Combined ablation of atrial fibrillation and minimally invasive mitral valve surgery: a case report

A partial lower inverted J sternotomy and an extended transseptal incision provide excellent exposure for minimally invasive mitral valve surgery. However, the extended trasnsseptal incision causes dividing the sinus node artery, which may result in conduction system disturbance and need for permanent pacemaker implantation. Therefore, there is a challenge in the patient who requires concomitant ablation for atrial fibrillation because of possible conduction system disturbance caused by extended transseptal incision. We describe a new strategy for combined ablation of atrial fibrillation with minimally invasive cardiac surgery by a transseptal approach to the mitral valve through a partial lower sternotomy incision. Cryoablation was performed using a T-shaped cryoprobe with a lesion set of pulmonary vein isolation and ablation of the left and right isthmus in performing mitral annuloplasty, tricuspid annuloplasty, and atrial septal defect closure through a limited sternotomy incision. This technique might minimize possible conduction system disturbance and provide good surgical result for the patients who undergo mitral valve surgery and ablation of atrial fibrillation.     

Hemisternotomy approach for aortic and mitral valve surgery

After exploring several less invasive approaches for cardiac valve surgery, we have concluded that the partial upper sternotomy is the incision of choice for minimally invasive aortic and mitral valve surgery. From March 1997 to January 1999, 827 patients had cardiac valve surgery using this approach; 462 had mitral valve procedures and 365 had aortic valve procedures. Of those having mitral valve surgery, 87% had mitral valve repair. Aortic valve surgery included replacement with stented bioprostheses (38%), allografts (29%), and mechanical prostheses (10%); in addition, 23% had aortic valve repair. Operative mortality was 0.8%. Conversion to full sternotomy was necessary in 2.4%. Blood use was low with 80% of patients receiving no blood transfusions. We conclude that all primary mitral and aortic procedures can be accomplished safely via partial upper sternotomy.     

Mini-Reoperative Mitral Valve Surgery

BACKGROUND: Reoperative surgery involving the atrioventricular valves places the patient at risk for cardiac or bypass graft injury upon reoperative sternotomy. Standard right thoracotomy can avoid these problems but is associated with a large incision and possibly more pulmonary complications. METHODS AND RESULTS: An alternative, minimally invasive approach for reoperative atrioventricular valve surgery was studied in 22 patients. Patient age was 66 +/- 10 years. Postoperative mitral regurgitation was 3.4 +/- 0.3 and New York Heart Association (NYHA) Class was III/IV, despite a mean ejection fraction of 44 +/- 14%. These patients had 1-4 prior procedures a mean of 5 years previously. An anterior 5th interspace incision of 5- to 10-cm was performed. A 1-cm segment of 5th rib was removed to facilitate exposure. Cardiopulmonary bypass was performed via ascending aorta or femoral artery cannula and bicaval venous cannulae. Systemic cooling (25 degrees) and fibrillatory arrest was used. Operations performed included mitral valve repair (12), mitral valve replacement (5), prosthetic mitral valve rereplacement (4), repair of perivalvular leak (3), tricuspid valve repair (5), and atrial septal defect closures (7). Mean bypass time was 109 +/- 21 minutes with a mean fibrillatory time of 62 +/- 12 minutes. There was no intraoperative or 30-day mortality. Patients were weaned from ventilation at a mean of 5 hours postoperatively and received 1.3 +/- 1 unit of blood. There were no wound complications or re-explorations for bleeding. At a mean follow-up of 15 +/- 8 months, survivors are NYHA Class I-II. When interviewed, all patients felt their recovery was more rapid and less painful than their original sternotomy. CONCLUSION: This minimally invasive approach to reoperative atrioventricular valve surgery is safe and technically feasible. It has become our preferred approach to the atrioventricular valves in patients with a previous sternotomy.     

Extended vertical transatrial septal approach to the mitral valve

Optimal mitral valve operation requires adequate exposure without impairment of atrial physiology, namely sinus node and atrioventricular node function. We used an extended vertical transseptal atrial approach in 34 consecutive patients. The extended vertical transseptal approach combines two semicircular atrial incisions circumscribing the tricuspid and mitral annuli anteriorly and superiorly, allowing exposure of the mitral valve by deflecting the ventricular side using stay sutures. The right atrium is opened anteriorly along the atrioventricular sulcus. The atrial septum is incised vertically through the fossa ovalis. The right atriotomy is extended superiorly in the right coronary fossa between the right atrial appendage and the atrioventricular sulcus to meet the septal incision. The two joint incisions are extended onto the left atrial roof transversely. At this point, the two semicircular incisions are performed and joined, and mitral valve operation is performed. There were 18 women and 16 men. Five patients had ischemic mitral valve regurgitation, 18 had mitral valve prolapse, and 11 had rheumatic heart disease. The mitral valve was replaced in 17 patients and repaired in 17. There were no perioperative complications associated with the atriotomies, ie, no bleeding, no atrioventricular nodal dysfunction, and no sinus node dysfunction. The extended vertical transatrial septal approach provides good mitral valve exposure without inherent complications.     

Biatrial transseptal approach in case of difficult exposure to the mitral valve

The biatrial transseptal approach according to the Dubost technique provides an excellent exposure to the mitral valve. Over a 5-year period (1984 to 1989) we used this approach in 210 patients. We believe that this incision is indicated in the following situations: reoperation on the mitral valve and acute mitral insufficiency with little enlargement of the left atrium.     

Minimally Invasive Approach for Redo Mitral Valve Surgery: A True Benefit for the Patient

ABSTRACT Objectives Redo mitral valve surgery via sternotomy is associated with a substantial morbidity and mortality. This study evaluated a minimally invasive technique for mitral valve redo procedures. Material and Methods: Out of a series of 394 patients undergoing mitral valve repair or replacement via a right minithoracotomy, 39 patients underwent redo mitral valve surgery (59 ± 13 years, 23 female). Previous cardiac surgeries included 17 patients with mitral valve repair, 6 patients with mitral valve replacement, 3 patients with aortic valve replacement, 2 patients with atrial septal defect closure, and 11 patients with coronary artery bypass grafting (CABG). In all cases, femoro-femoral cannulation was performed. The port access technique was applied in patients undergoing redo valve surgery. In patients with prior CABG, the operation was performed using deep hypothermia and ventricular fibrillation. Results: In all cases, sternotomy was avoided. The mitral valve was replaced in 20 patients and repaired in 19. Time of surgery and cross-clamp time were comparable with the overall series (168 ± 73 [redo] vs 168 ± 58 min and 52 ± 21 [redo] vs 58 ± 25 min). Mortality was 5.1%. One patient had transient hemiplegia due to the migration of the endoclamp. All other patients had uneventful outcomes and normal mitral valve function at 3-month's follow-up. Conclusion: Redo mitral valve surgery can be performed safely using a minimally invasive approach in patients with a previous sternotomy. The right lateral minithoracotomy offers excellent exposure. It minimizes the need for cardiac dissection, and thus, the risk for injury. Avoiding a resternotomy increases patient comfort of redo mitral valve surgery.     

Minimally invasive approach for redo mitral valve surgery: a true benefit for the patient

OBJECTIVES: Redo mitral valve surgery via sternotomy is associated with a substantial morbidity and mortality. This study evaluated a minimally invasive technique for mitral valve redo procedures. MATERIAL AND METHODS: Out of a series of 394 patients undergoing mitral valve repair or replacement via a right minithoracotomy, 39 patients underwent redo mitral valve surgery (59+/-13 years, 23 female). Previous cardiac surgeries included 17 patients with mitral valve repair, 6 patients with mitral valve replacement, 3 patients with aortic valve replacement, 2 patients with atrial septal defect closure, and 11 patients with coronary artery bypass grafting (CABG). In all cases, femoro-femoral cannulation was performed. The port access technique was applied in patients undergoing redo valve surgery. In patients with prior CABG, the operation was performed using deep hypothermia and ventricular fibrillation. RESULTS: In all cases, sternotomy was avoided. The mitral valve was replaced in 20 patients and repaired in 19. Time of surgery and cross-clamp time were comparable with the overall series (168+/-73 [redo] vs 168+/-58 min and 52+/-21 [redo] vs 58+/-25 min). Mortality was 5.1%. One patient had transient hemiplegia due to the migration of the endoclamp. All other patients had uneventful outcomes and normal mitral valve function at 3-month's follow-up. CONCLUSION: Redo mitral valve surgery can be performed safely using a minimally invasive approach in patients with a previous sternotomy. The right lateral minithoracotomy offers excellent exposure. It minimizes the need for cardiac dissection, and thus, the risk for injury. Avoiding a resternotomy increases patient comfort of redo mitral valve surgery.     

Minimally invasive reoperative isolated valve surgery: early and mid-term results

OBJECTIVE: Minimally invasive, nonsternotomy approaches for valve procedures may reduce the risks associated with cardiac surgery after prior sternotomy and may improve outcomes. We analyzed our institutional experience to test this hypothesis. METHODS: Between 1995 and 2002, 498 patients with previous cardiac operations via sternotomy underwent isolated valve surgery: 337 via median sternotomy (aortic = 160; mitral = 177) and 161 via mini-thoracotomy (aortic = 61; mitral = 100). Data were collected prospectively using the New York State Cardiac Surgery Report Form. RESULTS: Preoperative incidences of congestive heart failure, renal disease, and nonelective procedures were higher in the sternotomy group. Hospital mortality was significantly lower with the minimally invasive approach, 5.6% (9/161) versus 11.3% (38/337) (univariate, p = 0.04). However, multivariate analysis (odds ratio: 95% confidence intervals, p value) revealed that chronic obstructive pulmonary disease (6.6: 1.4 to 3.1, p = 0.001), renal disease (4.1: 1.52 to 11.2, p = 0.01), cerebrovascular disease (2.2: 1.03 to 4.78, p = 0.04), and ejection faction <30% (1.5: 0.96 to 5.5, p = 0.06) were associated with increased mortality. While mean bypass time, cross-clamp times, and stroke rates were comparable between groups, patients undergoing minimally invasive valve surgery had no deep wound infections (0% vs 2.4%, p = 0.05), less need for blood products (p = 0.02), and shorter hospital stays (p = 0.009). Five-year survival was higher with minimally invasive techniques as compared to a sternotomy approach (92.4 +/- 2% and 86.0 +/- 2%, respectively, p = 0.08). CONCLUSIONS: Reoperative valve surgery can be safely performed using a nonsternotomy, minimally invasive approach, with at least equal mortality, less hospital morbidity, decreased hospital length of stay, and slightly favorable mid-term survival as compared to sternotomy.     

Sinus node artery-preserving superior transseptal approach: a simple technique

With the use of the superior transseptal approach during mitral valve surgery, good exposure of the mitral valve can be achieved with simple traction sutures, which minimize the risk of deformation of the mitral valve. For this reason, we routinely perform mitral valvoplasty using the superior transseptal approach; however, we, occasionally encounter cases that develop postoperative atrial dysrhythmia. We have therefore, devised a very simple technique for preservation of the sinus node artery in the superior transseptal approach, which is effective for reducing the incidence of postoperative sinus node dysfunction. In this technique, during incision of the dome of the left atrium, the sinus node artery is carefully dissected and preserved.     

Surgical repair of mitral valve prolapse through a minimal right vertical infraaxillary thoracotomy

Abstract Background: Minimally invasive mitral valve surgery has been proven a safe and cosmetic alternative to the conventional median sternotomy approach. The aim of this study is to retrospectively evaluate the clinical outcome of mitral valve repair for leaflet prolapse through a minimal right vertical infraaxillary thoracotomy (RVIAT). Methods: From January 2003 to December 2011, 68 patients with mitral regurgitation (MR) due to leaflet prolapse underwent mitral valve repair through a RVIAT approach. There were 37 males and 31 females. The mean age of the patients was 37.8 ± 10.5 years. Of the 68 patients, 45 had posterior leaflet prolapse and 23 had anterior leaflet prolapse. Results: The mean incision length was 7.3 ± 1.8 cm (range 5.5 to 10.0 cm). Mitral valve repair technique included quadrangular resection with or without sliding repair (40 cases), edge to edge technique (six cases), artificial chordae (18 cases), chordal transfer (four cases), and ring annuloplasty was performed in all 68 patients. There was no severe morbidity and operative mortality. Echocardiography after operation demonstrated absence or trivial mitral regurgitation in 52 patients and mild regurgitation in 16 patients. During the 3 months ～8 years' follow-up period, one patient (1.5%) underwent mitral valve replacement through the median sternotomy due to recurrent severe MR. Other patients were in good condition. Conclusion: Surgical repair of mitral valve prolapse can be successfully performed through the RVIAT approach achieving excellent cosmetic and clinical results. (J Card Surg 2012;27:533-537).     

房顶及房间隔联合切口置换二尖瓣

目的报告１９９７年３～１２月用房顶及房间隔联合切口为１４例患者行二尖瓣置换术及术后心律随访结果。方法常规体外循环及心肌保护。首先做右心房斜切口，继而行房间隔切口，两切口汇于隔顶后向前切开左房顶３～４ｃｍ。带扣线置于左房顶切口下缘及房间隔作牵引，行二尖瓣置换。随访时复查心电图。结果无左房顶切口出血的病例，除１例术后死于急性肾功能衰竭和呼吸衰竭外，１３例患者恢复出院。随访结果：术前为窦性心律的３例患者术后仍为窦性心律，而术前为心房纤颤的１０例患者中除１例术后恢复窦性心律外，余９例仍为心房纤颤。结论在常规左心房直切口或经房间隔切口显露困难时，房顶及房间隔联合切口是一种较好的选择     

Minimally Invasive Valve Operations

Background. To reduce the morbidity from valvular heart operations, a right parasternal approach was introduced. We report our initial experience with the procedure.

Methods. From January 1996 through July 1996, 115 patients underwent primary isolated valve procedures. One hundred (85%) patients underwent the operation through a right parasternal incision.

Results. There was one hospital death secondary to a stroke on the fifth postoperative day. Three patients (two with aortic valve operations and one having a mitral valve procedure) required conversion to sternotomy. Mean aortic occlusion time was 71 minutes; mean cardiopulmonary bypass time was 93 minutes. Mean stay in the intensive care unit was 27 hours and mean hospital postoperative stay was 5.7 days. Seventy-seven percent of the patients did not receive blood transfusions. Comparison with median sternotomy demonstrated a reduction in both postoperative length of stay and direct hospital costs.

Conclusions. We conclude that this minimally invasive approach is safe for a variety of valve procedures and is effective in reducing surgical trauma and cost.     

Partial median sternotomy for pediatric cardiac surgery

In order to minimize scarring and thereby improve the postoperative cosmetic appearance of pediatric cardiac surgery patients, we perform partial median sternotomy incisions. A short midline skin incision, from 1 to 2 cm below the articular notch of the second rib to the xiphoid process, is made. The sternum was divided from the xiphoid process to the articular notch of the second rib. The thymus is mobilized and the pericardium incised longitudinally. The aorta and superior and inferior vena cava are mobilized to facilitate direct cannulation. Cardiopulmonary bypass is instituted in the usual fashion. Twenty-four pediatric patients underwent repair of cardiac anomalies through a partial median sternotomy incision at our institution between June 1997 and September 1998. The average age of the patients was 4 years and 4 months (range, 4 days to 12 years) and the average weight was 16.0 kg (range, 3.2 to 40.5 kg). Cases included 13 VSD (ventricular septal defect) [including one DCRV (double chambered right ventricle) and one PS (pulmonary stenosis)], 9 ASD (atrial septal defect), one ECD (endocardial cushion defect), and one DORV (double outlet right ventricle) with mitral atresia. All patients were extubated within 3 hours after surgery and the average length of the ICU stay was within 24 hours (except for one 4-day-old baby who died of LOS (low cardiac output syndrome) on the 16th postoperative day). There were no wound infections or hospital mortalities. In our experience, this approach is safe, provides good exposure, and provides excellent cosmetic results.     

Minimally invasive video-assisted mitral valve surgery: from Port-Access towards a totally endoscopic procedure

Right thoracotomy is an alternative to mid-sternotomy for left atrium access. The Port-Access approach is an option that reduces the skin incision and obviates rib spreading. PATIENTS AND METHODS: From February 1997 until November 1999, 121 patients underwent mitral valve surgery through a right antero-lateral thoracotomy using the Heartport cardiopulmonary bypass (CPB) system. Mean age was 60 years (31-84). Most patients had normal ejection fractions and were in NYHA Class II or III. Seventy-five patients had valve repair (62%) and 46 (38%) had valve replacement. Pathologies were myxoid (n = 80), rheumatic (n = 30), chronic endocarditis (n = 5), annular dilatation (n = 3), sclerotic (n = 1), ingrowing myxoma (n = 1), and one closure of a paravalvular leak. RESULTS: Two patients had conversion to sternotomy for aortic dissection (one died) with the Endo-Aortic Clamp, and two others for peripheral vascular problems. One patient died at postoperative day 1 after reoperation for failed repair, another with double valve surgery on postoperative day 4 after two revisions for bleeding. Twelve underwent revision for bleeding (10%). Three had prolonged ICU stay for respiratory insufficiency. Two late valve replacements for endocarditis occurred. Echographic control revealed residual insufficiencies (grade 1-2) in two valvular repairs. There were neither paravalvular leaks nor myocardial infarcts. There were no cerebrovascular accidents due to embolic phenomena. Mean ICU and hospital stay were 2.1 and 8.7 days, with a major difference between the first 30 patients and those who followed. CONCLUSION: Port-Access mitral valve surgery can be a valid alternative to conventional sternotomy and seems to be an important improvement in minimally invasive cardiac surgery.     

Minimally invasive technology for mitral valve surgery via left thoracotomy: experience with forty cases

BACKGROUND: Recent evolution of minimally invasive technology has expanded the application of the right thoracotomy approach for mitral valve surgery. These same technological advances have also made the left posterior minithoracotomy approach attractive in complex mitral procedures. METHODS: From 1996 to 2003, 921 isolated mitral valve procedures were performed without sternotomy; 40 (4.3%) of these were performed via left posterior minithoracotomy. In the left posterior minithoracotomy group, ages ranged from 18 to 84 years; 36 patients had had previous cardiac surgery (9 on > or =2 occasions). Other factors precluding right thoracotomy included mastectomy/radiation and pectus excavatum. RESULTS: Arterial perfusion was via femoral artery (n = 26) or descending aorta (n = 14); long femoral venous cannulas with vacuum-assisted drainage were used in 39 procedures. Two patients had direct aortic crossclamping, 18 had hypothermic fibrillation, and 20 had balloon endoaortic occlusion. The mean crossclamp and bypass times were 81.9 and 117.2 minutes, respectively. Hospital mortality was 5.0% (2/40); both deaths occurred in octogenarians. There were no injuries to bypass grafts or conversions to sternotomy. Complications included perioperative stroke (2/40; 5.0%), bleeding (2/40; 5.0%), and respiratory failure (1/40; 2.5%); 28 patients (70%) had no postoperative complications. There was no incidence of perioperative myocardial infarction, renal failure, sepsis, or wound infection. The median length of stay was 7 days. CONCLUSIONS: Advances in minimally invasive cardiac surgery technology are readily adaptable to a left-sided minithoracotomy approach to the mitral valve. The left posterior minithoracotomy approach is a valuable option in complicated reoperative mitral procedures with acceptable perioperative morbidity and mortality.     

Optimal exposure of the mitral valve through an extended vertical transeptal approach

The mitral valve was approached through a vertical transeptal incision extended into the roof of the left atrium in 111 patients. Good exposure was invariably provided even in unfavorable situations such as a small left atrium combined with right ventricular hypertrophy or a previously implanted aortic prosthesis. The only hospital death in the entire series was not related to this approach to the mitral valve. Due to breakage of the suture in the roof of the left atrium and to incomplete reconstruction of the atrial septum resulting in a large left-to-right shunt, 2 patients required reinstitution of cardiopulmonary bypass. Both had a smooth postoperative course. Other intra- or postoperative complications related to the incision did not occur. Duration of cardiopulmonary bypass and aortic occlusion was not significantly different from that of patients operated upon through the conventional left atrial approach in the year preceding the experience embraced by this study. Only 3 of 52 patients who were preoperatively in sinus rhythm were discharged in atrial fibrillation. Enhanced atrial vulnerability was demonstrated preoperatively in all 3. These data support a wide application of the extended vertical transeptal approach in mitral valve surgery.     

Minimally invasive video-assisted mitral valve surgery: our lessons after a 4-year experience

BACKGROUND: Right thoracotomy is a well known alternative to median sternotomy to gain access to the left atrium. To avoid the potential drawbacks associated with sternotomy coupled to the desire for a smaller scar and a more rapid rehabilitation in young and active patients, we investigated the purported advantages in patients undergoing video-assisted Port-Access mitral valve surgery. METHODS: Between February 1997 and November 2000, 175 patients (94 men, 81 women) with a mean age of 60 years (range 25 to 84) underwent either Port-Access mitral valve repair (n = 117) or replacement (n = 57) for degenerative disease (n = 112), rheumatic disease (n = 36), chronic endocarditis (n = 15), annular dilatation (n = 8), sclerotic disease (n = 2), and ingrowing myxoma (n = 1). There was one closure of a preexisting paravalvular leak. Standard Carpentier-Edwards repair procedures were used in all patients; in 14 patients polytetrafluoroethylene chordae were inserted for anterior leaflet prolapse. A total of 74 patients (42%) were in New York Heart Association functional class III/IV. RESULTS: Hospital mortality was 1.1% (n = 2). Four patients had conversion to sternotomy and conventional extra corporeal circulation for repair of a dissected aorta (n = 2) or the inabilty to proceed to a safe femoral cannulation (n = 2). Sixteen patients (9%) underwent a revision for bleeding. Mean cross-clamp time and perfusion time was 95 minutes (range 24 to 160) and 135 minutes (range 75 to 215) respectively. Mean intensive care unit and total hospital stay was 1.8 days (1 to 30) and 8.7 days (4 to 36), respectively. Three patients experienced late acute endocarditis: 2 had late mitral valve replacements and 1 patient had medical therapy for late prosthetic valve endocarditis. There were no myocardial infarctions, cerebrovascular events or peripheral ischemia due to thromboembolic phenomena. No wound complications were observed. The degree of patient satisfaction was very high. CONCLUSIONS: The video-assisted Port-Access mitral valve approach is a valid alternative to sternotomy, with the same standards of results and quality.     

Partial median "I" sternotomy: minimally invasive alternate approach for aortic valve replacement

Minimally invasive aortic valve replacement using the inversed L-like partial upper sternotomy has evolved during the last 10 years. It is performed with excellent results with regard to sternal stability and cosmesis. However, the lateral incision may result in sternal overriding, instability, or fracture. We present an alternate minimally invasive approach to aortic valve replacement. We performed a partial median "I" sternotomy in 30 consecutive patients: After a 6- to 8-cm skin incision, the sternum was incised from the jugulum downward to the corpus, ending at the level of the fourth or fifth intercostal space. No lateral incision of the sternum was performed. The access to the heart and aorta was excellent. During the postoperative course and during follow-up, clinical examination revealed sternal stability and normal wound healing in all patients. These results show that the partial median I sternotomy can be performed safely and provides excellent clinical and cosmetic results.     

Combined superior-transseptal approach versus conventional approach for mitral valve surgery.

OBJECTIVE: This study was designed to evaluate the safety and effectiveness of the combined superior-transseptal approach for mitral valve surgery. METHODS: We compared the preoperative status, operative factors, and postoperative outcomes among patients having mitral valve operations with three atrial incisions. The incisions were transseptal (n = 40), combined superior-transseptal (n = 33), and left atrial (n = 22). RESULTS: The cardiopulmonary bypass time and cross-clamp time were significantly higher in the superior-transseptal group compared with the transseptal group. No significant difference in blood loss was found among the three groups. The incidence of sinus node dysfunction in the early postoperative period was more common in the superior-transseptal group. The maintenance of sinus rhythm at the mid-term follow-up in patients with preoperative sinus rhythm was not significantly different among the three groups. On the other hand, a few patients in the superior-transseptal and transseptal groups with the preoperative sinus rhythm developed sick sinus syndrome requiring permanent pacemaker implantation. CONCLUSIONS: The use of the combined superior-transseptal approach was safe and effective, and was not associated with a higher incidence of rhythm disturbance. Because this approach provided an optimal exposure of the mitral valve and subvalvular apparatus, it has been positively adopted for use in patients undergoing complex and difficult mitral valve operation. To use this approach for patients undergoing mitral valve surgery through this approach, however, further follow-up study of the sinus node function is necessary.     

The transseptal approach to the mitral valve during multivalvular surgery

Abstract Aim: We investigated the short and mid‐term outcome of the transseptal approach to the mitral valve during multivalvular surgery. Methods: Within a three‐year period ending in May 2010, we used the transseptal approach in performing mitral valve surgery in 62 patients. Procedures performed were: mitral valve replacement and tricuspid annuloplasty in 40 patients, both aortic and mitral valve replacement with tricuspid annuloplasty in 13 patients, mitral valve and tricuspid valve replacement in eight patients and mitral valve repair and tricuspid annuloplasty in addition to coronary artery bypass surgery in one patient. Results: There were no complications associated with the transseptal approach. There were no conduction abnormalities, nor were there any procedure‐related deaths. Conclusion: We conclude that use of the transseptal approach for mitral valve operations is simple and safe in patients necessitating right atriotomy for concomitant procedures. (J Card Surg 2011;26:472‐474)