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.     

Mitral valve surgery using combined superior-transseptal approach to the left atrium]

Although various approaches to the mitral valve surgery have been tried in the past, it still may be difficult to obtain a good surgical field, particularly in cases of small left atrium or reoperation. We performed mitral valve surgery in 6 patients using the combined superior-transseptal approach to the left atrium proposed by Berreklouw. Exposure of the mitral valve was excellent and the operative procedure was simple in all cases. There were no differences in bleeding volume, length of operation or complication of arrhythmia between patients treated with this new approach and a group treated with conventional approach in our institute.     

Combined superior-transseptal approach to the left atrium

The combined superior-transseptal approach to the left atrium was used in 22 patients: to perform a mitral valve repair in 14 patients and mitral valve replacement in 8 patients. Mitral valve operation was combined with other cardiac procedures in 18 patients (82%) and was performed as a reoperation in 3 patients (14%). In all cases there was excellent exposure of the complete mitral annulus and subvalvar apparatus. There were no instances of postoperative bleeding, conduction defects, or intraatrial shunting related to the approach. The combined superior-transseptal approach to the left atrium is an excellent approach that can be used in most reoperations and primary procedures for isolated or combined mitral valve operations.     

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.     

Conservative approach to the treatment of mixed mitral valve disease

Belcher, J. R. (1973). Thorax, 28, 608-612. Conservative approach to the treatment of mixed mitral valve disease. One hundred patients with mixed mitral valve disease have been treated with the `stand-by' bypass principle. In 59 the valve was replaced; in 41 a closed transventricular valvotomy was done. The results in the two groups have been compared.     

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)     

Combined mitral valve and coronary artery surgery

During the past 10 years, 50 patients underwent combined coronary artery bypass grafting (CABG) and mitral valve replacement (MVR) at our clinic, with additional aortic valve replacement (AVR) in six cases. The early mortality was 8%. During the first half of the study period this mortality was 4/11 patients, but in the second half it was 0/39. All six patients with CABG + MVR + AVR survived the operation. Adverse factors were found to be advanced functional impairment, female sex, concomitant untreated aortic valvulopathy and elevated pulmonary vascular resistance. All 46 patients who survived the operation were followed up for a mean period of 31 months, and during that time there were nine deaths. The survival rate was 54% after 3 years and 40% after 5 years. Most of the patients had improved by at least one functional class. The good results in this series probably were attributable to improvements in surgical procedure (introduction of cold potassium cardioplegia) and in postoperative management (intra-aortic balloon pumping).     

Combined mitral valve surgery and the Maze III procedure

Atrial fibrillation is present in approximately 50% of patients undergoing surgery for mitral valve disease. In the past, surgeons were forced to ignore atrial fibrillation when performing open-heart surgery for other indications simply because there was no proper surgical solution and little awareness of the medical consequences of atrial fibrillation. The Maze procedure was introduced in 1987 and when properly performed, its results when combined with mitral valve surgery have been excellent, with no increase in perioperative morbidity and mortality and with documented long-term advantages over simply leaving patients with atrial fibrillation. In this study we evaluated our recent results in 53 patients undergoing mitral valve surgery in combination with the Maze III procedure. Our results indicate that the Maze III procedure is just as safe and effective in controlling atrial fibrillation associated with mitral valve disease as it is in controlling atrial fibrillation not associated with mitral valve disease.     

Novel approach to mitral valve repair in childhood dilated cardiomyopathy

Evidence is mounting that mitral valve repair can improve symptoms in adults with dilated cardiomyopathy. Data is currently lacking for children with dilated cardiomyopathy and options for annuloplasty are limited in children. We report on the successful management of a 21 month-old child in heart failure from dilated cardiomyopathy and severe mitral regurgitation. The echocardiogram showed severely dilated left heart cavities, severe mitral regurgitation from a dilated annulus (23 mm, Z-score 1.74) with discrete anterior leaflet tethering, and moderate systolic dysfunction. The mitral valve was repaired using a 16 mm Bioring Kalangos biodegradable annuloplasty ring. The patient was extubated on the third postoperative hour and discharged on the fifth postoperative day with trivial mitral regurgitation and a 5 mmHg mean transvalvular gradient. At 12 months, the patient is in NYHA class I and presents trivial central mitral regurgitation without any transmitral gradient. This represents the first report in successfully managing a child with dilated cardiomyopathy with mitral regurgitation using a novel biodegradable annuloplasty ring, which has the potential to durably remodel the mitral annulus and grow with the patient.     

Combined mitral valve and coronary artery surgery: ischemic versus non-ischemic mitral valve disease.

OBJECTIVES: Mitral valve combined with coronary artery surgery is associated with a higher hospital mortality than each operation in particular. Controversy exists regarding the predictive value of ischemic mitral valve disease (MVD) on outcome. METHODS: Between 1984 and 1997, 262 patients underwent mitral valve operations (replacement, n = 198; repair, n = 64) in combination with coronary revascularization. The etiology of MVD was secondary to ischemic heart disease (group I) in 82 (31%) patients, and non-ischemic (group II) in 180 (69%) patients (rheumatic, 139 patients (53%); degenerative, 41 patients (16%)). Both groups were similar in age, cardiac risk factors and pulmonary artery pressure. Patients of group I had significantly more severe coronary artery disease, more often an impaired left ventricle and myocardial infarction, and were in a worse functional condition. The mean number of bypass grafts was significantly higher in group I. The follow-up was 98% (230/234 patients). RESULTS: With 19.5%, the hospital mortality was significantly increased in group I compared with 6.7% in group II (P = 0.002; overall, 10.7%). Mitral valve repair or replacement had no influence on early outcome, although mitral valve repair was performed more often in group I (37 versus 19%). The survival (valve-related event-free survival) after discharge from hospital in the 1st, 5th and 10th year was 94 (94%), 70 (66%) and 53% (35%) in group I and 96 (95%), 79 (76%) and 54% (41%) in group II, respectively. The long-term functional capacity was equally good in both groups (New York Heart Association mean, 1.86 versus 1.72). CONCLUSIONS: Patients with ischemic MVD are in a worse cardiac condition with significantly higher hospital mortality than patients with non-ischemic MVD and coronary artery bypass grafting. Once discharged from hospital, both groups have comparable long-term outcomes, with the best results in patients with degenerative MVD.