Journal of Cardiac Surgery | 2021
Percutaneous coronary intervention before NeoChord mitral valve repair: Expanding the spectrum of hybrid procedures
Abstract
Coronary artery disease (CAD) and valvular heart disease are leading causes of major cardiovascular events worldwide and both conditions may coexist in a sizeable group of patients. Concomitant CAD and severe mitral regurgitation (MR) occur in approximately 42% of patients referred for surgical mitral valve replacement (SMVR). Traditionally, the management strategy for the patients with severe stenosis in major coronary arteries (>70% luminal stenosis or left main artery with >50% luminal stenosis) has been SMVR and coronary artery bypass grafting in a single procedure. Current guidelines support this approach with a class IIa recommendation. With the inception of new percutaneous and surgical techniques to treat severe valvular heart conditions, the potential benefits of coronary revascularization before these procedures are unknown. Moreover, there is no current standard management strategy for these patients. This lack of evidence has motivated active research to determine the real clinical impact of revascularization. To this end, in this issue of the Journal, Pradegan et al. examine the feasibility of performing percutaneous coronary intervention (PCI) before transapical off‐pump NeoChord mitral valve repair (microinvasive procedure) to treat significant degenerative MR. Within the database of NeoChord procedures carried out at the Padova University Hospital, the authors identified 17 patients with concomitant CAD who were included in the analysis. In nine patients (Group 1), CAD was found during the preoperative evaluation of the mitral valve disease. These patients underwent PCI with a median time of 2 months between PCI and the NeoChord procedure. In the remaining eight patients, CAD was an established component of their past medical history. In these cases, PCI was done following an acute coronary syndrome; and occurred with a median time of 30 months before the NeoChord repair. As expected, the time between the PCI and the mitral valve procedure was statistically significant. The latter group of patients underwent a follow‐up cardiac catheterization before the mitral procedure and none of them had to get a coronary intervention, as their stents were patent. The majority of patients had the single‐vessel disease (70.6%) and the left anterior descending artery was the predominantly affected vessel (58.8%). Furthermore, a significant number of patients were on dual antiplatelet therapy at the time of the NeoChord procedure (nine in Group 1 and one in Group 2). This difference was also significant from a statistical point of view. Interestingly, there were no surgical revisions for bleeding after NeoChord implantation. At 1‐year follow‐up, 16 patients were alive and 15 of them did not experience any major adverse events. Only one patient was reoperated due to late NeoChord failure. The data from Pradegan et al. suggest that performing (PCI) before transapical off‐pump NeoChord mitral valve repair (microinvasive procedure) in selected patients is safe and effective and it seems that a history of PCI before the procedure, regardless of timing does not have any impact on postprocedural outcomes. We should take a note of caution when we consider these results. Given the modest sample size and the relatively short follow‐up period, the data may be insufficient to demonstrate a true outcome. Nonetheless, it is encouraging that this total microinvasive strategy seems to be feasible in a real‐world scenario, with a high procedure success rate and low rates of adverse cardiac and bleeding events. Future studies should not only report the outcomes in the selected cases treated with PCI before transapical off‐pump NeoChord mitral valve repair but should also include the patient selection process detailing the inclusion/exclusion criteria for the total microinvasive strategy and describe more specifically the procedural planning process. This is especially important as the management of concomitant CAD in patients with severe mitral valve disease can be extremely challenging.