Case Study
Combined off-pump mitral repair and thoracoscopic maze surgery
Asian Cardiovascular & Thoracic Annals 0(0) 1–3 ! The Author(s) 2020 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/0218492320963978 journals.sagepub.com/home/aan
Manuel Carnero-Alca´zar1 , Javier Cobiella-Carnicer1, Patricia Mahia-Casado2 and Luis Carlos Maroto-Castellanos1
Abstract A 67-year-old man with severe mitral regurgitation and paroxysmal atrial fibrillation was admitted to our institution for surgical repair. The procedure was carried out off-pump. We first performed a totally thoracoscopic maze box lesion set with epicardial transmural radiofrequency, and clipped the left atrial appendage. The mitral valve prolapse was repaired by implanting three transapical neochordae. Six months later, the patient was in sinus rhythm with minimal residual mitral regurgitation on echocardiography. This novel approach is less invasive than the standard surgical correction and should ensure a faster recovery with similar safety and efficacy in selected cases. Keywords Atrial fibrillation, chordae tendineae, maze procedure, mitral valve insufficiency, thoracoscopy
Introduction We present a novel approach to surgical repair of severe mitral regurgitation and paroxysmal atrial fibrillation (AF) by a combined totally thoracoscopic maze procedure and transapical off-pump mitral valve repair with neochordal implantation.
Case report A 67-year-old man was admitted for mitral valve repair. During the previous two months, he had experienced two episodes of acute heart failure coinciding with paroxysmal AF. He had no previous history of arrythmia. On admission, he was in New York Heart Association class II–III. His CHA2DS2-VASc score was 2 so he was on oral anticoagulation. Echocardiography demonstrated severe mitral regurgitation with P2 prolapse (Figure 1). The anteroposterior mitral annulus diameter was 35 mm and the leafletto-annulus index was 1.27 (Figure 2). Left ventricular ejection fraction was preserved. The left atrial diameter was 4.9 cm. After discussing different surgical strategies with the patient, he opted for a combined totally thoracoscopic maze procedure and transapical off-pump mitral valve repair with neochordal implantation. First, we performed a totally thoracoscopic maze procedure. The right pulmonary veins were electrically
isolated with a radiofrequency clamp (EMR2 clamp, AtriCure, Mason, OH, USA). Lines were made in the left atrial roof and floor with an internally cooled radiofrequency pen (CoolRail Linear Pen, AtriCure). A left thoracoscopy was performed, Marshall’s ligament was dissected, and the left pulmonary veins were isolated with a radiofrequency clamp. Exit and entrance blockage of the pulmonary veins and posterior wall of the left atrium were tested with an isolator transpolar pen (MAX5TM, AtriCure). Finally, the left atrial appendage was excluded using a 45-mm AtriClip PRO (AtriCure; Video 1). The incision for the most caudal left chest trocar was enlarged to access the pericardium. We chose the best site to access the apex by pressing with one finger on the epicardium of the free wall of the left ventricle and observing its imprint in the cavity of the left ventricle in the echocardiogram. The patient was anticoagulated with 1.5 mg kg 1 of heparin. Four 4/0 expanded polytetrafluoroethylene 1 Department of Cardiac Surgery, Hospital Clınico San Carlos, Madrid, Spain 2 Department of Cardiology, Hospital Clınico San Carlos, Madrid, Spain
Corresponding author: Manuel Carnero Alca´zar, Secretaria Cirugıa Cardiaca, Hospital Clınico San Carlos, Plaza Cristo Rey s/n, 28040 Madrid, Spain. Email: [email protected]
2
Asian Cardiovascular & Thoracic Annals 0(0)
Figure 1. The P2 prolapse.
echocardiogram, and sutured to the apex of the left ventricle with slight over-tensioning so that minimal residual mitral regurgitation was observed. Six months later, the patient was in New York Heart Association class I, diuretics and oral anticoagulants were stopped, but he was still on beta blockers. Echocardiography revealed minimal mitral regurgitation, and 24-hour Holter monitoring at 1, 3, and 6 months after the procedure did not detect any episode of AF.
Discussion
Figure 2. Diameter of the mitral annulus (D1), and the anterior (D2) and posterior (D3) leaflet lengths.
neochordae were implanted in the free edge of the P2 escallop using a NeoChord DS-100 device (NeoChord, Inc., St. Louis Park, MN, USA). The neochordae were tensioned until perfect coaptation was observed in the
Transapical off-pump mitral valve repair with neochordal implantation has proved effective to treat Carpentier type II mitral regurgitation.1 Colli and colleagues2 demonstrated excellent short- and mid-term outcomes with this technique when mitral prolapse is anatomically favorable: isolated central posterior leaflet disease,2 and mitral annulus not severely enlarged (leaflet-to-annulus index >1.25),3 such as in our case. Before this case, we had performed 26 isolated transapical off-pump mitral valve repairs with neochordal implantation. This is now offered to patients who are good anatomical candidates, along with port-access or mid-sternotomy approaches. Although standard mitral valve repair is the gold standard to correct valve prolapse, this technique adds some benefits: a minimally invasive approach, valve repair under physiologic beating heart conditions, and avoidance of cardiopulmonary bypass. The number of neochordae to be implanted depends on the length of the prolapsing scallops, although we believe it is important to place as many as possible to prevent recurrences. As the left ventricular cavity reduces when mitral regurgitation is corrected, the mitral annulus also reduces and P2 prolapse may recur.4 For this reason, over-tensioning of
Carnero-Alca´zar et al. the polytetrafluoroethylene sutures is recommended so that when the left ventricle reduces, coaptation improves. The totally thoracoscopic maze procedure is effective and safe for the treatment of stand-alone AF, especially if it is paroxysmal and the left atrium is not severely enlarged.5 Because AF in this case was concomitant with mitral valve disease, a concomitant maze IV would have been recommended.6 However, we believe the effectiveness of a totally thoracoscopic maze would be close to that of a standard maze given that AF was paroxysmal and the left atrium was not severely enlarged. Our practice is to stop anticoagulation six months after the procedure if the left atrial appendage remains totally excluded (pouch
Combined off-pump mitral repair and thoracoscopic maze surgery
Asian Cardiovascular & Thoracic Annals 0(0) 1–3 ! The Author(s) 2020 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/0218492320963978 journals.sagepub.com/home/aan
Manuel Carnero-Alca´zar1 , Javier Cobiella-Carnicer1, Patricia Mahia-Casado2 and Luis Carlos Maroto-Castellanos1
Abstract A 67-year-old man with severe mitral regurgitation and paroxysmal atrial fibrillation was admitted to our institution for surgical repair. The procedure was carried out off-pump. We first performed a totally thoracoscopic maze box lesion set with epicardial transmural radiofrequency, and clipped the left atrial appendage. The mitral valve prolapse was repaired by implanting three transapical neochordae. Six months later, the patient was in sinus rhythm with minimal residual mitral regurgitation on echocardiography. This novel approach is less invasive than the standard surgical correction and should ensure a faster recovery with similar safety and efficacy in selected cases. Keywords Atrial fibrillation, chordae tendineae, maze procedure, mitral valve insufficiency, thoracoscopy
Introduction We present a novel approach to surgical repair of severe mitral regurgitation and paroxysmal atrial fibrillation (AF) by a combined totally thoracoscopic maze procedure and transapical off-pump mitral valve repair with neochordal implantation.
Case report A 67-year-old man was admitted for mitral valve repair. During the previous two months, he had experienced two episodes of acute heart failure coinciding with paroxysmal AF. He had no previous history of arrythmia. On admission, he was in New York Heart Association class II–III. His CHA2DS2-VASc score was 2 so he was on oral anticoagulation. Echocardiography demonstrated severe mitral regurgitation with P2 prolapse (Figure 1). The anteroposterior mitral annulus diameter was 35 mm and the leafletto-annulus index was 1.27 (Figure 2). Left ventricular ejection fraction was preserved. The left atrial diameter was 4.9 cm. After discussing different surgical strategies with the patient, he opted for a combined totally thoracoscopic maze procedure and transapical off-pump mitral valve repair with neochordal implantation. First, we performed a totally thoracoscopic maze procedure. The right pulmonary veins were electrically
isolated with a radiofrequency clamp (EMR2 clamp, AtriCure, Mason, OH, USA). Lines were made in the left atrial roof and floor with an internally cooled radiofrequency pen (CoolRail Linear Pen, AtriCure). A left thoracoscopy was performed, Marshall’s ligament was dissected, and the left pulmonary veins were isolated with a radiofrequency clamp. Exit and entrance blockage of the pulmonary veins and posterior wall of the left atrium were tested with an isolator transpolar pen (MAX5TM, AtriCure). Finally, the left atrial appendage was excluded using a 45-mm AtriClip PRO (AtriCure; Video 1). The incision for the most caudal left chest trocar was enlarged to access the pericardium. We chose the best site to access the apex by pressing with one finger on the epicardium of the free wall of the left ventricle and observing its imprint in the cavity of the left ventricle in the echocardiogram. The patient was anticoagulated with 1.5 mg kg 1 of heparin. Four 4/0 expanded polytetrafluoroethylene 1 Department of Cardiac Surgery, Hospital Clınico San Carlos, Madrid, Spain 2 Department of Cardiology, Hospital Clınico San Carlos, Madrid, Spain
Corresponding author: Manuel Carnero Alca´zar, Secretaria Cirugıa Cardiaca, Hospital Clınico San Carlos, Plaza Cristo Rey s/n, 28040 Madrid, Spain. Email: [email protected]
2
Asian Cardiovascular & Thoracic Annals 0(0)
Figure 1. The P2 prolapse.
echocardiogram, and sutured to the apex of the left ventricle with slight over-tensioning so that minimal residual mitral regurgitation was observed. Six months later, the patient was in New York Heart Association class I, diuretics and oral anticoagulants were stopped, but he was still on beta blockers. Echocardiography revealed minimal mitral regurgitation, and 24-hour Holter monitoring at 1, 3, and 6 months after the procedure did not detect any episode of AF.
Discussion
Figure 2. Diameter of the mitral annulus (D1), and the anterior (D2) and posterior (D3) leaflet lengths.
neochordae were implanted in the free edge of the P2 escallop using a NeoChord DS-100 device (NeoChord, Inc., St. Louis Park, MN, USA). The neochordae were tensioned until perfect coaptation was observed in the
Transapical off-pump mitral valve repair with neochordal implantation has proved effective to treat Carpentier type II mitral regurgitation.1 Colli and colleagues2 demonstrated excellent short- and mid-term outcomes with this technique when mitral prolapse is anatomically favorable: isolated central posterior leaflet disease,2 and mitral annulus not severely enlarged (leaflet-to-annulus index >1.25),3 such as in our case. Before this case, we had performed 26 isolated transapical off-pump mitral valve repairs with neochordal implantation. This is now offered to patients who are good anatomical candidates, along with port-access or mid-sternotomy approaches. Although standard mitral valve repair is the gold standard to correct valve prolapse, this technique adds some benefits: a minimally invasive approach, valve repair under physiologic beating heart conditions, and avoidance of cardiopulmonary bypass. The number of neochordae to be implanted depends on the length of the prolapsing scallops, although we believe it is important to place as many as possible to prevent recurrences. As the left ventricular cavity reduces when mitral regurgitation is corrected, the mitral annulus also reduces and P2 prolapse may recur.4 For this reason, over-tensioning of
Carnero-Alca´zar et al. the polytetrafluoroethylene sutures is recommended so that when the left ventricle reduces, coaptation improves. The totally thoracoscopic maze procedure is effective and safe for the treatment of stand-alone AF, especially if it is paroxysmal and the left atrium is not severely enlarged.5 Because AF in this case was concomitant with mitral valve disease, a concomitant maze IV would have been recommended.6 However, we believe the effectiveness of a totally thoracoscopic maze would be close to that of a standard maze given that AF was paroxysmal and the left atrium was not severely enlarged. Our practice is to stop anticoagulation six months after the procedure if the left atrial appendage remains totally excluded (pouch
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