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Ann Thorac Surg 1996;62:1542-1544
© 1996 The Society of Thoracic Surgeons

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How To Do It

Minimally Invasive Mitral Valve Operations

Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio

Accepted for publication July 24, 1996.

	Abstract

Top Footnotes Abstract Introduction Technique Comment References

 
A technique for mitral valve operations is described in which exposure is performed through a small right parasternal incision. Via a transseptal approach, excellent exposure to the mitral valve is obtained, allowing surgical correction of the diseased valve.

	Introduction

Top Footnotes Abstract Introduction Technique Comment References

 
Good exposure of the mitral valve is one of the most important factors for performing repair or replacement. Lillehei and colleagues [1] were the first to employ cardiopulmonary bypass for repair of a mitral valve lesion. They approached the valve through a right thoracotomy and an incision in the left atrium posterior to the intraatrial groove. Effler and associates [2] modified this technique using an incision in the intraatrial septum. Currently, median sternotomy with an incision of the left atrium is the standard approach to the mitral valve because the incision is easily opened and closed, there is minimal patient morbidity, and easy access to the entire heart is possible. This tactic provides excellent exposure of the mitral valve in patients with an enlarged left atrium. In patients with a small atrium, exposure can be limited, especially in patients with an increased anterior posterior dimension.

The desire to improve exposure stimulated surgeons to seek alternative methods that would provide better exposure of the mitral valve and its subvalvular mechanism. A transseptal approach was described by Dubost and colleagues [3] using a biatrial incision and transecting the septum. Guiraudon and associates [4] described an approach via the right atrium. The intraatrial septum was incised vertically and the incision extended into the dome of the left atrium. Using a 10-cm right parasternal incision, we have approached the mitral valve via an incision in the intraatrial septum as described by Guiraudon and associates.

	Technique

Top Footnotes Abstract Introduction Technique Comment References

 
Standard hemodynamic monitoring is used and external defibrillator pads are placed posteriorly and anteriorly on the lateral left chest wall. The right side of the chest is elevated 30 degrees. The chest is prepared and draped to enable sternotomy, should this become necessary. A 10-cm incision is made extending from the inferior border of the right second costal cartilage to the superior edge of the fifth costal cartilage, 3 cm lateral to the sternum. The third and fourth cartilages are completely resected. This exposes the right internal mammary artery, which is mobilized and ligated to enhance exposure and insure hemostasis. The pericardium is incised longitudinally, and the edges are suspended from the chest wall to elevate the right side of the heart. The right common femoral artery is cannulated for arterial return. A right-angled cannula is placed in the superior vena cava, and a venous cannula is placed from the right common femoral vein into the inferior vena cava. Cardiopulmonary bypass is initiated. After decompression of the right side of the heart, the superior and inferior vena cava are snared. The aorta is cross-clamped and antegrade cardioplegia is administered.

The right atriotomy incision is begun at the right atrial appendage and extended cephalad toward the dome of the left atrium and caudal toward the inferior vena cava. The septum is incised in the foramen ovale, and the incision is extended cephalad to the superior end of the septum (Fig 1). Retrograde cardioplegia is initiated by placing a pursestring suture around the coronary sinus and inserting a cannula under direct vision. Stay sutures retract the right atrial wall and intraatrial septum to expose the mitral valve (Fig 2). The septal incision can be extended into the dome of the left atrium (Fig 3). Exposure is enhanced by placing retractors in the superior and inferior portions of the incision to retract the left atrial wall (Fig 4). The mitral valve is either repaired or replaced.

View larger version (52K): [in this window] [in a new window]   Fig 1. . Right atrium is opened and interatrial septum is exposed; stay sutures are placed on the right atrial wall. The dotted lines indicate the septum incision.

View larger version (67K): [in this window] [in a new window]   Fig 2. . The septum is opened; the mitral valve is exposed. Stay sutures are placed on the edge of the septal wall.

View larger version (77K): [in this window] [in a new window]   Fig 3. . Exposure of the mitral valve is enhanced by extending the incision into the dome of the left atrium.

View larger version (50K): [in this window] [in a new window]   Fig 4. . Exposure of the mitral valve is enhanced by placing retractors in the superior and inferior portions of the atrial septal wall.

During April and May 1996, minimally invasive mitral valve operations were performed on 25 patients. All patients underwent mitral valve repair using the Cosgrove-Edwards Flexible Annuloplasty System. There were no hospital deaths, reoperations for bleeding, embolic complications, wound infections, or valve repair failures. No sinus node dysfunction or atrioventricular dissociation resulted.

	Comment

Top Footnotes Abstract Introduction Technique Comment References

 
Interest in minimally invasive surgical techniques for coronary artery surgery continues to increase. Early follow-up demonstrates that less invasive procedures maintain the effectiveness of the operation, reduce cost, accelerate patient recovery, and decrease total hospital length of stay. These benefits encouraged the application of minimally invasive techniques for valve procedures. Of concern was the fact that surgical correction of acquired mitral valve disease requires adequate visualization of the valve. The posterior anatomic position of the mitral valve and the proximity of the mitral valve to the base of the atrial septum raised concerns regarding the adequacy of exposure. Via a right parasternal incision and transatrial septal approach, satisfactory exposure of the mitral valve was obtained without the need for forceful retraction. Although the surgical field is smaller than with a median sternotomy, the mitral valve is positioned in the center of the incision and, if the atrium is small, extension of the incision over the dome of the left atrium provides a substantial improvement of exposure.

Extension of the incision into the dome of the left atrium may cause injury to the sinus node artery. This may cause a sinus node dysfunction in the early postoperative period, which is transient in the majority of patients [5].

The only situation where this invasive procedure has not provided adequate exposure is in patients with pectus excavatum where the heart is located entirely in the left hemithorax. Other procedures, such as repair of atrial septal defects and procedures on the tricuspid valve may be possible via this approach.

As in minimally invasive operations for myocardial revascularization, the smaller incision has many potential advantages. There is less trauma and less pain reported by the patients. With median sternotomy, the most common pain reported by patients is back pain, largely due to traction on the ribs and thoracic ligaments. The smaller incision in minimally invasive operations greatly reduces this discomfort. Additionally, the smaller incision reduces the risks for wound infection and blood loss. Patients recover more rapidly and are discharged from the hospital earlier, reducing total hospital cost. This minimally invasive technique simplifies the operative procedure, reduces surgical trauma, and is cosmetically more attractive to patients (Fig 5).

View larger version (113K): [in this window] [in a new window]   Fig 5. . A small right anterior parasternal incision (10 cm in length) through the third and fourth costal cartilages was performed to approach the mitral valve. Two stab wounds, to the left of the incision, were for insertion of the chest drainage tubes. This patient is shown 5 days postoperatively.

	Footnotes

Top Footnotes Abstract Introduction Technique Comment References

 
Address reprint requests to Dr Cosgrove, Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195.

	References

Top Footnotes Abstract Introduction Technique Comment References

 

1. Lillehei CW, Gott VL, DeWall RA, Varco RL. The surgical treatment of stenotic or regurgitant lesions of the mitral and aortic valves by direct vision utilizing a pump-oxygenator. J Thorac Surg 1958;35:154–91.
2. Effler DB, Groves LK, Martinez WV, Kolff WJ. Open heart surgery for mitral insufficiency. J Thorac Surg 1958;36:665–76.
3. Dubost C, Guilmet D, Parades B, et al. Nouvelle technique d'ouverture de l'oreillette gauche en chirurgie à coeur ouvert: l'abord bi-auriculair transseptal. Presse Med 1966;74:1607–8.[Medline]
4. Guiraudon GM, Ofiesh JG, Kaushik R. Extended vertical transatrial septal approach to the mitral valve. Ann Thorac Surg 1991;52:1058–62.[Abstract]
5. Kumar N, Saad E, Prabhakar G, De Vol E, Duran CM. Extended transeptal versus conventional left atriotomy: early postoperative study. Ann Thorac Surg 1995;60:426–30.[Abstract/Free Full Text]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): José L. Navia Delos M. Cosgrove, III Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Navia, J. L. Articles by Cosgrove, D. M. Search for Related Content PubMed PubMed Citation Articles by Navia, J. L. Articles by Cosgrove, D. M., III