Ann Thorac Surg 2006;81:378-380
© 2006 The Society of Thoracic Surgeons
How to do it
Novel Technique for Volume Reduction of Giant Left Atrium: Simple and Effective "Spiral Resection" Method
Hiroshi Sugiki, MD
a
,
Toshifumi Murashita, MD, PhD
a
,
*
,
Keishu Yasuda, MD, PhD
a
,
Hirosato Doi, MD
b
a Department of Cardiovascular Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
b Cardiovascular Center, Hokkaido Ohno Hospital, Sapporo, Japan
Accepted for publication October 14, 2004.
* Address correspondence to Dr Murashita, Department of Cardiovascular Surgery, Hokkaido University Graduate School of Medicine, Kita-14, Nishi-5, Kita-ku, Sapporo 060-8648, Japan. (Email: muratosh{at}med.hokudai.ac.jp).
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Abstract
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Despite some controversial studies, an enlarged left atrium has an impact on postoperative complications, and surgical correction should be considered, particularly in patients with a markedly enlarged left atrium. We present herein 2 patients with a giant left atrium (left atrial dimensions of 107 and 93 mm on echocardiograms), and describe an effective and simple procedure, the "spiral resection" method, to reduce any part of the dilated wall of the left atrium with a single incision.
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Introduction
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A giant left atrium associated with mitral valve disease can cause postoperative respiratory dysfunction with compression of the bronchus and hemodynamic disturbance produced by compression of the posterolateral portion of the left ventricle [1]. In addition, the presence of a giant left atrium increases the thromboembolic risk despite anticoagulant therapy after operation. Since some [2] have reported that the left atrium size is a major predictive factor of death, reduction of its volume could reduce patients' mortality and morbidity [1]. Although many surgical procedures have been proposed to reduce the size of the left atrium together with good exposure of the mitral valve, their effectiveness is not well established. We present herein 2 patients with giant left atrium, and describe an effective and simple procedure, the "spiral resection" method, to reduce any part of the dilated wall of the left atrium with a single incision.
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Technique
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Two patients underwent the spiral resection procedure. Case 1 was a 66-year-old man with heart failure due to mitral regurgitation, who had a 13-year-history of atrial fibrillation. His condition was complicated with atelectasis of both lungs because of the compression of bronchi by the enlarged left atrium. Case 2 was a 59-year-old man with congestive liver who had a 10-year-history of atrial fibrillation due to mitral regurgitation.
The heart was exposed by median full sternotomy. Cardiopulmonary bypass was established by standard aorta and inferior vena cava cannulation, whereas the superior vena cava (SVC) was cannulated directly by a cannula with a curved tip. The heart was protected by means of intermittent antegrade and retrograde cold blood cardioplegia. The mitral valve was exposed by the combined superior-transseptal approach reported by Berreklouw and colleagues [3]. Thus, the right atrium was opened obliquely, and the interatrial septum was opened longitudinally at the fossa ovarium to enter the left atrium. This incision was extended cranially through the roof of the left atrium to obtain good exposure of the entire mitral annulus, and mitral procedures such as repair (case 1) or replacement (case 2) were performed.
Then, in case 1 (Fig 1, A), the incision of the left atrial roof was extended laterally in the direction of the left atrium appendage, which was resected, and was extended to the posteroinferior wall of the left atrium where the dilated wall was located between both ostia of the inferior pulmonary vein (PV) and mitral annulus. Then this incision was further extended to the inferior wall of the left atrium (between the right inferior PV and mitral annulus), and came around to reach the right side free wall of the left atrium. This incision was further extended cranially, parallel to the atrial groove, to reach the left atrium wall between the right upper PV and SVC. As a result, there was a single spiral incision from the atrial septum to the right lateral wall of the left atrium through the roof, lateral, posterior and inferior walls of the left atrium. Along this long incision, a strip of the left atrium wall was resected with 3 to 4 cm in width including the atrial septum, and then the left atrium was sutured with 4-0 polypropylene along the resection line. The suture closing was started at the middle of the posterior wall of the left atrium, and first the inferior and right lateral left atrium was closed with one end of the suture followed by the closure of the left atrium roof and atrial septum with the other end of the suture.
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Fig 1. Schematic illustration of the "spiral resection" method for giant left atrium. The mitral valve is exposed by the combined superior-transseptal approach (A). In case 1, the incision of the superior wall is extended in the direction of the left atrial appendage (dashed line, 1), and then to the posteroinferior wall. This incision is further extended to the inferior wall, and comes around to reach the right side free wall (B). In case 2, however, the incision of the superior wall is extended to the posterior wall between the left and right pulmonary veins (dashed line, 2). This incision is further extended to the inferior wall, and comes around to reach the right side free wall (C).
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In case 2 (Fig 1, B), however, the incision at the roof of the left atrium was extended to the posterior wall of the left atrium between the left and right PVs because this part of the wall was markedly dilated compared with the left lateral wall. Then the incision was further extended to the inferior wall of the left atrium, and came around to reach the right side free wall of the left atrium, as done in case 1 (Fig 1, C). The left atrium appendage was closed from the inside in this case. After closing the interatrial septum, the aorta was declamped, and the right atrial free wall was resected to reduce the volume of the right atrium if necessary. In both cases, the volume of the right atrium was reduced, and tricuspid annuloplasty was performed with a rigid ring.
In case 1, the cardiothoracic ratio on the chest roentogenogram was markedly reduced from 92% to 71%, while the left atrium diameter measured by ultrasonic echocardiography was reduced from 107 mm to 67 mm. In case 2, the cardiothoracic ratio was reduced from 64% to 54%, and the left atrium diameter was reduced from 93 mm to 67 mm. The chest CT clearly demonstrated the reduced size of the left atrium in case 2 (Fig 2). Although postoperative reexploration was required in case 2, hemodynamic and respiratory conditions were excellent in both cases. Atrial fibrillation remained in both cases.
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Fig 2. Computed tomography before (left) and after (right) operation in case 2. Left atrial dimension is markedly reduced. (LA = left atrium; LV = left ventricle; RA = right atrium.)
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Comment
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Surgical techniques to reduce the left atrium vary from plication of the posteroinferior wall of the atrium along the outlet area of the pulmonary veins [1], to resection and suture by multiple resections of the left atrium wall [4] or autotransplantation [5]. The plication technique sometimes results in insignificant left atrium volume reduction, particularly in patients with a markedly enlarged left atrium as in this report (left atrium diameter greater than 100 mm). Lessana and coworkers [5] reported the autotransplantaion approach in which large and circumferential resection of the left atrium can be achieved; however, the vena cave, aorta, and pulmonary artery need to be transected where they are not diseased. In both the plication and the resection and suture methods, the atrial septum is not plicated, whereas with the spiral resection method presented in this report, the atrial septum can be plicated if necessary. In patients with a markedly enlarged left atrium, all parts of the left atrium wall are enlarged, including the atrial septum; therefore, this method can remove the redundant atrial wall of the left atrium, superior, lateral (case 1) or posterior (case 2), inferior and right side walls along a single incision. Because the suture line is long, one has to be careful of bleeding. It should also be stressed that the left atrium wall needs to be isolated from its adhesion to release the tension, depending on the width of the strip of atrial wall removed.
In addition to effective volume reduction of the left atrium, this spiral resection method can also provide excellent exposure of the mitral annulus compared with other approaches. Despite some controversial studies [2, 6], we believe that giant left atrium has an impact on postoperative complications, and that surgical correction should be considered, particularly for patients with a markedly enlarged left atrium. The spiral resection method described here is simple and very effective for such patients.
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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. Plication procedure for reduction of compression to the left ventricle, bronchus, and pulmonary parenchyma J Thorac Cardiovasc Surg 1983;85:885-892.[Abstract]
- Reed D, Abbott RD, Smucker ML, Kaul S. Prediction of outcome after mitral valve replacement in patients with symptomatic chronic mitral regurgitation. The importance of left atrial size Circulation 1991;84:23-34.[Abstract/Free Full Text]
- Berreklouw E, Ercan H, Schonberger JP. Combined superior-transseptal approach to the left atrium Ann Thorac Surg 1991;51:293-295.[Abstract/Free Full Text]
- 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]
- Lessana A, Scorsin M, Scheuble C, Raffoul R, Rescigno G. Effective reduction of a giant left atrium by partial autotransplantation Ann Thorac Surg 1999;67:1164-1165.[Abstract/Free Full Text]
- Di Eusanio G, Gregorini R, Mazzola A, et al. Giant left atrium and mitral valve replacementrisk factor analysis. Eur J Cardiothorac Surg 1988;2:151-159.[Abstract/Free Full Text]
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Abstract
Introduction
