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Ann Thorac Surg 1997;63:1123-1127
© 1997 The Society of Thoracic Surgeons

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Original Article: Cardiovascular

Conventional Left Atrial Versus Superior Septal Approach for Mitral Valve Replacement

Departments of Cardiac Surgery, Anaesthesiology, and Cardiology, Catholic University, Rome, Italy

Accepted for publication November 7, 1996.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Patient Population Surgical Technique Follow-up Statistical Analysis Results Mortality and Morbidity Reexploration for Bleeding and... Modification of Cardiac Rhythm Late Results Comment References

 
Background. This study was designed to evaluate the safety and effectiveness of the superior septal approach for routine mitral valve replacement.

Methods. One hundred forty-six consecutive patients undergoing mitral valve replacement at our institution were randomly assigned to undergo the procedure using either the conventional left atriotomy or the superior septal approach. Postoperatively and during the follow-up, 12-lead electrocardiography, 24-hour Holter monitoring, and transthoracic and transesophageal echocardiography were performed in all patients.

Results. The cardiopulmonary bypass and cross-clamp times were significantly higher in the superior septal group. No significant difference in blood loss was found between the two groups, and no residual atrial septal defect was found in patients in whom we used the superior septal approach. The maintainance of sinus rhythm at late follow-up and the incidences of postoperative arrhythmias and newly developed atrioventricular block were not significantly different between the two groups.

Conclusions. The use of the superior septal approach to the mitral valve is not associated with a greater incidence of rhythm disturbances or other complications. Because this approach provides optimal exposure of the valve and the subvalvular apparatus, it has been routinely adopted for use in patients undergoing mitral valve replacement at our institution.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Patient Population Surgical Technique Follow-up Statistical Analysis Results Mortality and Morbidity Reexploration for Bleeding and... Modification of Cardiac Rhythm Late Results Comment References

 
Adequate exposure of the mitral valve and the subvalvular apparatus is critical to the success of mitral valve procedures. The traditional longitudinal left atrial incision, although widely used, may not provide optimal visualization, especially in patients with a deep chest or small left atrium.

In contrast, the superior septal approach, described by Guiraudon and colleagues [1] in 1991, is usually able to optimally expose the mitral apparatus in every anatomic situation; however, the risk of transecting the sinus node artery and the internodal pathways and the need to reconstruct the wall of the atria and the interatrial septum were considered important limitations to its routine use in mitral valve procedures [2].

In this prospective, randomized study, we compared the safety and efficacy of the superior septal approach with those of the traditional left atrial incision in patients undergoing mitral valve replacement.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Patient Population Surgical Technique Follow-up Statistical Analysis Results Mortality and Morbidity Reexploration for Bleeding and... Modification of Cardiac Rhythm Late Results Comment References

 
The study protocol was approved by the ethics committee of the Catholic University on November 25, 1989, and informed consent was obtained from each patient. One hundred forty-six consecutive patients scheduled to undergo mitral valve replacement at our institution from January 1990 to March 1992 were randomly assigned to undergo the procedure using either the conventional atrial approach or the superior septal incision. Particular attention was paid to all surgical problems and postoperative complications that arose related to the atrial incision. The cardiopulmonary bypass and cross-clamp times, postoperative blood loss, and alterations in cardiac rhythm in the two groups were compared.

	Patient Population

Top Footnotes Abstract Introduction Material and Methods Patient Population Surgical Technique Follow-up Statistical Analysis Results Mortality and Morbidity Reexploration for Bleeding and... Modification of Cardiac Rhythm Late Results Comment References

 
The main preoperative data for the patients in both groups are summarized in Table 1. The two groups were comparable in terms of age, sex distribution, functional status, dimension of the left atrium, mean ejection fraction, presence of tricuspid insufficiency, pulmonary systolic pressure, and preoperative cardiac index.

	Surgical Technique

Top Footnotes Abstract Introduction Material and Methods Patient Population Surgical Technique Follow-up Statistical Analysis Results Mortality and Morbidity Reexploration for Bleeding and... Modification of Cardiac Rhythm Late Results Comment References

Myocardial protection was achieved by warm blood cardioplegia, and isothermic cardiopulmonary bypass was used in all patients.

A traditional left atrial incision, parallel to the interatrial sulcus, was used in the control group. The incision was started from the superior vena cava and extended inferiorly to the mitral annulus. Closure was achieved with two 3-0 polypropylene running sutures started from the two ends of the atriotomy and tied in the midpoint. If a concomitant procedure on the tricuspid valve was planned in patients in this group, we used the traditional oblique right atriotomy, taking care to avoid the sinus node region.

In the superior septal approach group, the right atrium was opened along the anterior aspect of the atrioventricular groove. A 2- to 3-cm incision was made in the interatrial septum starting from the inferior end of the fossa ovale; the right atriotomy was then extended superiorly between the right appendage and the atrioventricular groove to join the interatrial incision. At the point where the two incisions met, the roof of the left atrium was opened for 4 to 5 cm. Closure was performed as described by Guiraudon [1] using 4-0 polypropylene running sutures, first closing the roof of the left atrium and then the septal incision. The two sutures were tied where they met, and the right atrial incision was closed.

The surgical procedures performed in the two groups are summarized in Table 2.

	Follow-up

Top Footnotes Abstract Introduction Material and Methods Patient Population Surgical Technique Follow-up Statistical Analysis Results Mortality and Morbidity Reexploration for Bleeding and... Modification of Cardiac Rhythm Late Results Comment References

Each patient was then followed up at our institution by clinical examination, surface electrocardiography, 24-hour Holter monitoring, and two-dimensional echocardiography 6 months after operation and then every year thereafter.

The mean follow up was 25.4 months in the superior septal approach group (range, 2 to 49 months) and 27 months in the control group (range, 3 to 48 months).

	Statistical Analysis

Top Footnotes Abstract Introduction Material and Methods Patient Population Surgical Technique Follow-up Statistical Analysis Results Mortality and Morbidity Reexploration for Bleeding and... Modification of Cardiac Rhythm Late Results Comment References

 
All results were expressed as the mean ± the standard deviation, and differences were considered significant when the p value was less than 0.05. Differences between groups were analyzed with Student's t test for independent samples. Categoric data were examined with contingency tables and ² or Fisher's test, as appropriate. Independent predictors of sinus rhythm were evaluated by discriminant function analysis.

	Results

Top Footnotes Abstract Introduction Material and Methods Patient Population Surgical Technique Follow-up Statistical Analysis Results Mortality and Morbidity Reexploration for Bleeding and... Modification of Cardiac Rhythm Late Results Comment References

 
Cardiopulmonary Bypass and Cross-Clamp Time
The cardiopulmonary bypass and cross-clamp times were significantly longer in the superior septal approach group (p < 0.001 for both): the mean cardiopulmonary bypass time was 97.3 ± 35 minutes (range, 45 to 223 minutes) in the superior septal approach group and 77 ± 30 minutes (range, 24 to 229 minutes) in the control group, whereas the cross-clamp time was 79 ± 29 minutes in the former (range, 34 to 187 minutes) and 58 ± 20 minutes in the latter (range, 14 to 126 minutes).

	Mortality and Morbidity

Top Footnotes Abstract Introduction Material and Methods Patient Population Surgical Technique Follow-up Statistical Analysis Results Mortality and Morbidity Reexploration for Bleeding and... Modification of Cardiac Rhythm Late Results Comment References

 
Thirteen patients died in the hospital, 7 in the superior septal approach group (9.6%) and 6 in the control group (8.2%; p = not significant). However, none of the deaths was related to the type of atrial approach used. In the superior septal approach group, sepsis was the cause of death in 3 patients, low cardiac output in 3, and renal failure in 1. In the control group, sepsis was the cause of death in 2 patients, low cardiac output in 3, and multiorgan failure in 1. No differences were observed in the mean intensive care unit stay in the two groups: it was 30 hours in the superior septal approach group (range, 23 to 190 hours) and 31 hours in the control group (range, 26 to 289 hours). The major postoperative complications and the number of cases are shown in Table 3. No statistical difference in the incidence of postoperative complications was found between the two groups. No residual atrial septal defect was found postoperatively in the superior septal approach group.

	Reexploration for Bleeding and Postoperative Blood Loss

Top Footnotes Abstract Introduction Material and Methods Patient Population Surgical Technique Follow-up Statistical Analysis Results Mortality and Morbidity Reexploration for Bleeding and... Modification of Cardiac Rhythm Late Results Comment References

In 1 of the patients in whom we used the superior septal approach, bleeding from the roof of the left atrium (discovered after weaning from cardiopulmonary bypass) necessitated the reinstitution of bypass so that the site of bleeding could be closed with two additional single stitches.

No statistically significant difference in the blood loss in the first 24 hours after operation was found between the two groups, in that the mean blood loss on the first day was 466 ± 225 mL in the superior septal approach group (range, 160 to 1,320 mL) and 425 ± 287 mL in the control group (range, 146 to 1,510 mL).

	Modification of Cardiac Rhythm

Top Footnotes Abstract Introduction Material and Methods Patient Population Surgical Technique Follow-up Statistical Analysis Results Mortality and Morbidity Reexploration for Bleeding and... Modification of Cardiac Rhythm Late Results Comment References

 
EARLY RESULTS.
No statistically significant difference in the cardiac rhythm in the early postoperative period was found between the superior septal approach and the control groups among the patients who were in sinus rhythm preoperatively: 52% in the superior septal approach group and 46% in the control group maintained their rhythm at hospital discharge. The difference in the incidence of a newly developed junctional rhythm or atrioventricular block in the two groups of patients at the time of hospital discharge, although greater in the superior septal approach group, was also not statistically different: it was 23% in the superior septal approach group and 8.6% in the control group.

Discriminant function analysis showed that only the presence of sinus rhythm preoperatively was predictive of the persistence of sinus rhythm at hospital discharge (p < 0.01; Wilks' lambda, 0.52). The type of atrial approach or myocardial protection used, as well as all the other factors analyzed (age, sex, left atrium diameter, mean ejection fraction, mean pulmonary arterial pressure, cardiac index, tricuspid insufficiency, New York Heart Association functional class) were not found to be significantly associated with the persistence of sinus rhythm at hospital discharge. Complete atrioventricular block necessitated implantation of a permanent pacemaker in 5 patients (2 in the superior septal approach group and 3 in the control group).

Detailed data about the modifications in cardiac rhythm occurring in the two groups are shown in Table 4.

	Late Results

Top Footnotes Abstract Introduction Material and Methods Patient Population Surgical Technique Follow-up Statistical Analysis Results Mortality and Morbidity Reexploration for Bleeding and... Modification of Cardiac Rhythm Late Results Comment References

None of the factors examined at late follow-up was found to have a significant influence on the maintainance of sinus rhythm.

	Comment

Top Footnotes Abstract Introduction Material and Methods Patient Population Surgical Technique Follow-up Statistical Analysis Results Mortality and Morbidity Reexploration for Bleeding and... Modification of Cardiac Rhythm Late Results Comment References

 
Adequate exposure of the mitral valve and the subvalvular apparatus plays a key role in the success of mitral valve operations. Mitral valve exposure during mitral valve replacement is particularly critical if the native valve is calcified or if a previously implanted mitral prosthesis has to be removed. Mitral visualization can be particularly difficult in patients with a deep chest, small left atrium, or adhesions. In such circumstances the conventional left atriotomy may not provide adequate exposure of the mitral valve. Several alternative surgical approaches have been described over the years to overcome these problems. For example, Mayer and associates [3] described a superior approach to the left atrium, Brawley [4] described a combined right atrial and septal incision, and Selle [5] extended the traditional incision into the roof of the left atrium, thereby dividing the superior vena cava. The transseptal approach was first described by Julian and associates [6] and then modified by other authors [7, 8]. More recently, Guiraudon and colleagues [1] proposed an extended vertical transatrial septal incision. This approach invariably provides optimal exposure of both the mitral valve and the subvalvular apparatus; however, because of the need to transect both the sinus node artery and part of the internodal pathway, concern continues to exist about this leading to postoperative rhythm disturbances [9, 10]. Moreover, the need to reconstruct the wall of both the atria and the interatrial septum has prompted some concern about this leading to excessive postoperative bleeding or about the atrial wall being lacerated [11, 12].

Because most of the reported series are quite small and lack either a control group or long-term follow up (Table 5), this has not allowed definite conclusions to be drawn concerning the effectiveness and safety of the superior septal approach. Berreklouw and associates [14] in 1991 reported on a series of 22 patients who underwent combined mitral and tricuspid valve procedures using the superior septal incision. No major postoperative complications were reported, and all patients in sinus rhythm preoperatively maintained their rhythm postoperatively. A larger series was reported on by Alfieri and co-authors [15] in the same year. These authors described the results obtained in 111 patients who underwent mitral valve operations using the superior septal approach. Because no major rhythm disturbances or postoperative complications arose, they suggested the possible routine use of this approach. Similar results were achieved and conclusions drawn by Kon and colleagues [16] in 1993.

In our experience the routine use of the superior septal approach was not associated with a significantly higher incidence of postoperative rhythm disturbances as compared with the incidence associated with the traditional left atrial approach. The percentage of patients who were in sinus rhythm preoperatively and who maintained their rhythm either at discharge or at late follow-up was similar in the two groups. Likewise, the percentage of patients showing junctional rhythm postoperatively was similar in both groups.

Almost 25% (18/73) of the patients in the control group underwent a concomitant tricuspid valve procedure performed through a conventional oblique right atriotomy. The incidence of junctional rhythm or atrioventricular blocks in these patients was not statistically greater than that in patients who underwent only mitral valve replacement in this group or in patients who had a tricuspid procedure performed through the transseptal approach. However, the development of junctional rhythm or atrioventricular blocks in this kind of patient is usually thought to be related more to the interposition of the atrioventricular node through the two prostheses than to the atrial approach used [19].

The exact role of sinus node ischemia and a lesion in the interatrial pathways in influencing cardiac rhythm is not definitely understood, though experimental data indicate a possible influence of sinus node artery lesions on cardiac rhythm [20] and clinical observations in patients who have undergone a Mustard or Fontan procedure seem to confirm this influence [21]. On the other hand, the experience derived from transplantations, the surgical treatment of Wolff-Parkinson-White syndrome [22, 23], and other experimental settings contradicts this hypothesis [24].

As suggested by Smith [17], it is likely that transection of the sinus node artery and part of the internodal pathways leads to minor rhythm disturbances, expressed, for example, by variations in the P-wave axis and morphology. In our experience, however, these minor alterations do not seem to have major clinical implications. Moreover, the influence of the atrial approach on postoperative rhythm disturbances is probably limited [15], being outweighed by the more important influence of either the high interatrial pressure [25] and the demonstrated electrical instability, even in patients in sinus rhythm preoperatively [15].

No major complications (blood loss from the atrial suture, residual atrial septal defect) were associated with the use of the superior septal approach in our experience. The only significant difference between the two groups was the longer cardiopulmonary bypass and cross-clamp times in the superior septal approach group.

Better exposure in every anatomic situation (especially in patients with a small left atrium and in patients undergoing redo operations) and no need for atrial retractors are further advantages of the superior septal approach.

In conclusion, minor changes in cardiac rhythm and a longer operative time are the only disadvantages of the superior septal approach. In our opinion these minor limitations are largely outweighed by the optimal exposure of the mitral valve and subvalvular apparatus provided by this approach, so that its routine use in mitral valve procedures seems definitely justified.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Patient Population Surgical Technique Follow-up Statistical Analysis Results Mortality and Morbidity Reexploration for Bleeding and... Modification of Cardiac Rhythm Late Results Comment References

 
Address reprint requests to Dr Gaudino, Istituto di Cardiochirurgia, Policlinico A. Gemelli, Largo A. Gemelli 8, 00168 Rome, Italy.

	References

Top Footnotes Abstract Introduction Material and Methods Patient Population Surgical Technique Follow-up Statistical Analysis Results Mortality and Morbidity Reexploration for Bleeding and... Modification of Cardiac Rhythm Late Results Comment References

 

1. Guiraudon GM, Ofiesh JG, Kaushik R. Extended vertical transatrial septal approach to the mitral valve. Ann Thorac Surg 1991;52:1058–62.[Abstract/Free Full Text]
2. Kovacs GS, Szabados S. Superior septal approach to the mitral valve. Ann Thorac Surg 1994;57:516–24.[Free Full Text]
3. Mayer BW, Verska JJ, Lindesmith GG, Jones JC. Open repair of mitral valve lesion. The superior approach. Ann Thorac Surg 1965;4:453–7.
4. Brawley RK. Improved exposure of the mitral valve in patients with a small left atrium. Ann Thorac Surg 1978;29:179–81.
5. Selle JG. Temporary division of the superior vena cava for exceptional mitral valve exposure. J Thorac Cardiovasc Surg 1984;88:302–4.[Abstract]
6. Julian OC, Lopez M, Dye WS, et al. Simultaneous repair of mitral and tricuspid valves through right atrium and intraatrial septum. Arch Surg 1959;78:745–54.
7. Bowman FO, Malm JR. The transseptal approach to mitral valve repair. Arch Surg 1965;90:329–31.[Medline]
8. McGrath LB, Levett JM, Gonzales-Lavin L. Safety of the right atrial approach for combined mitral and tricuspid valve procedures. J Thorac Cardiovasc Surg 1988;96:756–9.[Abstract]
9. Starek PJK. Technical aspects of uncomplicated valve replacement. In: Heart valve replacement and reconstruction. Chicago: Year Book, 1987:61-79.
10. David TE. In discussion of Guiraudon GM, Ofiesh JG, Kaushik R. Extended vertical transsatrial septal approach to the mitral valve. Ann Thorac Surg 1991;52:1058–62.[Abstract/Free Full Text]
11. Campanella C. In discussion of Guiraudon GM, Ofiesh JG, Kaushik R. Extended vertical transatrial septal approach to the mitral valve. Ann Thorac Surg 1991;52:1058–62.[Abstract/Free Full Text]
12. Horowitz MD. In discussion of 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/Free Full Text]
13. Smith CR. Septal-superior exposure of the mitral valve. J Thorac Cardiovasc Surg 1992;103:623–8.[Abstract]
14. Berreklouw E, Ercan H, Schonberger P. Combined superior-transseptal approach to the left atrium. Ann Thorac Surg 1991;51:293–5.[Abstract/Free Full Text]
15. Alfieri O, Sandrelli L, Pardini A, et al. Optimal exposure of the mitral valve through an extended vertical transseptal approach. Eur J Cardiothorac Surg 1991;5:294–9.[Abstract/Free Full Text]
16. 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/Free Full Text]
17. Smith CR. Efficacy and safety of the superior-septal approach to the mitral valve. Ann Thorac Surg 1993;55:1357–8.[Free Full Text]
18. Kumar N, Saad E, Prabhakar G, De Vol E, Duran CMG. Extended transseptal versus conventional left atriotomy: early postoperative study. Ann Thorac Surg 1995;60:426–30.[Abstract/Free Full Text]
19. Kirklin JW, Barratt-Boyes BG. Cardiac surgery, 2nd ed. New York: Churchill Livingstone, 1993:597-8.
20. Tamiya T, Yamashiro T, Hata A, Kuge K, Asano S, Sato T. Electrophysiological study of dysrhythmias after atrial operations in dogs. Ann Thorac Surg 1992;54:717–24.[Abstract/Free Full Text]
21. Edwards WD, Edwards JE. Pathology of the sinus node in d-transposition following the Mustard operation. J Thorac Cardiovasc Surg 1978;75:213–8.[Abstract]
22. Ellenbogen KA, Arrowood JA, Cohen MD, Szentpetery S. Limitations of esophageal electriocardiography in recording atrial rhythms after orthotopic heart transplantation. J Heart Transplant 1987;6:167–70.[Medline]
23. Guiraudon GM, Klein GJ, Sharma AD, Yea R, Pineda EA, Mc Lellan DG. Surgical approach to the anterior septal accessory pathways in 20 patients with the Wolff-Parkinson-White syndrome. Eur J Cardiothorac Surg 1988;2:201–6.[Abstract/Free Full Text]
24. James TN, Hershey EA. Experimental studies of the pathogenesis of atrial arrhythmias in myocardial infarction. Am Heart J 1962;63:196–211.[Medline]
25. Kon ND. In discussion of 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/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): Mario Gaudino Francesco Alessandrini Franco Glieca Gianfederico Possati Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Gaudino, M. Articles by Possati, G. Search for Related Content PubMed PubMed Citation Articles by Gaudino, M. Articles by Possati, G.