An elastic polymer tube is interposed between the leaflet and the free myocardial wall and secured to the epicardial
surface by an adjustable knot. The MitraFlex (TransCardiac Therapeutics, Atlanta, GA, USA) places an anchor in the inner LV myocardium and another on the leaflet via a thoracoscopic transapical approach and connects the two with a synthetic chord; it can also perform an edge-to-edge repair at the same time. The NeoChord (NeoChord, Inc., Minnetonka, Inhibitors,research,lifescience,medical USA)25 uses a mini-thoracotomy transapical access to capture the leaflet, and the chords are then exteriorized, adjusted, and tightened to the left ventricular myocardium. The V-Chordal (Valtech Cardio Ltd, Or-Yehuda, Israel)26 system uses a slow rotation of a helical element to fixate the chorda to the papillary muscle (Figure 2). Currently, the chordae are then sutured to the leaflets by direct vision through a mini-thoracotomy left atriotomy approach, Inhibitors,research,lifescience,medical but a clip-attaching
mechanism is already under development, to allow transfemoral access. Figure 2 The V-Chordal Device, Inhibitors,research,lifescience,medical a Surgically Implantable Adjustable Chordae Device. Alternative techniques for leaflet repair have been proposed. The Percu-Pro (Cardiosolutions, Stoughton, USA) is a space-occupying “buoy” anchored at the LV apex through a transseptal approach that should fill the gap between leaflets. The Thermocool irrigation ablation Ganetespib order electrode (Biosense Webster, Inc., Diamond
Bar, CA, USA) delivers, in the context of degenerative disease, radiofrequency energy to the leaflets to provoke shrinking and reduced motion.27 ANNULOPLASTY PROCEDURES Annuloplasty is a fundamental step Inhibitors,research,lifescience,medical to achieve effective and durable results after surgery.28 To achieve similar outcomes, transcatheter procedures should probably incorporate annular remodeling. In addition, the lack of a reliable annuloplasty device is impacting the eligibility for transcatheter interventions. Up to a third of patients screened for MitraClip are refused Inhibitors,research,lifescience,medical due to unfavorable anatomy, including annular dilatation.29 Transcatheter annuloplasty may therefore Florfenicol both improve outcomes and expand therapeutic indications. Different devices to reduce and reshape the mitral annulus are at different stages of research and development, addressing different anatomical and pathophysiological concepts. Indirect Annuloplasty (Sinoplasty) The coronary sinus (CS) encircles the posterior mitral annulus, and it may allow devices to be delivered to affect indirectly the posterior mitral annulus geometry. Although the CS approach is a consolidated procedure, it has important limitations: the CS is variably located at a certain distance from the mitral annulus (frequently increased in case of severe MR with annular dilation),30 and circumflex coronary artery compression has been frequently observed.