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Ann Thorac Surg 2006;82:834-839
© 2006 The Society of Thoracic Surgeons

Original article: Cardiovascular

Minitransseptal Versus Left Atrial Approach to the Mitral Valve: A Comparison of Outcomes

Jeffrey J. Nienaber, MD, Donald D. Glower, MD*

Department of Surgery, Duke University Medical Center, Durham, North Carolina

Accepted for publication April 3, 2006.

* Address correspondence to Dr Glower, Box 3851 Duke University Medical Center, Durham, NC 27710 (Email: glowe001{at}mc.duke.edu).

Presented at the Forty-second Annual Meeting of The Society of Thoracic Surgeons, Chicago, IL, Jan 30–Feb 1, 2006.


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Discussion
 References
 
BACKGROUND: Approaches to the mitral valve include left atriotomy (LA) through the interatrial groove and transseptal approach (TS) through the right atrium. Left atriotomy is more commonly used, but TS offers better mitral visualization in difficult cases. While TS has been associated with more atrial arrhythmias, heart block, and difficulty in repair, strong data are lacking.

METHODS: Retrospective chart review was conducted of 531 consecutive patients undergoing a mitral valve procedure through sternotomy by a single surgeon between 1989 and 2003. Of these, 273 were performed through the standard LA approach and 258 by a "minitransseptal" approach consisting of a 6-cm vertical incision in the interatrial septum without incising the roof of the right or left atria.

RESULTS: Subset analysis of isolated mitral procedures showed no significant differences in cross-clamp time or total bypass time. Although significantly more TS patients required new pacemakers (10.5% TS versus 5.1% LA) or had new junctional rhythm (8.7% TS versus 4.2% LA), TS patients also had more concomitant valve procedures and redo sternotomies. Multivariate analysis showed that the incidence of new pacemakers was linked most strongly with redo procedures, but TS was not an independent predictor of needing a new pacemaker, new junctional rhythm, or new atrial fibrillation.

CONCLUSIONS: The minitransseptal approach can provide excellent mitral valve exposure in difficult cases without any significant increase in junctional rhythm, atrial fibrillation, or new pacemaker requirements.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Discussion
 References
 
Since the early years of modern cardiac surgery, two basic approaches to the mitral valve have been used. In 1958, Effler wrote, "the actual entry into the left atrium may be accomplished in either of two ways: (1) through the fossa ovalis by way of the right atrium, and (2) through the posterior interatrial groove" [1]. Although the latter approach became and remains the preferred method for most surgeons, the transseptal approach has been revisited in more recent years in various forms by those seeking better exposure of the mitral valve [2–4]. Many surgeons find a transseptal approach to be useful in settings such as prior surgery to avoid scarring around the interatrial groove, or in the setting of difficult anatomy, such as a small left atrium or ventricular hypertrophy.

To address such challenges, several transseptal approaches have been developed. Dubost and colleagues [2] utilized a transverse transseptal incision that extended medially from the right superior pulmonary vein to the right atrium and through the interatrial septum (Fig 1). Brawley [3] used a similar technique, extending a conventional posterior interatrial groove incision perpendicularly into the septum and right atrium. The approach of Berreklouw and colleagues [4] and Guiraudon and associates [5] is through a superior (or extended vertical) transseptal incision through the right atrium superiorly into the left atrium along with an interatrial septostomy to the inferior pole of the fossa ovalis. While these approaches can offer excellent exposure of the mitral valve in challenging cases relative to the conventional left atrial incision, many have been hesitant to adopt them for various reasons. Because the incisions are longer, for example, closure time is prolonged, and the area at risk for bleeding is larger. There are also concerns about increased arrhythmogenicity (at both the sinus and atrioventricular nodes), although clinical studies have failed to consistently show significant differences from the conventional approach in this respect [6–13].


Figure 1
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  		Fig 1. Approaches to the mitral valve: A = superior left atrial, B = Dubost transverse transseptal, C = conventional left atriotomy, D = minitransseptal, E = extended vertical/superior transseptal.

 
The approach to the mitral valve used by many at this institution has been through a limited right atriotomy and septostomy (Fig 2), which has been described by others previously [14–15]. Although this "minitransseptal" approach has been in use for several decades, sufficient outcomes data on the safety of the approach with respect to postoperative arrhythmias are lacking. To address some of the concerns raised in the literature regarding transseptal approaches, this paper presents outcomes data from a single surgeon's experience with more than 500 mitral valve procedures utilizing either the conventional left atriotomy or the minitransseptal approach.


Figure 2
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  		Fig 2. Minitransseptal approach to the mitral valve. After a right atriotomy, a separate incision is made through the fossa ovalis (D). Stay sutures or a vein retractor are used to retract the incised septum (A), thus exposing the mitral valve (B). The tricuspid valve is also well visualized with this approach (C).

 

   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Discussion
 References
 
Surgical Technique
Although this technique [14, 15] can be used with a variety of chest incisions (median sternotomy, ministernotomy, right anterior thoracotomy), the median sternotomy approach will be described, as this is the group focused on in this paper. Briefly, after a midline sternotomy, the superior vena cava is cannulated either directly or at the lateral, superior aspect of the right atrium. The inferior vena cava is similarly cannulated at the inferior, lateral portion of the right atrium or through the groin to keep the medial right atrium clear for the right atriotomy. After cardiopulmonary bypass is instituted, a 6-cm vertical incision is made in the right atrium parallel to the atrioventricular groove from the base of the right atrial appendage to a point medial and superior to the inferior vena cava (Fig 2). A second incision is then made in the atrial septum and extends from the inferomedial edge of the septum secundum up toward the medial base of the superior vena cava without incising the superior surface of the right or left atria and without connecting to the right atriotomy incision. Stay sutures and an optional vein retractor are used to retract the medial edge of the atrial septostomy (Fig 2). For closure, both the atrial septostomy and the right atrial incisions are repaired with a running 3-0 polypropylene suture.

Patient Population, Procedures, and Analysis
The Institutional Review Board of Duke University approved the study and waived the requirement for individual consent. The patient population is a consecutive series of all 553 patients undergoing a mitral valve procedure (repair, replacement, or inspection) through a median sternotomy between the years 1989 and 2003 by a single surgeon. This study excluded patients with chest incisions other than sternotomy to avoid biases related to the chest incision itself. Retrospective chart review was performed in all patients and included only data from the index hospitalization. Age, sex, operative year, preoperative ejection fraction, cross-clamp time, total bypass time, mortality during the same admission, type of mitral procedure (repair, replacement, or inspection), and concomitant procedures (tricuspid or aortic valve procedures, coronary artery bypass grafting) were recorded. Patients with current or past episodes of atrial fibrillation or junctional rhythm were designated as having preoperative atrial fibrillation or junctional rhythm, respectively. All patients had continuous electrocardiographic telemetry during their postoperative stay. In this study, telemetry data were limited to those episodes of new atrial fibrillation or junctional rhythm lasting more than 1 hour and sufficiently impacting the patient's clinical course to warrant documentation in the medical record. Patients who had these rhythms postoperatively but who did not have the respective preoperative rhythm were designated as having new atrial fibrillation or new junctional rhythm. Patients admitted with a permanent pacemaker were considered to have a preoperative pacemaker, and those who received a permanent pacemaker during the same hospitalization for any reason were designated as having a new pacemaker.

Statistical analysis was performed using StatsDirect. Numerical values were compared using unpaired t tests, and categorical variables were compared using {chi}2 analysis.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Discussion
 References
 
Of 553 total patients, the following were excluded from further analyses: 15 who underwent a concomitant maze procedure, 5 who had a concomitant septal myomectomy, and 2 patients who had the procedure performed through the superior left atrial approach (Fig 1) [16]. The remaining 531 patients were divided into two groups: left atriotomy (LA, n = 273) and transseptal (TS, n = 258).

Patient characteristics and operative factors are listed in Table 1. While there were no differences in age or preoperative ejection fraction, there were significantly more males in the TS group (Table 1). Operative factors listed in Table 1 indicate that the TS group had significantly more concomitant tricuspid and aortic valve procedures performed. The percentage undergoing concomitant coronary artery bypass grafting was not significantly different. There were significantly more mitral valve replacements among the TS versus LA patients and fewer mitral valve repairs. The number of redo sternotomies was significantly greater in the TS group. Finally, the average operative year was significantly later in the TS group (2000, versus 1996 for LA; p < 0.0001), as the TS approach became our preferred technique over time. This is best illustrated in Figure 3, which shows the number of cases performed by each approach over time.


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  		Table 1. Patient Characteristics and Operative Factors
 

Figure 3
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  		Fig 3. Approach to the mitral valve over time, showing the number of patients per year undergoing a mitral valve procedure by median sternotomy through either the left atriotomy (white bars) or the minitransseptal approach (black bars).

 
The TS patients had significantly longer total bypass time and cross-clamp time (Table 1). To determine whether the longer times were due to the minitransseptal approach itself or, rather, to the performance of more redo and concomitant valve procedures among the TS patients, subset analysis was performed on the patients who underwent only a non-redo mitral valve procedure (n = 65 LA and n = 16 TS). In this subset analysis, neither total bypass time (158 minutes LA versus 164 minutes TS; p = 0.58), nor cross-clamp time (98 minutes LA versus 105 minutes TS; p = 0.48), were significantly different.

There were no significant differences in the incidence of preoperative atrial fibrillation, preoperative junctional rhythm, or preoperative pacemaker placement between LA and TS patients (Table 2). The number of patients who had new atrial fibrillation postoperatively was also not significantly different (Table 2). Univariate analysis found that age and concomitant coronary artery bypass grafting were associated with the development of new atrial fibrillation, but TS was not (Table 3). While concomitant tricuspid procedure appeared to be protective against the development of atrial fibrillation, concomitant tricuspid procedure was significantly associated with preoperative atrial fibrillation (p < 0.0001), thus creating a selection bias.


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  		Table 2. Patient Preoperative Conditions and Postoperative Outcomes
 

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  		Table 3. Univariate Analysis
 
The incidence of new junctional rhythm postoperatively was significantly higher among TS patients (Table 2). Univariate analysis showed that TS, concomitant aortic procedure, and redo sternotomy were significantly associated with the development of new junctional rhythm, although there was insufficient statistical power to determine whether any of these were independent predictors in a multivariate analysis (Table 3). Subset analysis of non-redo isolated mitral valve patients showed that new postoperative junctional rhythm was not more common for TS (1 of 16; 6%) than for LA (4 of 65; 6%; p = 0.9).

The need for a permanent pacemaker was also significantly higher among the TS patients (Table 2). Univariate analysis revealed that TS, redo sternotomy, concomitant aortic valve procedure, and the operative year were associated with the need for a permanent pacemaker (Table 3). Multivariate analysis showed that only redo sternotomy (p = 0.01) was a clear independent predictor of permanent pacemaker need. Specifically, the TS approach was not a significant independent predictor of pacemaker need in a multivariate analysis. Thus, while there was a significantly greater need for a new permanent pacemaker among TS patients, the TS approach was not an independent predictor of this.


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Discussion
 References
 
These data from a single-center, single-surgeon study of more than 500 consecutive mitral valve procedures suggest that the minitransseptal approach has outcomes comparable with those of the conventional left atriotomy approach. This study represents the largest case-series to date directly comparing different atrial incisions and the largest study evaluating outcomes of the minitransseptal approach. Several smaller studies have compared different approaches to the mitral valve. In a nonrandomized study of 152 patients, Masuda and colleagues [17] compared the Berreklouw and Guiraudon superior transseptal approach with conventional left atriotomy. They found that 96% of LA patients (n = 24) with preoperative sinus rhythm remained in sinus rhythm postoperatively compared with 78% of superior transseptal patients (n = 18), which was not statistically significant. At an average follow-up time of 16.1 and 13.8 months, respectively, 88% of LA patients and 83% of superior transseptal patients who had preoperative sinus rhythm were still in sinus rhythm. This finding suggested that the superior transseptal approach, which requires a more extensive incision than our minitransseptal approach, may have a higher incidence of new, early postoperative arrhythmias but that the incidence of new arrhythmias in the long-term was similar to the LA approach.

Kumar and coworkers [8] conducted a prospective, nonrandomized study on 89 patients (24 LA and 65 superior transseptal). They found that 38% of superior transseptal patients had junctional rhythm postoperatively compared with 13% of LA patients, which was statistically significant. By 6 weeks, 12% of these transseptal patients were still in junctional rhythm, compared with 0% of the LA patients, but no patients in the study required permanent pacemakers. In another prospective, nonrandomized study, Utley and associates [7] compared 149 patients undergoing mitral valve procedures through either the LA (n = 66), superior transseptal (n = 46), or minitransseptal (n = 37) approach. After multivariate analysis, they found that the type of incision was not predictive of the need for permanent pacemakers. Furthermore, the LA and minitransseptal approaches were predictors of retention of sinus rhythm postoperatively whereas the superior transseptal approach was not.

On the other hand, one randomized study [13] of 146 patients (73 LA and 73 superior transseptal) found no significant difference in the incidence of junctional rhythm or atrial fibrillation either before hospital discharge or at later follow-up. These studies suggest that, if the incidence of arrhythmias is increased among superior transseptal patients, it is most likely a transient junctional rhythm. Furthermore, these prior studies and the current study suggest that the incidence of new junctional rhythm is probably not increased among patients treated through the minitransseptal approach, which is essentially a less extensive version of the superior transseptal incision.

The potential advantages of the minitransseptal incision over the left atrial approach are several. Depending upon chest anatomy, visualization of the valve may be improved because the valve can be seen looking straight down through the sternotomy rather than from the right lateral position. Less dissection is required in redo cases because the interatrial groove does not need to be exposed. Repeat operations were done in the current series using the minitransseptal approach for the second time, and very little scar was present on the interatrial septum owing to its intracardiac location. The approach can be used with either small or large atria and, should a tricuspid valve procedure need to be done concomitantly, there is no need for a second incision since the tricuspid valve can be readily visualized through the right atriotomy (Fig 2). Bypass and cross-clamp times are not necessarily increased, and the incisions are easy to close. Finally, the minitransseptal approach can be one (but not the only) means to make valvular surgery easier to learn for trainees and easier to teach, because both the surgeon and the assistant have an adequate view of the valve from opposite sides of the table. In fact, with this approach, most mitral procedures could be done entirely with the surgeon standing on either the right or left side of the patient.

The minitransseptal incision also has potential advantages over the superior transseptal incision of shorter atrial incisions, faster atrial closure time, less potential for bleeding from shorter and more accessible suture lines, and less proximity to the sinoatrial node and sinoatrial blood supply. Although the superior transseptal approach can provide even wider exposure of the mitral valve than the minitransseptal approach, the minitransseptal incision can easily be extended to a superior transseptal incision in those rare circumstances where exposure proved inadequate (an event that did not occur in this series).

There are some disadvantages to the minitransseptal approach, however. Because the opening in the septum is small relative to the LA or superior transseptal approaches, the field of view may seem limited. One cannot perform a conventional, surgical Maze procedure using the minitransseptal incision without modification of either the maze incision or the minitransseptal incisions. Also, the minitransseptal incision is inherently an anterior approach not suited for the lateral thoracotomy approach, although it can be used with an anterior thoracotomy [18]. Finally, there is a learning curve associated with the approach, as the two incisions need to be kept away from cannulation sites and away from the atrioventricular node, mitral annulus, and aortic root medially.

There are also limitations to our study of the minitransseptal approach. The retrospective nature of the study cannot eliminate the possibility of selection bias between the LA versus TS patients. The average year that the procedure was performed (LA versus TS) was significantly different, thus exposing the two groups to potential differences in operator experience and concomitant medical therapeutic practices. Although attempts were made to correct for intergroup variability through multivariate analysis, a randomized study would have been preferable. The retrospective nature of this study may have missed minor postoperative arrhythmias that were not documented in the medical record, although this limitation should have affected both groups equally. Finally, the study only included in-hospital data and did not assess for potential long-term complications such as late arrhythmias. Prior studies suggest that most new atrial arrhythmias declare themselves prior to discharge [8, 12]. Thus, the current study focused on the period during which arrhythmias are most likely to develop and during which any gross differences between the two approaches are most likely to be observed.

In summary, although the minitransseptal approach to the mitral valve was described as early as the 1950s, it has not had the degree of usage that the left atrial approach through the posterior interatrial groove has had. While the outcomes of different approaches to the mitral valve have been compared in several smaller studies, few have included the minitransseptal approach, which offers excellent visualization of the mitral valve in a variety of situations. Our single-surgeon, single-center experience with more than 500 mitral valve procedures through median sternotomy suggests that the minitransseptal approach offers outcomes comparable to those of the left atriotomy approach. These data suggest that the minitransseptal technique can be a valuable tool in the armamentarium of the surgeon seeking better exposure of the valve without risking the prolonged closure times and arrhythmias that may be associated with more extensive transseptal incisions.


   Discussion
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Discussion
References
 
DR ROBERT A. E. DION (Leiden, the Netherlands): I rise to congratulate you for your presentation. In fact, I am using exactly the same approach for years. From a technical point of view, one has to incise the foramen ovale vertically along its right border. One should warn the surgeon not to incise the foramen ovale in the middle or along the left border, because then the blade of the retractor comes too close from the anterior annulus of the mitral valve. Would you agree?

DR NIENABER: That has been our experience as well.

DR DION: You state that it provides a limited exposure. However, using for instance a Cosgrove retractor, one can pull a lot on the septum without tearing on the condition that one has not incised the inferior ridge of the foramen ovale. This is always a tip I give to my young colleagues. Then it provides a very satisfactory exposure, also in the setting of ischemic mitral regurgitation when the left atrium may be rather small.

The last point I would like to ask you is why do you say it is less interesting for the maze procedure?

DR NIENABER: Mainly because you have to make basically a separate incision, the left atriotomy incision, to do the traditional maze incision or the traditional maze approach.

DR DION: So you mean the true "cut-and-sew" maze?

DR NIENABER: Right, correct.

DR L. HENRY EDMUNDS (Philadelphia, PA): I am almost embarrassed to ask a technical question, but how deep do you dissect Sondergaard's cleft for the lateral approach, or do you dissect it at all?

DR NIENABER: I am sorry, how deep do we dissect what?

DR EDMUNDS: Sondergaard's cleft, the interatrial septum from the outside. Never heard of it? That reminds me of Santana.

DR NIENABER: Dissection of Sondergaard's cleft varied, sometimes minimal, sometimes all the way to the edge of the septum secundum.

DR I. AYHAN OZDEMIR (Mugla, Turkey): I congratulate you on an excellent presentation. I agree with you it is the most difficult case. I wonder what percentage you used tricuspid annuloplasty in your cases? Most of the time we use tricuspid surgery and mitral surgery at the same time with the right atrial approach. Thank you.

DR NIENABER: I am sorry, what percentage we used?

DR OZDEMIR: Tricuspid surgery at the same time.

DR NIENABER: How often we use the same incision for tricuspid procedures?

DR OZDEMIR: Yes.

DR NIENABER: I think it is basically the same approach for a tricuspid procedure. Nineteen percent of the transeptal patients had concurrent tricuspid procedures.

DR SARY F. ARANKI (Boston, MA): I have another question for you. Which patients don't you use this approach on, any particular set?

DR NIENABER: Which don't we?

DR ARANKI: Yes.

DR NIENABER: As far as I know, there aren't really any contraindications to it. It is a pretty versatile approach.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Discussion
 References
 

  1. Effler DB, Groves LK, Martinez WV, Kolff WJ. Open heart surgery for mitral insufficiency J Thorac Surg 1958;36:665-676.[Medline]
  2. Dubost C, Guilmet D, de Parades B, Pedeferri G. New technic of opening of the left auricle in open-heart surgerythe transseptal bi-auricular approach. [translation] Presse Med 1966;74:1607-1608.
  3. Brawley RK. Improved exposure of the mitral valve in patients with a small left atrium Ann Thorac Surg 1980;29:179-181.[Abstract]
  4. Guiraudon GM, Ofiesh JG, Kaushik R. Extended vertical transatrial septal approach to the mitral valve Ann Thorac Surg 1991;52:1058-1062.[Abstract]
  5. Berreklouw E, Ercan H, Schonberger JP. Combined superior-transseptal approach to the left atrium Ann Thorac Surg 1991;51:293-295.[Abstract]
  6. Hake U, Dahm M, Schmid FX, Mayer E, Oelert H. The extended transseptal approach in complex mitral valve surgery—evaluation of risks and benefits Thorac Cardiovasc Surg 1996;44:67-70.[Medline]
  7. Utley JR, Leyland SA, Nguyenduy T. Comparison of outcomes with three atrial incisions for mitral valve operationsright lateral, superior septal and transseptal. J Thorac Cardiovasc Surg 1995;109:582-587.[Abstract/Free Full Text]
  8. Kumar N, Saad E, Prabhakar G, De Vol E, Duran CM. Extended transseptal versus conventional left atriotomyearly postoperative study. Ann Thorac Surg 1995;60:426-430.[Abstract/Free Full Text]
  9. Alfieri O, Sandrelli L, Pardini A, et al. Optimal exposure of the mitral valve through an extended vertical transeptal approach Eur J Cardiothorac Surg 1991;5:294-299.[Abstract]
  10. Takeshita M, Furuse A, Kotsuka Y, Kubota H. Sinus node function after mitral valve surgery via the transseptal superior approach Eur J Cardiothorac Surg 1997;12:341-344.[Abstract]
  11. Garcia-Villareal OA, Gonzalez-Oviedo R, Rodriguez-Gonzalez H, Martinez-Chapa HD. Superior septal approach for mitral valve surgerya word of caution. Eur J Cardiothorac Surg 2003;24:862-867.[Abstract/Free Full Text]
  12. Gaudino M, Nasso G, Minati A, et al. Early and late arrhythmias in patients in preoperative sinus rhythm submitted to mitral valve surgery through the superior septal approach Ann Thorac Surg 2003;75:1181-1184.[Abstract/Free Full Text]
  13. Gaudino M, Alessandrini F, Glieca F, et al. Conventional left atrial versus superior septal approach for mitral valve replacement Ann Thorac Surg 1997;63:1123-1127.[Abstract/Free Full Text]
  14. Bowman FO, Malm JR. The transseptal approach to mitral valve repair Arch Surg 1965;90:329-331.[Abstract/Free Full Text]
  15. McGrath LB, Levett JM, Gonzalez-Lavin L. Safety of the right atrial approach for combined mitral and tricuspid valve procedures J Thorac Cardiovasc Surg 1988;96:756-759.[Abstract]
  16. Meyer BW, Verska JJ, Lindesmith GG, Jones JC. Open repair of mitral valve lesionsthe superior approach. Ann Thorac Surg 1965;1:453-457.
  17. Masuda M, Tominaga R, Kawachi Y, et al. Postoperative cardiac rhythms with superior-septal approach and lateral approach to the mitral valve Ann Thorac Surg 1996;62:1118-1122.[Abstract/Free Full Text]
  18. Cosgrove III DM, Sabik JF, Navia JL. Minimally invasive valve operations Ann Thorac Surg 1998;65:1535-1538.[Abstract/Free Full Text]



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