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Superior Septal Approach to Mitral Valve Surgery

Monday, June 22, 2015

By

Ovidio Garcia-Villarreal

This video demonstrates the case of a 47-year-old male patient who was diagnosed with severe mitral valve regurgitation and prolapse in P2. The patient was in NYHA functional class II, and a mitral valve repair was performed by P2 quadrangular resection, plus annuloplasty. A superior septal approach was used to address the mitral valve.

Critical Surgical Steps:

  1. Use bicaval cannulation.
  2. Insert a right-angled cannula in the superior vena cava.
  3. Cross-clamp the aorta and administer the cardioplegia.
  4. Open the right atrium parallel to the right atrio-ventricular groove.
  5. Open the interatrial septum on the fossa ovalis.
  6. Join both incisions at the mid-point between the ascending aorta and superior vena cava.
  7. Extend the incision upwards in the left atrial roof before reaching the base of the left atrial appendage.
  8. Expose the mitral valve with one or two small retractors.
  9. Perform the mitral valve repair.
  10. Close the incision in the left atrial roof with double-running 3/0 Prolene suture.
  11. Close the incision in the fossa ovalis with double-running 3/0 Prolene suture, until reaching the other suture. 
  12. Close the upper end of the incision in the right atrium with double-running 3/0 Prolene suture.
  13. Close the lower end of the right atriotomy with double-running 4/0 Prolene suture until the two ends of the suture line are joined.
  14. Complete the operation as usual.

Comments

Submitted by Mathias Aazami on
Thanks for such a nice video Dr Garcia. One should highlight the advantage of RA incision in this technique that do not severe the Crista which integrity is of notice for geometry of tricuspid valve annulus. I would suggest Dr Gracia to use innominate vein cannulation (Fr 22) instead of SVC cannulation for an enhanced exposure. Hope see soon your own technique for LA reduction by superior atrial approach. Bravo.
Submitted by Ghassan Musleh on
I use this approach when the left atrium is small . The problem with this approach is that it takes longer time to close the many incisions in the left and right atrium and is associated with higher incidence of post op atrial fibrillation you can get a good exposure of the mitral valve using the left atrial approach when the left atrium is big which is the case in most patients.
Submitted by Michael Byrom on
I use this approach regularly, and see no increase in AF compared to the other surgeons in our unit. This is also the opinion of the surgeon who taught me this technique, who used it for decades. I also disagree that the LA approach gives good exposure in many cases, though it may sometimes. This exposure also means that your assistant can see the operation, which facilitates training. Some additional points to those made: stay 1cm away from the aortic root with the incision on the LA roof, to allow closure of the incision. You do not need to extend far across the LA roof, only a couple of cm is sufficient. Also in most cases you do not need retractor blades at all, simply two 4/0 pledgetted matters sutures. I recommend the youtube video of Arie Blitz in addition to this educational video https://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja&uact=8&ved=0CCMQtwIwAQ&url=http%3A%2F%2Fwww.youtube.com%2Fwatch%3Fv%3DBm67V59f7q0&ei=clWaVYiPHuS6mQXvzJzwBA&usg=AFQjCNFUgRUdhOtj2yPWbcEWEwdi6nnKiw&bvm=bv.96952980,d.dGY
Submitted by Ovidio Garcia-Villarreal on
Muchas gracias, Benigno. Espero que éste video sirva a los residentes para que tengan diversas opciones de abordajes para la mitral. The most important thing in a mitral valve surgery, in addition to know the theoretical bases,is to see properly the valve ! Saludos.
Submitted by Ovidio Garcia-Villarreal on
Thank you very much, Mathias. I have never tried in this way with a venous cannula through the innominate vein. I would like to see a video about this technique prior to try it. It sounds interesting. Kind regards, Ovidio.
Submitted by Ovidio Garcia-Villarreal on
Thanks a lot, Ghassan. I have almost never seen new AF with this technique. I've seen more commonly temporary AV block or some other cardiac rhythm disturbances. But regardless of rhythm disturbance, it usually disappears within 14 days after surgery. These are my data with this technique: Postoperative heart rhythm Atrial fibrillation (NOT NEW) (39.8%) Normal sinus rhythm ……….(54.9%) AV block………………………(3%) Other disturbances…………..(3%) Permanent pacemaker…….. (2.7%) Best kind regards, Ovidio.

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