CT for the transapical off-pump mitral valve repair with neochord implantation procedure

The advent of transapical echocardiography-guided mitral valve (MV) repair with implantation of polytetrafluoroethylene neochordae (NeoChord, St. Louis Park, Minnesota) has identified some critical aspects of the procedure that require accurate understanding of cardiac anatomy 1, 2. In particular, transapical access, used for transcatheter aortic valve replacement, does not provide direct alignment with the MV, which is more posterior with respect to the aortic valve (Figure 1). Thus, posterolateral ventricular access provides a better approach to the MV, reducing the risk of the device interfering with the native subvalvular apparatus and enabling a more physiological axis orientation of implanted neochordae (Figure 2) 1, 2. Cardiac computed tomography has recently been used as an additional tool for pre-operative procedure planning (Figure 3, Online Video 1) and for post-operative assessment of implanted neochordae (Figures 4 and 5, Online Videos 2, 3, 4, and 5). Ideal access can be identified by projecting the desired neochordae trajectory inside the left ventricle, starting from the diseased MV leaflet toward the left ventricular epicardial surface between the papillary muscles.