Ann Thorac Surg 1999;67:298-299
© 1999 The Society of Thoracic Surgeons
Correspondence
Additional maneuvers to improve mitral valve exposure through the conventional left atriotomy
Lalit Kapoor, MCh, DNBa,
Ashok Bandypadhyay, MCha,
Sushan Mukhopadhyay, MCha
a B.M. Birla Heart Research Centre, 1/1 National Library Ave, Calcutta 700 027, India
e-mail: abandyopadhyay{at}hotmail.com
To the Editor
We read the article "Optimizing Mitral Valve Exposure with Conventional Left Atriotomy" [1] with interest, as we have been using similar techniques for more than 5 years now. We would like to mention the maneuvers we use, as there are some features that have not been included in the article by Drs McCarthy and Cosgrove.
The maneuvers we use are as follows:
- We open the pericardium slightly to the right of the midline. Thus, when the right edge of the pericardium is hitched up under the self-retaining retractor, the heart rotates away from the surgeon.
- We do not hitch up the left pericardial edge, to enable the left ventricle to drop away.
- We mobilize both the superior vena cava and inferior vena cava. The superior vena cava is mobilized by cutting the pericardium on the medial aspect and blunt dissection on the lateral aspect. Similarly, the inferior vena cava is freed from the surrounding tissues by about 2.5 cm. These simple and safe maneuvers take at most two minutes.
- We perform direct superior vena cava and inferior vena cava cannulation using Pacifico right-angled cannulas (Medtronic DLP, Grand Rapids, MI), which permit further freedom in lifting the left atrial edge upward and to the left.
- Upon completion of cannulation, we perform additional dissection on the left atrial roof, separating it from the right pulmonary artery lateral to the superior vena cava. This additional step permits the left atrial incision to be carried 1 cm behind the superior vena cava, under the right pulmonary artery.
- We make it a point to cut the lateral pericardial reflection between the lower left pulmonary vein near the inferior vena cava, to open the oblique sinus laterally. Again this permits extension of the atriotomy incision behind the inferior vena cava into the oblique sinus, should the need arise. In our experience, this particular maneuver is most useful. It permits the deepest tethering point of the heart to be released.
- We also develop the interatrial groove extensively thereby pushing the right atrium away and making our atriotomy more anteriorly on the left atrium. During this atriotomy, we are of course careful not to open the interatrial septum inadvertently. The added advantage of this anterior incision is that the left atrial closure is invariably very dry.
- And finally, we often place a cold sponge on the left lateral aspect of the left ventricle, which pushes the mitral valve toward the right.
The fact that in our experience of more than 700 mitral valve operations we have not once had to adopt any of the more radical approaches described testifies to the efficacy of our multipronged approach. We prefer these minor maneuvers, rather than resorting to any one of the more radical approaches to the mitral valve using alternate atriotomies. We suggest that recourse should be taken using the more innovative approaches only if all of these relatively simple techniques fail.
Acknowledgments
We acknowledge Dr Devi P. Shetty, ex-Chief Cardiac Surgeon, B. M. Birla Heart Research Centre, Calcutta, India.
References
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McCarthy J.F., Cosgrove D.M., III Optimizing mitral valve exposure with conventional left atriotomy. Ann Thorac Surg 1998;65:1161-1162.[Abstract/Free Full Text]
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