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Ann Thorac Surg 2001;72:663-664
© 2001 The Society of Thoracic Surgeons

Correspondence

Combined transseptal superior approach to mitral valve: management of left superior vena cava

Alok Mathur, MCha, Saify Arsiwala, MCha, Karan Singh Yadav, MCha, Anil Sharma, MDa, Prakash Chandwani, MDa

a Tongia Heart and General Hospital, 7, Vivekanand Marg, C-Scheme, Jaipur, India

e-mail: alok26mathur{at}hotmail.com

To the Editor

Of the various approaches for mitral valve operations, we have been using the combined transseptal and superior approach more often, and it is the approach of choice during minimally invasive mitral valve operation as described by Cosgrove and Gillinov [1]. The indications and efficacy of this approach have been described previously [2, 3]. A persistent left superior vena cava (LSVC) is sometimes associated with the mitral valve lesion and has to be dealt with separately.

Anatomically, LSVC draining into coronary sinus forms part of the floor of left atrium (Fig 1). If the mitral valve is approached by the combined transseptal and superior approach, the LSVC can be canulated either directly or through the coronary sinus. The latter approach is easier and does not involve incising the LSVC. We cannulated the LSVC through the coronary sinus in our first patient of LSVC with mitral valve disease. We found that because of the anatomy of the coronary sinus, the rigid LSVC cannula pushed the mitral valve anteriorly, making exposure extremely difficult (Fig 2).



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  		Fig 1. Direct left superior vena cava (LSVC) cannulation does not interfere with exposure of the mitral valve.

 


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  		Fig 2. Left superior vena cava cannulation through the coronary sinus lifts up the mitral valve and hinders exposure.

 
In another patient who had partial anamolous venous return with intact atrial septum, mitral valve disease, and persistent LSVC, we changed our technique. We cannulated the LSVC directly just superior to the left atrial appendage using a separate right-angled metal tipped 20F cannula. The exposure of the mitral valve was excellent. We have been using this technique of LSVC cannulation whenever we encounter LSVC while conducting mitral valve operations through a combined transseptal and superior approach. We have not found any additional risk or morbidity for the procedure due to direct LSVC cannulation.

References

  1. Cosgrove D.M., Gillinov A.M. Partial sternotomy for mitral valve operations: operative techniques in cardiac and thoracic surgery. Operative Techniques in Cardiac & Thoracic Surgery 1998;3:62-72.
  2. Berreklouw E., Ercan H., Schönberger J.P. Combined superior- transseptal approach to the left atrium. Ann Thorac Surg 1991;51:293-295.[Abstract/Free Full Text]
  3. Arsiwala S., Parikh P., Dixit S., Agney M., Kole S., Saksena D. Combined superior-transseptal approach to the mitral valve. Ann Thorac Surg 1992;53:180-181.



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