Ann Thorac Surg 1995;59:222-224
© 1995 The Society of Thoracic Surgeons
Case Report
Mitral Valve Replacement After Previous Right Pneumonectomy
Mohammad Bashar Izzat, FRCS,
Idriss A. Regragui, FRCS,
Gianni D. Angelini, FRCS
Department of Cardiac Surgery, University of Bristol, Bristol, United Kingdom
Accepted for publication May 10, 1994.
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Abstract
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Adequate exposure of the mitral valve is essential to the safe and effective performance of valve replacement. We describe a successful mitral valve replacement performed in a patient who had undergone a right pneumonectomy. After a median sternotomy was made, the mitral valve was approached through an incision in the left atrial appendage that extended to the origin of the left superior pulmonary vein. The operation was uncomplicated, and the patient made an uneventful recovery.
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Introduction
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Although satisfactory exposure of the mitral valve can usually be achieved using one of the standard approaches, displacement of the heart to the right side as the result of right lung resection can make visualization of the mitral apparatus very difficult, jeopardizing effective surgical treatment. We describe an approach to the mitral valve through the left atrial appendage in a patient who had undergone a right pneumonectomy 10 years earlier.
A 65-year-old man was referred for mitral valve replacement. Ten years earlier, he had undergone a right pneumonectomy for the removal of a bronchial carcinoid tumor, and at that time was noted to have mild mitral regurgitation. Recurrent attacks of atrial fibrillation and increasing effort dyspnea of recent onset had prompted his current admission. On examination, he was found to have marked precordial pulsation at the right sternal edge and a loud pansystolic murmur in the right anterior and posterior side of his chest. A chest x-ray study showed marked displacement of the heart shadow into the right pneumonectomy space (Fig 1
). Transthoracic echocardiography confirmed that the heart apex was directly behind the lower sternum and the mitral valve was at the level of right fifth intercostal space, in the midaxillary line. There was an enlarged left atrium, marked prolapse of both leaflets of the mitral valve, and severe mitral regurgitation. A coronary angiogram confirmed that the coronary arteries were normal.
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Fig 1. . Preoperative chest x-ray study showing marked displacement of the heart shadow into the right pneumonectomy space.
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At operation, a median sternotomy was made. The left pleura and lung, which were crossing the midline, were carefully peeled off the pericardium and retracted laterally. The pericardial sac, which occupied the right pleural cavity, was opened. The heart was displaced to the right and rotated counterclockwise around its long axis, which brought both the left atrium and left ventricle more into view (Fig 2A). The right-sided shift of the heart pushed the right atrium away from the operative field, such that only the right atrial appendage could be seen. None of the standard approaches to the mitral valve appeared feasible; therefore, we decided to approach the mitral valve through the left atrial appendage.
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Fig 2. . Left atrial appendage approach to the mitral valve. (A) View of the line of incision (broken line) in the left atrial appendage extending to the left superior pulmonary vein. (B) The margins of the incision are retracted by stay sutures, and the mitral valve is visualized.
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Cannulation for cardiopulmonary bypass was achieved by inserting an arterial cannula into the ascending aorta and a two-stage venous cannula through the right atrial appendage. The heart was arrested using antegrade cold crystalloid St. Thomas' cardioplegic solution. An incision was made in the left atrial appendage. This was extended into the left superior pulmonary vein, as, due to the malposition of the heart, this provided the best exposure (Fig 2B
). The anterolateral commissure of the mitral valve was 2 cm from the incision, and the valve leaflets could be visualized without difficulty or the need for forceful retraction. Exposure was facilitated by the placement of stay sutures around the margin of the incision. The valve was found to have degenerated with rupture of multiple chordae tendineae supporting the anterior and posterior leaflets. The valve was replaced with a bileaflet mechanical prosthesis (27 mm; CarboMedics, Austin, TX) and the atrial incision was closed with a running 3-0 monofilament suture starting in the left superior pulmonary vein. Air was evacuated from the heart by aspirating with a needle and syringe through the left atrial appendage and the apex of the left ventricle, both of which were easily accessible. Cardiopulmonary bypass was discontinued without the need for inotropic agent support. The patient recovered uneventfully and was discharged home on the seventh postoperative day. His postoperative progress as of 6 months has been satisfactory. The patient is in New York Heart Association functional class I, and transthoracic echocardiography has confirmed good prosthetic valve function.
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Comment
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Complete visualization of the mitral apparatus is a prerequisite for accurate repair or replacement of the mitral valve. In most situations, after a median sternotomy has been made, the classic approach, which involves an incision in the left atrium posterior and parallel to the interatrial groove, is satisfactory. However, exposure can be difficult under certain circumstances, such as when the left atrium is small. Several techniques have been described and used in an attempt to improve exposure of the mitral apparatus, including the superior-septal and transseptal approaches [1–5]. The approach to the mitral valve through a left thoracotomy and left atrial appendage, first described by Clowes and associates [6] in 1962, has disappeared from routine practice following the widespread adoption of the median sternotomy incision for open heart surgical procedures.
In our patient, the marked displacement of the heart to the right made it impossible to retract the right atrium and interatrial septum. An approach through a left thoracotomy was not an option because of the risk of damaging the remaining lung. Adequate exposure of the mitral valve was obtained through the left atrial appendage without the need to retract any of the heart chambers. The technique was relatively simple, did not require complicated reconstruction at the end of the main procedure, and did not result in a prolonged operative time.
With this case report, we wish to emphasize and remind surgeons that, in special circumstances, the long forgotten left atrial appendage approach to the mitral valve may provide the solution to a difficult surgical problem.
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Acknowledgments
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We thank Gary M. James for providing the illustrations.
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Footnotes
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Address reprint requests to Mr Angelini, British Heart Foundation, Department of Cardiac Surgery, Bristol Royal Infirmary, Bristol BS2 8HW, United Kingdom.
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References
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- Meyer BW, Verska JJ, Lindesmith GG, Jones JC. Open repair of mitral valve lesions: the superior approach. Ann Thorac Surg 1965;1:453–7.
- Barner HB. Combined superior and right lateral left atriotomy with division of the superior vena cava for exposure of the mitral valve. Ann Thorac Surg 1985;40:365–7.[Abstract]
- Smith CR. Septal-superior exposure of the mitral valve, the transplant approach. J Thorac Cardiovasc Surg 1992;103:623–8.[Abstract]
- Brawley RK. Improved exposure of the mitral valve in patients with a small left atrium. Ann Thorac Surg 1980;29: 179–80.[Abstract]
- Kon ND, Tucker WY, Mills SA, Lavender SW, Cordell AR. Mitral valve operation via an extended transseptal approach. Ann Thorac Surg 1993;55:1413–7.[Abstract]
- Clowes GHA, Neville WE, Sancetta SM, et al. Results of open surgical correction of mitral valvular insufficiency and description of technique for approach from left side. Surgery 1962;51:138–54.
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Abstract
Introduction
