The Superior Septal Approach to the Mitral Valve

This is very easy and excellent approach to the mitral valve. I use it for the reconstruction purpose and it can be done literally in three cuts with scissors, in 15 secs. The exposure is perfect. The only left question are rhythm disturbances due to the SA node artery cut down.... I haven`t noticed any arrhythmia in my practice, but I did only a dozen cases since I started using this approach. And it is easy and fast to close it, despite some arguments about it...as long as you don`t overly incise. What are your opinions?

Thank you for your comment and your question. There is a price to be paid for the increased exposure from this incision, and it is sinus node dysfunction postoperatively. I have seen it occur on a number of occasions, but generally this has been transient. Several theories for the occurrence of sinus node dysfunction have been advanced, and most of these focus on either injury to a portion of the sinus node that wraps medially over the junction of the SVC with the RA or injury to the sinus node artery that may often traverse across the incision superiorly.

I have been using this approach over the last 17 years. I think it could be useful for : 1) teaching purposes: using the paraseptal appoach (midline total sternotmy) the 1st assistant has not a less than optimal wiew of the mitral valve and of the surgical procedures used; 2) mitral valve surgery in case of small/normal left atrium : the exposure of the valve is optimal (i.e. mixomas, acute MR due to papillary muscle rupture). About the sinus node damage I experienced that dividing the sinus node artery ( when it runs on the roof of the left atrium) is not always followed by AV block . Usually the pattern of the "P" wave at EKG is different than preop and the voltage is low. When there is AV block it usually disappears before hospital discharge . "Memento": put 4 temporary pacing wires(2 atrial, 2 ventricular ), always. R Gaeta , MD Cardiac Surgery, Univerity of Messina , Messina, Italy

Thank you for your comments, Dr. Gaeta. I completely agree with you. Although it takes a bit longer to close the incisions than a conventional left atrial approach, I think the exposure, particularly in smaller left atria, is worth the effort.

Though there are other widely practised approach, I find this technique very easy, quick & with a great exposure of the mitral arena. One can avoid SA node complications by limiting the extent superiorly. I also agree with Dr Gaeta about the benefit in terms of teaching and training.

This is very simple method for reaching successful mitral valve surgery in many situations. I usually use this approach during the mitral valve surgery, Although Dr. Biltz showed superior septal incision with MAZE procedure in his YouTube posting, I have an concern when it comes to be performed combined with MAZE procedure.