Ann Thorac Surg 2003;75:1985-1986
© 2003 The Society of Thoracic Surgeons
How to do it
Surgical treatment of giant left atrium using a combined superior-transseptal approach
Sadatoshi Yuasa, MD*a,
Takeshi Soeda, MDa,
Shinji Masuyama, MDa,
Kazuki Shimizu, MDa,
Mitsuhiko Matsuda, MDa
a Department of Cardiovascular Surgery, Matsue Red Cross Hospital, Shimane, Japan
Accepted for publication November 13, 2002.
* Address reprint requests to Dr Yuasa, Department of Cardiovascular Surgery, Matsue Red Cross Hospital, 200 Horo-machi, Matsue 690-8506, Japan
e-mail: mrchlib2{at}web-sanin.co.jp
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Abstract
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We report on the usefulness of a combined superior-transseptal approach for the surgical treatment of giant left atrium. The posteroinferior wall and the roof of the left atrium were easily plicated and the mitral valve procedure was simple.
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Introduction
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Agiant left atrium associated with mitral valve disease frequently causes postoperative problems with respect to hemodynamics and may also compress the esophagus or bronchus [1, 2]. Kawazoe and associates proposed that plication of a giant left atrium could be done through an incision on the right side along the interatrial groove [1]. Also, Sinatra and associates proposed triangular resection of the atrial wall with simple direct suture through an incision on the right side along the interatrial groove [3]. The ideal approach to the mitral valve would provide undistorted exposure of the mitral annulus and left atrium. Berreklouw and associates have proposed a combined superior-transseptal approach to the left atrium for excellent exposure of the complete mitral annulus [4]. In the present patient, we plicated a giant left atrium via the superior-transseptal approach, and found that it was easy to complete both the mitral valve procedure and atrial plication.
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Technique
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The heart was exposed by median sternotomy. After heparinization, the ascending aorta was cannulated. The superior vena cava was also cannulated directly by a cannula with a short curved tip, whereas the inferior vena cava cannula had a long curved tip. The aorta was cross-clamped and cardioplegic solution was infused to arrest the heart. Both cavae were snared and the right atrium was opened obliquely lateral to the inferior vena cava. The interatrial septum was opened longitudinally at the fossa ovarium. Then, the septum and lateral parts of the right atrial wall were retracted using stay sutures. Next, the incision was extended caudally to the inferior limbus, and cranially through the roof of the left atrium in the direction of the left atrial appendage [4] (Fig 1).
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Fig 1. Exposure of the left atrium and mitral valve, as well as plication of the posteroinferior wall of the left atrium.
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The posteroinferior wall of the left atrium, which was distended and included the ostia of the left and right inferior pulmonary veins and the mitral annulus, was plicated in a semilunar fashion from the upper border of the left atrial appendage to the posteromedial portion of the mitral valve. Several stay sutures of 4-0 or 3-0 Prolene were placed at 15 to 20 mm from the ostia of the pulmonary veins and 10 mm from the mitral valve annulus. Then, plication was continued by placing sutures in an over-and-over fashion [1] (Fig 1).
After the mitral valve procedure, plication was done from the caudal border of the left atrial appendage upward through the cranial part of the atrium along the incision line with a continuous over-and-over 3-0 Prolene suture. The effectiveness of the plication procedure was confirmed by transthoracic echocardiography (Fig 2). The diameter of the left atrium decreased from 86 to 58 mm after the operation, whereas the right ventricle diameter was not changed.
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Fig 2. Effective plication of the left atrium was confirmed by transthoracic echocardiography (M mode) before (A) and after (B) the operation. (RV = right ventricle; Ao= aortic valve; LA = left atrium.)
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Comment
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We recommend the combined superior-transseptal approach to the left atrium because it provides excellent exposure of the complete mitral annulus and left atrium. The posteroinferior wall of the left atrium and the atrial roof are easily plicated, and the mitral valve procedure can also be done easily. If necessary, additional plication can be performed between the ostia of the left and right pulmonary veins, and the right side of the left atrium is easily plicated from the right with continuous over-and-over 3-0 Prolene sutures. It is advisable to perform plication at some distance from the mitral annulus, so as to avoid injury to the left circumflex coronary artery. A giant left atrium associated with mitral valve disease frequently causes postoperative problems with respect to hemodynamics and may also compress the esophagus or bronchus [1, 2]. Accordingly, this technique is recommended to prevent such postoperative problems. Also, the combined superior-transseptal approach to the left atrium provides easier access to the mitral annulus than techniques involving an incision on the right side along the interatrial groove [1, 3].
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References
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- Kawazoe K., Beppu S., Takahara Y., et al. Surgical treatment of giant left atrium combined with mitral valvular disease. J Thorac Cardiovasc Surg 1983;85:885-892.[Abstract]
- Piccoli G.P., Massini C., Eusanio G.D., et al. Giant left atrium and mitral valve disease: early and late results of surgical treatment in 40 cases. J Cardiovasc Surg 1984;25:328-336.[Medline]
- Sinatra R., Pulitani I., Antonazzo A., Melina G. A novel technique for giant left atrium reduction. Eur J Cardiothorac Surg 2001;20:412-414.[Abstract/Free Full Text]
- Berreklouw E., Ercan H., Schonberger J.P. Combined superior-transseptal approach to the left atrium. Ann Thorac Surg 1991;51:293-295.[Abstract/Free Full Text]
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Abstract
Introduction
