Category
Heart
The chance of developing heart valve disease increase with age. Royal Brompton Hospital leads the way in providing alternative beating heart minimally invasive treatments, suitable for high-risk patients with mitral valve disease. 

In the UK, heart valve disease affects around one and a half million people over the age of 65. With the population in this age bracket set to double to 19 million by 2050, there is likely to be a major increase in the prevalence of heart valve disease.

Since 2007, Royal Brompton Hospital has provided internationally renowned beating heart and transcatheter therapies for valvular heart disease. The service brings together a multi-disciplinary heart team who ensure patients with complex comorbidities and high surgical risk have access to novel and minimal access lifesaving treatments for valvular heart disease.

For patients diagnosed with mitral valve disease, conventional surgery is considered to be the gold standard treatment. But older or frail patients with complex mitral valve problems or younger patients with significant co-morbidities may be considered at prohibitive risk for open-heart surgery.

At Royal Brompton Hospital, the heart team is investing in new alternative treatment options to improve the chances of survival and recovery for these patients.

The NeoChord procedure is an innovative approach used for beating heart mitral valve repair. Using a minimally invasive technique, implantation of transventricular neochordae (artificial chordae) under live echo guidance enables treatment of severely regurgitant mitral valves. The procedure provides real-time confirmation of mitral valve repair without the need for the standard midline incision or temporarily stopping the heart.

Mitral regurgitation 

The mitral valve separates the upper left heart chamber from the lower left chamber and helps direct blood flow through the heart. Mitral regurgitation occurs when the valve becomes damaged and fails to close properly. This results in blood flowing backwards or leaking through the valve when the heart contracts.

There are several conditions that can lead to mitral regurgitation, but most commonly the chordae attached to mitral valve leaflets (chordae tendinae) become elongated and thinned and may rupture. This can lead to incomplete closure of the valve (mitral valve prolapse) and result in a severe leak. This is known as severe mitral regurgitat ion.

Symptoms can include shortness of breath, fatigue and palpitations. In severe cases, patients can experience worsening heart failure and increased pressure on the pulmonary vessels which can affect the lungs.

An innovative approach to mitral valve disease

Royal Brompton Hospital is the only centre across England, Scotland and Wales with expertise in beating heart mitral valve repair with NeoChord. High-risk patients with mitral regurgitation who have been declined treatment at other UK centres have been offered successful treatment at the hospital with this procedure.

NeoChord mitral valve repair is an off-pump technique that does not require a heart-lung bypass machine. Instead, specialist mitral surgeons can repair the valve while the heart is still beating, aided by image guidance from cardiologists with expertise in mitral echocardiography.

Using the NeoChord system, mitral valve repair is performed through a small incision between the ribs (thoracotomy).

 

Echo guidance is used to navigate the delivery system through the apex of the left ventricle towards the damaged area of the mitral valve. The prolapsing segment is grasped and artificial chordae are implanted on the beating heart. The NeoChords are adjusted to the optimal length to eliminate mitral regurgitation.

NeoChord beating mitral valve repair

Mitral valve repair using the NeoChord system is an alternative treatment option for patients diagnosed with severe degenerative mitral valve regurgitation.

This approach may be suited to patients who have undergone previous cardiac surgery, failed mitral repair, have insufficient lung capacity or are too high risk or other reasons to withstand conventional surgery.

Pre-operative valve analysis and intraoperative 2D and 3D transoesophageal echocardiography (TOE) provide important guidance for the NeoChord device. During the mitral valve repair procedure, the NeoChord device is navigated to the leaking segments of the mitral valve while the heart is beating.

Artificial chordae are implanted in place of the elongated or ruptured chordae during the procedure. Real-time feedback from TOE is used to accurately adjust the length of new artificial chordae until the mitral regurgitation is eliminated.

Resolution of mitral regurgitation on the beating heart offers a novel advantage over conventional surgery where the length of implanted chordae is estimated on an arrested heart. The success of the mitral repair can only be confirmed after the heart has been restarted and weaned from the heartlung bypass machine.’

Ms Rashmi Yadav, consultant cardiac surgeon, explains: “The NeoChord procedure is a novel approach, used to restore normal mitral valve function. The beating-heart repair provides minimally invasive treatment of regurgitant mitral valves with real-time confirmation of repair using TOE.”

“This innovative approach allows the heart team to treat extreme or high risk patients who may otherwise be denied life-saving treatment.”

Post treatment

The procedure usually takes between one to two hours. The time it takes to fully recover varies depending on factors such as age and overall health, and can vary between three to five days.

Mitral valve repair lowers the risk of stroke and infection (endocarditis), and usually eliminates the need for long-term use of blood thinners (anticoagulants). For most people, the NeoChord procedure will greatly improve symptoms and quality of life.

Referring a patient

For patients with mitral valve regurgitation, conventional surgery is still the gold standard treatment. The surgical members of our transcatheter valve team have international reputations in mitral surgery, particularly mitral repair.

For patients with complex mitral valve problems, the team will review each patient and advise on the most suitable treatment. They can help ensure each patient is directed to the most suitable clinician for their condition.


At a glance

Procedure

NeoChord beating heart mitral valve repair

Carried out by

Ms Rashmi Yadav

TOE guidance by

Dr Alison Duncan

What problem does it solve?

Mitral valve prolapse and mitral regurgitation can be treated using NeoChord – a minimally invasive, beating heart repair technique. This alternative treatment is intended for use when the native chordae tendinae have become elongated or ruptured.

NeoChord can suit patients considered to be high risk. This may be due to age, frailty, complex comorbidities, previous cardiac surgery or failure of a previous surgical mitral
valve repair.

How does it work?

The NeoChord procedure is performed through a small incision between the ribs (thoracotomy). Using 2D and 3D echo guidance, the delivery system is inserted into the left ventricle and navigated to the area of mitral valve prolapse.

The prolapsing segment of the mitral valve is grasped by the NeoChord device and artificial chordae placed along the mitral leaflet. The chordae are titrated to an optimal length on the beating heart which ensures resolution of mitral regurgitation.