Extended trans-septal versus left atrial approach in mitral valve surgery: 1017 patients’ experience

Correspondence to Dr Syed Saleem Mujtaba, Department of Cardiothoracic Surgery, Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK; [email protected]

Introduction

The mitral valve may be accessed directly via the left atrium after development of Sondergaard’s groove or through the interatrial septum after incising the right atrium. While the left atrial (LA) approach has traditionally been most popular among surgeons, visualisation and access to the mitral valve can sometimes be difficult and challenging especially with regard to the anterior leaflet and annulus. The interatrial trans-septal (TS) approach affords superior access and can be transverse or vertical.

Lillehei et al ¹ exposed the valve by means of a left atriotomy posterior to the interatrial groove from the right thorax. Effler et al ² modified this approach by operating on the mitral valve through the interatrial septum from the right chest.

Dubost and colleagues³ used a TS incision which extended medially from right superior pulmonary vein to right atrium and through the interatrial septum. Guiraudon et al ⁴ alternatively described a superior septal or extended vertical TS incision through the right atrium superiorly into left atrium along with an interatrial septostomy to the inferior pole of fossa ovalis.

The risks of transecting the sinus node artery and the internodal pathways and the need to reconstruct the wall of the atria and the interatrial septum have been considered important limitations. Because the incisions are longer, closing time is prolonged and there may be more risk of bleeding. There are concerns regarding postoperative atrial fibrillation and complete heart block requiring permanent pacemaker which may be of greater incidence than for conventional approaches despite the superior access to the mitral valve which is afforded.

To address the concerns raised in the literature regarding the extended vertical trans-septal approach (EVTSA), this paper presents our experience with more than 1000 mitral valve procedures utilising either the traditional LA or EVTSA.

Surgical technique

After midline sternotomy is performed and heparin given, the superior vena cava is cannulated directly. The inferior vena cava is similarly cannulated at the inferior, lateral portion of the right atrium. Both cavae are encircled with tapes. After cardiopulmonary bypass (CPB) is instituted with aortic return, cardioplegia is delivered through the ascending aorta after cross-clamping and is repeated every 45...