.
12. da Rocha ESJG, Spampinato R, Misfeld M, et al. Barlow’s mitral valve disease: a comparison of Neochordal (Loop) and edge-to-edge (Alfieri) minimally invasive repair techniques. Ann Thorac Surg. 2015;100:2127–2133.
13. David TE, Ivanov J, Armstrong S, Rakowski H. Late outcomes of mitral valve repair for floppy valves: implications for asymptomatic patients. J Thorac Cardiovasc Surg. 2003;125:1143–1152.
14. Ramlawi B, Gammie JS. Mitral valve surgery: current minimally invasive and transcatheter options. Methodist Debakey Cardiovasc J. 2016;12:20–26.
15. Cao C, Gupta S, Chandrakumar D, et al. A meta-analysis of minimally invasive versus conventional mitral valve repair for patients with degenerative mitral disease. Ann Cardiothorac Surg. 2013;2:693–703.
16. Cheng DC, Martin J, Lal A, et al. Minimally invasive versus conventional open mitral valve surgery: a meta-analysis and systematic review. Innovations (Phila). 2011;6:84–103.
17. Davierwala PM, Seeburger J, Pfannmueller B, et al. Minimally invasive mitral valve surgery: “The Leipzig experience”. Ann Cardiothorac Surg. 2013;2:744–50.
18. Ding C, Jiang DM, Tao KY, et al. Anterolateral minithoracotomy versus median sternotomy for mitral valve disease: a meta-analysis. J Zhejiang Univ Sci B. 2014;15:522–532.
19. Falk V, Cheng DC, Martin J, et al. Minimally invasive versus open mitral valve surgery: a consensus statement of the international society of minimally invasive coronary surgery (ISMICS) 2010. Innovations (Phila). 2011;6:66–76.
20. Glauber M, Miceli A, Canarutto D, et al. Early and long-term outcomes of minimally invasive mitral valve surgery through right minithoracotomy: a 10-year experience in 1604 patients. J Cardiothorac Surg. 2015;10:181.
21. McClure RS, Athanasopoulos LV, McGurk S, Davidson MJ, Couper GS, Cohn LH. One thousand minimally invasive mitral valve operations: early outcomes, late outcomes, and echocardiographic follow-up. J Thorac Cardiovasc Surg. 2013;145:1199–1206.
22. Modi P, Hassan A, Chitwood WR Jr. Minimally invasive mitral valve surgery: a systematic review and meta-analysis. Eur J Cardiothorac Surg. 2008;34:943–952.
23. Miceli A, Murzi M, Canarutto D, et al. Minimally invasive mitral valve repair through right minithoracotomy in the setting of degenerative mitral regurgitation: early outcomes and long-term follow-up. Ann Cardiothorac Surg. 2015;4:422–427.
24. Suri RM, Burkhart HM, Rehfeldt KH, et al. Robotic mitral valve repair for all categories of leaflet prolapse: improving patient appeal and advancing standard of care. Mayo Clin Proc. 2011;86:838–844.
25. Feldman T, Foster E, Glower DD, et al. Percutaneous repair or surgery for mitral regurgitation. N Engl J Med. 2011;364:1395–1406.
26. Cohn LH, Byrne JG. Minimally invasive mitral valve surgery: current status. Tex Heart Inst J. 2013;40:575–576.
27. Colli A, Manzan E, Rucinskas K, et al. Acute safety and efficacy of the NeoChord procedure†. Interact Cardiovasc Thorac Surg. 2015;20:575–580.
28. Colli A, Zucchetta F, Torregrossa G, et al. Transapical off-pump mitral valve repair with Neochord Implantation (TOP-MINI): step-by-step guide. Ann Cardiothorac Surg. 2015;4:295–297.
29. Gammie JS, Wilson P, Bartus K, et al. Transapical beating-heart mitral valve repair with an expanded polytetrafluoroethylene cordal implantation device: initial clinical experience. Circulation. 2016;134:189–197.
30. Koch CG, Li L, Duncan AI, et al. Morbidity and mortality risk associated with red blood cell and blood-component transfusion in isolated coronary artery bypass grafting. Crit Care Med. 2006;34:1608–1616.
31. Ritwick B, Chaudhuri K, Crouch G, Edwards JR, Worthington M, Stuklis RG. Minimally invasive mitral valve procedures: the current state. Minim Invasive Surg. 2013;2013:679276.
32. Gammie JS, Zhao Y, Peterson ED, O’Brien SM, Rankin JS, Griffith BP. J. Maxwell Chamberlain Memorial Paper for adult cardiac surgery. Less-invasive mitral valve operations: trends and outcomes from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg. 2010;90:1401–1408, 1410.e1.
33. Stevens LM, Rodriguez E, Lehr EJ, et al. Impact of timing and surgical approach on outcomes after mitral valve regurgitation operations. Ann Thorac Surg. 2012;93:1462–1468.
34. Trento A. Clinical outcomes associated with robotic repair of the mitral valve. Mayo Clin Proc. 2011;86:834–835.
35. Speziale G, Nasso G, Esposito G, et al. Results of mitral valve repair for Barlow disease (bileaflet prolapse) via right minithoracotomy versus conventional median sternotomy: a randomized trial. J Thorac Cardiovasc Surg. 2011;142:77–83.
36. Holzhey DM, Shi W, Borger MA, et al. Minimally invasive versus sternotomy approach for mitral valve surgery in patients greater than 70 years old: a propensity-matched comparison. Ann Thorac Surg. 2011;91:401–405.
37. Krishnaswamy A, Mick S, Navia J, Gillinov AM, Tuzcu EM, Kapadia SR. Transcatheter mitral valve replacement: a frontier in cardiac intervention. Cleve Clin J Med. 2016;83:S10–S17.
38. Muller DWM; Tendyne Global Feasibility Trial Investigators. Reply: the feasibility of transcatheter mitral valve replacement for patients with symptomatic mitral regurgitation. J Am Coll Cardiol. 2017;69:3124.

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