Anesthetic management of patients undergoing transapical implantation of artificial chordae to correct mitral regurgitation Robertas Stasys Samalavicius, Ieva Norkiene, Vilius Janusauskas, Karolis Urbonas, Diana Zakarkaite, Agne Drasutiene, Audrius Aidietis, Kestutis Rucinskas   Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania Introduction: Transapical impantation of NeoChord is an emergent beating heart technique for correction of mitral regurgitation through minimal invasive left minithoracotomy. The purpose of this study was to evaluate the anesthetic management and procedural success of patients undergoing this procedure. Methods: Observational bioethics committee approved prospective study. From December 2011 to November 2015 sixty five patients underwent mitral valve repair with NeoChord system in our institution. Balanced anaesthesia with fentanyl- propofol-sevofluran was used in all cases. Patient core temperature was attempted to keep above 36°C with warming blanket and warm infusion fluids. A 2D and 3D TEE was used in all patients to navigate the NeoChord deployment instrument mainly to posterior mitral valve leafleat(63 cases out of 65). Following effective leaflet capture artificial chordae were deployed. Optimal placement of artificial chordae was evaluated by placing them under tension and observing significant contribution to MR reduction. Cell saver was used in all cases. Following surgery all patients were transferred to the ICU. Results: Mean age of the patients was 61,2±12 years (range 33-87 ), male/female ratio 45/20. Most patients had severe mitral regurgitation (grade IV – 19 (29%), grade III – 46(71%)). The average preoperative euroscore II – 1,25±1,1% (range 0,46-4,23). Mean duration of the procedure was 127±25 minutes (range 70 – 200). Average reduction of mitral regurgitation was from pre-procedural grade 3,3±0,5 to 0,5±0,7 immediately following the procedure. One patient was converted to conventional mitral valve repair due to failure to effectively deploy neochords. All patients underwent uneventful postoperative course. The average time to extubation was 4,2±2,3 hours and length of ICU stay - 29±18 hours. Only three patients (4,7%) of those with successful repair of mitral regurgitation with neochord implantation needed any allogeneic blood products. Conclusion: Anaesthesia for transapical NeoChord implantation could be performed safely under beating-heart conditions, with short procedural time and minimal perioperative patient morbidity. Two dimensional and three dimensional TEE plays a vital role during the NeoChord implantation. TEE: All procedures were performed under transesophageal echocardiography (TEE). Both two and three dimensional (2D and 3D ) imaging modalities are used. The ideal LV entry site was identified from 2D long-axis view (Figure 1), applying a pressure to LV apex – “finger test”. The introduction of NeoChord DS1000 system into the LV cavity was performed under 2D TEE (three-chamber view and X-plane modality with two orthogonal 2D planes displayed simultaneously). The device was positioned according to prolapsing segment. The presence of two planes with a high frame rate fascilitated the navigation of the device through the LV cavity and across the MV plane (Figure 2). When the device passed the MV annular plane and entered the left atrium, imaging was switched into real-time 3D zoom modality Live 3D Zoom enabled affective leaflet grasping and suture deployment throught LV cavity (Figure 3). After the suture was deployed and the device retrieved from the LV, the surgeon applied tension on the leaflet. A 3D TEE “surgical view” was used then to evaluate the anatomical effect (reduction/disappearance of the prolapse) and 2D-Color Doppler was used to evaluate reduction of the mitral regurgitation. These maneuvers were repeated after implantation of each new artificial chorda (usually 3 or 4 times), until desired effect was reached (Figure 4). Table 1: Patient demographics and co-morbidities Total number of patients 65 Male patient, n (%) 45 (69%) Age (in years), mean ± SD 61,2 ± 12 BMI (kg/m2), mean ± SD 27 ± 4,4 EUROSCORE II, mean ± SD 1,25 ± 1,07 Patients in NYHA I, n (%) 3 (5%) Patients in NYHA II, n (%) 34 (52%) Patients in NYHA III, n (%) 26 (40%) Patients in NYHA IV, n (%) 1 (2%) Creatinine clearance, mean ± SD 65,2 ± 22,2 Creatinine clearance less than 85*, n (%) 22 (34%) Recent myocardial infarction, n (%) 0 (0%) Diabetes, n (%) 2 (3%) COPD, n (%) 3 (4.6%) Pulmonary hypertension ( > 50mmHg), n (%) 8 (15%) Peripheral vascular disease, n (%) 1 (2 %) Hypertension, n (%) 64 (50 %) Table 3: Peri-operative data   Total number of patients 64 Intraoperative variables Duration of surgery (min), mean ± SD 127 ± 25 Intraoperative fluid balance (ml), mean ± SD +1537 ± 683 Blood loss during surgery (ml), mean ± SD 636 ± 461 Re-transfusion of washed erythrocytes (ml), mean ± SD 318 ± 228 Re-transfusion of washed erythrocytes, n (%) 46 (71%) Intraoperative blood loss in patients who had re-transfusion (ml), mean ± SD 691 Intraoperative blood loss (no re-transfused patients (ml), mean ± SD 636 Blood products usage Transfussion of RBC n (%) 2 (3%) Transfusion of platelets n (%) 0% Transfusion of FFP, n (%) 1 (2%) Postoperative variables Chest tube drainage (ml) Mean ± SD 248 ± 142 Atrial fibrillation n (%) 8 (12 %) Need of inotropic support n (%) 20 (31 %) Resternotomy n (%) Duration of postoperative CMV (h), mean ± SD 4,2 ± 2,3 Length of ICU stay (hours), mean ± SD 29 ± 18 Post-procedure length of stay in hospital (days), mean ± SD 9 ± 3 Figure 3. Neochord DS1000 device introduction(A) and passage through LV cavity and subvalvular aparatus (B,C) (2D TEE at 120– 140°). Figure 2: Identification of ideal LV entry site by 2D long-axis view with „finger“ test. LVEF – left ventricular ejection fraction, LVEDD – left ventricular end diastolic volume, LVESD – left ventricular end systolic volume, LA – left atrium, IVS – intraventricular septum, MR – mitral regurgitation, TR – tricuspid regurgitation. *Estimated creatinine clearance calculated with Cocckford-Gault formula; BMI – body mass index, COPD – chronic obstructive pulmonary disease, NYHA: New York Heart Association, SD: Standard deviation Table 2: Patient preoperative cardio-echoscopy data   Total number of patients 65 LVEF (%) (Mean ± SD) 56 ± 4 LVEDD (cm) Mean ± SD 5,9 ± 0,62 LVESD (cm) Mean ± SD 3,54 ± 0,65 LA volume index (ml/m2) Mean ± SD 73 ± 22 IVSd (cm) Mean ± SD 1 ± 0,1 Percentage of patients with MR 3+ 46 (71%) Percentage of patients with MR 4+ 19 (29%) Percentage of patients with TR 0+ 26 (40%) Percentage of patients with TR 1+ 28 (43%) Percentage of patients with TR 2+ 11 (17%) Figure 1. Neochord DS1000 device Figure 5. Evaluation of the repair by its anatomical aspect (A - before, B-after the procedure) and functional aspect with  2D Color Doppler (C - before, D-after the procedure) . Figure 4. Neochord DS1000 device introduction(A) and passage through LV cavity and subvalvular aparatus (B,C) (2D TEE at 120– 140°). CMV – controlled mechanical ventilation, ICU – intensive care unit, RBC – red blood cells, FFP – fresh frozen plasma