Ann Thorac Surg 2009;87:694-697. doi:10.1016/j.athoracsur.2008.03.043
© 2009 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Revisiting the Dome Approach for Partial Sternotomy/Minimally Invasive Mitral Valve Surgery
Sherard Little, MDa,
Michael Flynn, MDa,
Gösta B. Pettersson, MD, PhDa,*,
A. Marc Gillinov, MDa,
Eugene H. Blackstone, MDa,b
a Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
b Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
Accepted for publication March 18, 2008.
* Address correspondence to Dr Pettersson, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Ave, Desk F24, Cleveland, OH 44195 (Email: petterg{at}ccf.org).
| Dr Gillinov discloses that he has a financial relationship with Edwards Lifesciences, Medtronic, and St. Jude.
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Abstract
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Background: When partial upper sternotomy is used for minimal access mitral valve surgery, the valve is usually approached through an extended transseptal incision. Limiting the left atrial incision to the dome offers adequate visualization of the mitral valve for standard repairs or replacement. We describe the surgical technique and early experience with this dome approach.
Methods: Forty-two patients had minimally invasive mitral valve surgery through partial upper sternotomy and incision in the left atrial dome. Surgical technique, operative findings, echocardiographic results, and complications are reported.
Results: In all cases, the operation was completed without extending the sternotomy or atrial incision. Thirty patients (71%) underwent valve repair and 12 (29%) valve replacement. Repair techniques included ring anuloplasty, quadrangular posterior leaflet resection with or without sliding repair, commissural closure, and Alfieri repair. One patient had post-repair severe systolic anterior motion of the anterior mitral leaflet and underwent valve replacement. Thirty-nine had no or trivial mitral regurgitation and no systolic anterior motion; 3 had 1+ mitral regurgitation after repair. Six had concomitant aortic or tricuspid valve repair/replacement. There were no operative deaths. Two patients underwent reoperation for bleeding. Seven (17%) had postoperative bradycardia requiring temporary pacing, and 1 (2.4%) required permanent pacemaker insertion.
Conclusions: Combined with partial upper sternotomy, the left atrial dome incision offers adequate exposure of the mitral valve for standard procedures. This approach rarely divides the sinus node artery and is easy and fast to use.
Minimal access mitral valve surgery has become standard of care, and at our center, the majority of patients undergoing isolated mitral valve surgery are operated on using less invasive approaches. Currently, several minimal access approaches are used, including direct vision, endoscopic, and robotic through limited sternotomy or thoracotomy incisions. Our classical approach has been partial upper sternotomy through which an incision is made in the right atrial free wall and atrial septum and extended onto the dome of the left atrium—a so-called extended transeptal incision [1]. The incision in the heart is longer than in the skin, divides the sinus node artery, is time consuming to close, and messy to reopen and reclose when that is necessary. Use of the dome incision only with a partial sternotomy was reported by Gundry and colleagues [2], who described this approach in 6 patients—1 undergoing mitral valve repair and 5 having mitral valve replacement. We have revisited this approach and found it useful. The purpose of this paper is to describe our surgical technique for upper partial sternotomy with left atrial dome incision for mitral valve surgery and to report our early experience.
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Patients and Methods
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Between October 1, 2004, and July 1, 2007, 42 patients underwent partial upper sternotomy with a dome approach to the mitral valve. Twenty-three were female, and mean age was 57 years (range, 30 to 79). Indications for surgery were degenerative disease in 34 patients (81%), rheumatic disease in 2 (5%), and endocarditis in 6 (14%). This study has Institutional Review Board ethical approval in accordance with the Helsinki Declaration.
Surgical Technique
Through an 8-cm midline skin incision, a J-shaped partial upper sternotomy with extension into the fourth left intercostal space is performed. A mini-Finochietto retractor is then placed to spread the sternal edges. The pericardium is elevated to create a pericardial well, the patient is administered heparin, and standard aortic and bicaval cannulation is performed. Once normothermic cardiopulmonary bypass is commenced, both cavae are isolated, the aorta clamped, and the heart arrested with antegrade blood cardioplegia. A stab wound is made in the dome of the left atrium and a basket sucker introduced. A small incision is then made in the right atrium for direct cannulation of the coronary sinus. Retrograde cardioplegia is administered and repeated every 15 minutes.
The ascending aorta is vented and gently retracted to the left with a malleable retractor, and the superior vena cava is retracted to the right. A stay suture may be placed in the tip of the right auricle to retract it inferiorly. The stab wound in the dome of the left atrium is extended behind the aorta, staying superior to the orifice of the left atrial appendage, and to the right toward the atrial septum in the direction of the fossa ovalis, but not into the atrial septum (Fig 1A). Using a hand-held retractor, the anterior lip of the left atrial incision is retracted anteriorly and inferiorly. A stay suture is placed in the interatrial septum in the fibrous tissue at the upper corner of the fossa ovalis; tension on this suture facilitates visualization and is key to good exposure of the mitral valve (Fig 1B). Placement of posterior anuloplasty or valve replacement sutures with gentle traction further improves exposure of the valve. The valve is then further evaluated and repaired or replaced using standard techniques and instruments (Figs 1C and D). The left atrial appendage can be inverted and excised if indicated.
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Fig 1. Operative technique. The orientation is with patient's head to bottom of figures. (A) After open placement of the retrograde cardioplegia cannula in the coronary sinus, an incision is performed in the dome of the left atrium and extended from the atrial septum to just above the orifice of the left auricle. (B) Using two traction sutures and a retractor, the mitral valve is exposed and the pathology and repair strategy decided. (C) The actual repair is performed using standard techniques, in this case rectangular resection of P2, anulus plication, and insertion of an anuloplasty ring. (D) Closure of the atriotomy is simple and completed with deairing of the atrium.
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At completion of the valve repair or replacement, the left atrium is closed with 4-0 polypropylene and deaired, and the left heart is allowed to fill. Antegrade warm terminal cardioplegia is given. Thereafter, the retrograde cardioplegia catheter is removed, right atriotomy closed, caval snares released, and aortic clamp removed. The patient is weaned from cardiopulmonary bypass. Aortic venting is continued until there is no evidence of intracardiac air on transesophageal echocardiography.
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Results
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Thirty patients (71%) had valve repair (88% of those with degenerative disease) and 12 (29%) valve replacement (Table 1). In all cases, the operation was completed without extending the atrial incision beyond the dome. Six patients had other valve procedures, including aortic valve replacement (1), aortic valve debridement for fibroelastoma (1), tricuspid valve repair (3), and closure of a patent foramen ovale (1). Two patients required reopening for bleeding; the atrial dome closure was intact and hemostatic in both cases. Seven patients (17%) had postoperative bradycardia requiring temporary pacing. At discharge, 37 patients (88%) were in sinus rhythm, 4 were in atrial fibrillation (2 of whom were in atrial fibrillation preoperatively), and 1 had a junctional rhythm requiring permanent pacemaker insertion.
In 1 patient (65 years old) who had bileaflet prolapse and repair with P1-A1 commissural closure and ring anuloplasty, systolic anterior leaflet motion developed after repair, and the patient underwent subsequent mitral valve replacement during a second pump run, again using only the dome incision. Thirty-nine (93%) of the remaining patients had no or trivial mitral regurgitation and no systolic anterior leaflet motion; 3 had 1+ mitral regurgitation on predischarge echocardiography.
There were no deaths. Mean aortic clamp time was 70 ± 17 minutes.
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Comment
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Access to the mitral valve through the dome of the left atrium was first reported by Meyer and colleagues [3] and Saksena and colleagues [4]. In patients undergoing mitral valve surgery through upper partial sternotomy, we found approaching the mitral valve through the dome to be technically easy. In this experience, visualization through the dome was adequate for both mitral valve repair and replacement. For concomitant tricuspid valve repair, we used a separate right atrial incision. Closure of the dome incision is simple and fast. This compares with closure of the extended transseptal incision, which requires careful reconstruction of the right and left atria and interatrial septum. For patients requiring complex repairs, for example, replacement in the setting of anular calcification or concomitant procedures, the optimal approach—minimal access or conventional full sternotomy—is decided case by case.
The dome incision avoids dividing the sinus node artery in most cases, in contrast to the extended transseptal incision. In our experience and in reports of others, dividing the sinus node artery may result in conduction system disturbances [2, 5, 6]. Several studies suggest that the extended transseptal incision carries an increased risk of early postoperative arrhythmias compared with the standard left atrial incision [5, 7–11]. Kumar and colleagues [12] have documented a 38% early postoperative prevalence of junctional rhythm in patients who have undergone the extended transseptal approach, with resolution of sinus rhythm in a certain proportion of patients. Other studies indicate similar early and late postoperative cardiac rhythm regardless of atrial incision [13–15]. Comparing outcomes in 131 patients approached through the dome, interatrial groove, or atrial septum, Legare and colleagues [16] found no difference in the prevalence of postoperative arrhythmias and permanent pacemaker insertion among the techniques. In a large retrospective study, Lukac and colleagues [17] demonstrated a statistically significant difference in the occurrence of pacemaker insertion for sick sinus syndrome between patients undergoing the extended transseptal approach and left atriotomy through the interatrial groove (6% versus 2.3%, respectively; p = 0.01).
Although we have not performed a randomized study comparing these approaches, in the current report the prevalence of postoperative bradycardia requiring temporary pacing and the need for permanent pacemaker insertion after use of the dome incision were low. That could be related to preservation of the sinus node artery as well as the anterior internodal bundle. Further studies of larger numbers of patients are required to determine whether, when compared with the extended transseptal approach, this incision confers an advantage with regard to arrhythmias.
In conclusion, the dome approach is suitable for minimally invasive mitral valve surgery performed through partial upper sternotomy. It offers good exposure of the mitral valve and is less likely to divide the sinus node artery, and it is therefore expected to be associated with less postoperative sinus node dysfunction.
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Acknowledgments
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Gösta B. Pettersson is supported in part by the Peter and Elizabeth C. Tower and Family Endowed Chair in Cardiothoracic Research, James and Sharon Kennedy, the Slosburg Family Charitable Trust, and Stephen and Saundra Spencer. A. Marc Gillinov is supported in part by the Judith Dion Pyle Endowed Chair in Heart Valve Research. Eugene H. Blackstone is supported in part by the Kenneth Gee and Paula Shaw, PhD, Chair in Heart Research.
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References
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Abstract
Introduction
