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Safety of the right atrial approach for combined mitral and tricuspid valve procedures
J
THoRAc CARDIOV ASC SURG
1988;96:756-9
Safety of the right atrial approach for combined mitral and tricuspid valve procedures Patients wtdergoing operation for combined mitral and tricuspid valvular disease may bave the repair performed through the right atrium and the interatrial septum. Although the transseptal method is an established procedure, recent reports bave stressed the disadvantages of this operation and wtderscored the risk of the development of complete atrioventricular dissociation with this technique. A review of our results with this approach confinns the efficacy and safety of this method. The surgical protocols used are described.
Lynn B. McGrath, MD, James M. Levett, MD, and Lorenzo Gonzalez-Lavin, MD, Browns Mills and New Brunswick, N.J.
~rious methods to access the mitral valve for opera-
tion have been described.':" Early in the development of cardiac surgery, the transseptal exposure of the mitral valve was reported by Julian and colleagues." Subsequently, other authors have advocated various technical modifications. 14, 15 Recent reports have claimed that this technique risks damage to the atrioventricular conduction system, may result in atrioventricular dissociation, and does not give satisfactory exposure when there is a small left atrium.":" These criticisms of this procedure prompted a review of our results with this method. Methods Patients. In March 1986 we adopted the transseptal approach to the mitral valve for routine use when concomitant tricuspid valve operation was required. Seventeen patients were operated on between March 1986 and November 1987, There were 13 female and four male patients. The ages ranged from 16 years to 74 years, mean 56.6 years. Nine of the patients had undergone 14 previous procedures, A standard oblique right atriotomy incision was made and an interatrial transseptal approach to the mitral valve was used in each, All 17 patients underwent mitral valve replacement (MVR). From the Department of Surgery, Deborah Heart and Lung Center, Browns Mills, N.J., and the Departmentof Surgery, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick, N.J. Received for publication Sept. 30, 1987. Accepted for publication Feb. 20, 1988. Address for reprints: Dr. Lynn B. McGrath, Assistant Professor of Surgery, Attending Department of Surgery, Deborah Heart and Lung Center, Browns Mills, NJ 08015.
756
Fifteen had a simultaneous tricuspid valve operation: eight had tricuspid valve annuloplasty and seven had tricuspid valve replacement. One patient undergoing MVR had concomitant closure of a fossa ovalis atrial septal defect. One patient underwent isolated repeat MVR with the transseptal technique, because of difficulty in exposing the left atrium caused by severe adhesions from a previous MVR. Four patients were operated on with a right thoracotomy, in three because of multiple prior sternotomy incisions and in one patient because a prior left radical mastectomy with postoperative irradiation resulted in severe radiation dermatitis involving the sternum and the wall of the left side of the chest. Operative technique. The heart is generally approached through a median sternotomy incision. Cardiopulmonary bypass is established with ascending aortic and direct caval vein cannulation at a flow rate of 2.2 L/min/m 2 and a temperature of 28 0 C. Cold blood cardioplegia is infused into the aortic root and reinfused at 3D-minute intervals. The caval tapes are secured, an oblique right atriotomy incision is made, and stay sutures are placed on the right atrial wall to arrange the exposure. The septal incision is made in the posterior portion of the fossa ovalis and is extended superiorly and inferiorly (Fig. I). The incision may be extended anteriorly to make a flap of the fossa ovalis, based on the anterior limbus, if necessary for exposure (Fig. I, dotted lines). Stay sutures are placed on the edge of the fossa ovalis to expose the mitral valve (Fig. 2). The stay sutures alone are usually satisfactory to allow visualization of the left atrial structures, Two small right angled retractors may be used, although when these are used care must be taken to avoid traction on the area of the atrioventricular node (Fig. 3). After the mitral valve procedure is performed, the incision in the fossa ovalis is closed primarily with a continuous 3-0 monofilament suture. The tricuspid valve repair is then performed. The right atriotomy incision is closed and the caval tapes are released. The patient is weaned from cardiopulmonary bypass after air bubbles are removed from the heart.
Volume 96 Number 5 November 1988
Right atrial approach to mitral, tricuspid valves 7 5 7
Fig. I. Stay sutures are placed on right atrial wall and incision is made in posterior aspect of fossa ovalis. Dotted lines indicate site for anterosuperior and anteroinferior extension of septotorny, if required for exposure.
Fig. 2. Stay sutures are placed on cut edge of fossa ovalis and mitral valve is exposed.
Results
Exposure of the mitral and tricuspid valves was satisfactory with this method. No technical problems were encountered. One reentry for bleeding was necessary (5.9%) because of diffuse coagulopathy. There was one hospital death (5.9%: 70% confidence limits 0.76% to 18.6%) as a result of renal failure on postoperative
day 21. There was one reoperation (5.9%) at 27 days postoperatively for prosthetic valve endocarditis. The latter patient, who had initially undergone MVR for native valve endocarditis, successfully underwent transseptal reoperation. There were no episodes of transient or permanent atrioventricular dissociation noted (0%: 70% confidence
The Journal of Thoracic and Cardiovascular Surgery
7 5 8 McGrath, Levett, Gonzalez-Lavin
suture line. In those patients in whom multiple previous mitral valve operations have been performed, we believe that this may be a safer operation, because redissection and reclosing of the left atrium and pulmonary veins is not necessary. In conclusion, we affirm that the right atrial approach to the mitral and tricuspid valves is a satisfactory technique and that it carries a low risk of complications. REFERENCES
Fig. 3. Small retractors may be placed on anterior limbus to improve exposure of left atrium. Gentle retraction is used to avoid injury to atrioventricular node.
limits 0% to 10.7%). The 12 patients who were in atrial fibrillation preoperatively remained in atrial fibrillation after operation. The five patients who were in normal sinus rhythm preoperatively remained in sinus rhythm after repair. There have been no episodes of thromboembolism during the short follow-up period. All patients were followed up from 32 to 372 days postoperatively, with a mean of 116 days. Discussion Many routes of surgical access to the mitral valve have been described.':" Generally these different techniques are recommended when there is a difficult mitral valve exposure. The approach to the mitral valve through the right atrium and interatrial septum has been variously described previously."!' Recent reports have claimed that this technique affords poor visualization when there is a small left atrium and that it results in an increased risk of conduction system disturbances,":" although no supporting data have been presented. We have found that this method provides good exposure and ease of operation on the mitral valve, even when there is a small left atrium. It is an especially convenient technique in those patients in whom concomitant tricuspid valve operation is necessary to either repair or replace the tricuspid valve. The incision in the interatrial septum is easily closed and provides a secure
1. Lillehei CW, Gott VL, De Wall RA, Varco RL. Surgical correction of pure mitral insufficiency by annuloplasty under direct vision. Lancet 1957;77:446-9. 2. Clowes GHA Jr, Neville WE, Sancetta SM, et al. Results of open surgical correction of mitral valvular insufficiency and description of technique for approach from left side. Surgery 1962;51: 138-54. 3. Meyer BW, Verska JJ, Lindesmith GG, Jones Jc. Open repair of mitral valve lesions: the superior approach. Ann Thorac Surg 1965;1:453-7. 4. Grunwald RP, Attai-Lari A, Robinson G. Left-sided cannulation of the right atrium for mitral surgery. Ann Thorac Surg 1966;2:601-6. 5. Saksena OS, Tucker BL, Lindesmith GG, Nelson RM, Stiles QR, Meyer BW. The superior approach to the mitral valve. Ann Thorac Surg 1971;12:146-53. 6. Brawley RK. Improved exposure of the mitral valve in patients with a small left atrium. Ann Thorac Surg 1980;29: 179-83. 7. Cohn LH. Mitral valve replacement. In: Cohn LH, ed. Modern technics in surgery. Volume 29: Cardiac/thoracic surgery. New York: Futura, 1980:29-1-10. 8. Pifarre R, Balderman S, Sullivan HJ, Montoya A, Bakhos M. Technique to facilitate mitral valve exposure. Ann Thorac Surg 1982;33:92-3. 9. Richi AA, Sade RM, May MG, Hohn AR. Repair of left atrial abnormalities in children by the superior approach. Ann Thorac Surg 1981;31:433-6. 10. Pezzella AT, Effler DB, Levy IE. Operative approaches to the left atrium and mitral valve apparatus. Tex Heart Inst J 1983;10:119-23. 11. Selle JG. Temporary division of the superior vena cava for exceptional mitral valve exposure. J THoRAc CARDlOVASC SUliG 1984;88:302-4. 12. Zacharias A. Alternative method to improve exposure for difficult mitral valve procedures. Ann Thorac Surg 1986;42:336-7. 13. Julian OC, Lopez M, Dye WS, et al. Simultaneous repair of mitral and tricuspid valves through right atrium and intraatrial septum. Arch Surg 1959;78:745-54. 14. Bowman FO Jr, Maim JR. The transseptal approach to mitral valve repair. Arch Surg 1965;90:329-31.
Volume 96 Number 5 November 1988
15. Patel Jc. Technique chirurgicale. Presse Med 1966; 74:1607-16. 16. lonescu MI, Cohn LH. Cardio-pulmonary by-pass. In: Mitral valve disease: diagnosis and treatment, Glasgow, Scotland: Butterworth, 1985:194. 17. Kirklin JW, Barratt-Boyes BG. Alternative surgical
Right atrial approach to mitral. tricuspid valves
7 59
approaches to the mitral valve. In: Starek PJK, ed. Cardiac surgery. New York: John Wiley, 1986:364-5. 18. Starek PJK. Technical aspects of uncomplicated valve replacement. In: Heart valve replacement and reconstruction. Chicago: Year Book Medical Publishers, 1987: 61-79.
Bound volumes available to subscribers Bound volumes of THE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY are available to subscribers (only) for the 1988 issues from the Publisher, at a costof $51.00 ($68.00 international) for Vol. 95 (January-June)and Vol. 96 (July-December). Shipping charges are included. Each boundvolume containsa subjectand author indexand all advertising is removed. Copies are shipped within 60 days after publication of the last issue of the volume. The binding is durable buckram with the JOURNAL name, volume number, and year stamped in goldon the spine. Payment must accompany all orders. Contact The C.V. Mosby Company, Circulation Department, 11830 Westline Industrial Drive, St. Louis, Missouri 63146-3318, USA; phone (800) 325-4177, ext. 351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular JOURNAL subscription.
THoRAc CARDIOV ASC SURG
1988;96:756-9
Safety of the right atrial approach for combined mitral and tricuspid valve procedures Patients wtdergoing operation for combined mitral and tricuspid valvular disease may bave the repair performed through the right atrium and the interatrial septum. Although the transseptal method is an established procedure, recent reports bave stressed the disadvantages of this operation and wtderscored the risk of the development of complete atrioventricular dissociation with this technique. A review of our results with this approach confinns the efficacy and safety of this method. The surgical protocols used are described.
Lynn B. McGrath, MD, James M. Levett, MD, and Lorenzo Gonzalez-Lavin, MD, Browns Mills and New Brunswick, N.J.
~rious methods to access the mitral valve for opera-
tion have been described.':" Early in the development of cardiac surgery, the transseptal exposure of the mitral valve was reported by Julian and colleagues." Subsequently, other authors have advocated various technical modifications. 14, 15 Recent reports have claimed that this technique risks damage to the atrioventricular conduction system, may result in atrioventricular dissociation, and does not give satisfactory exposure when there is a small left atrium.":" These criticisms of this procedure prompted a review of our results with this method. Methods Patients. In March 1986 we adopted the transseptal approach to the mitral valve for routine use when concomitant tricuspid valve operation was required. Seventeen patients were operated on between March 1986 and November 1987, There were 13 female and four male patients. The ages ranged from 16 years to 74 years, mean 56.6 years. Nine of the patients had undergone 14 previous procedures, A standard oblique right atriotomy incision was made and an interatrial transseptal approach to the mitral valve was used in each, All 17 patients underwent mitral valve replacement (MVR). From the Department of Surgery, Deborah Heart and Lung Center, Browns Mills, N.J., and the Departmentof Surgery, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick, N.J. Received for publication Sept. 30, 1987. Accepted for publication Feb. 20, 1988. Address for reprints: Dr. Lynn B. McGrath, Assistant Professor of Surgery, Attending Department of Surgery, Deborah Heart and Lung Center, Browns Mills, NJ 08015.
756
Fifteen had a simultaneous tricuspid valve operation: eight had tricuspid valve annuloplasty and seven had tricuspid valve replacement. One patient undergoing MVR had concomitant closure of a fossa ovalis atrial septal defect. One patient underwent isolated repeat MVR with the transseptal technique, because of difficulty in exposing the left atrium caused by severe adhesions from a previous MVR. Four patients were operated on with a right thoracotomy, in three because of multiple prior sternotomy incisions and in one patient because a prior left radical mastectomy with postoperative irradiation resulted in severe radiation dermatitis involving the sternum and the wall of the left side of the chest. Operative technique. The heart is generally approached through a median sternotomy incision. Cardiopulmonary bypass is established with ascending aortic and direct caval vein cannulation at a flow rate of 2.2 L/min/m 2 and a temperature of 28 0 C. Cold blood cardioplegia is infused into the aortic root and reinfused at 3D-minute intervals. The caval tapes are secured, an oblique right atriotomy incision is made, and stay sutures are placed on the right atrial wall to arrange the exposure. The septal incision is made in the posterior portion of the fossa ovalis and is extended superiorly and inferiorly (Fig. I). The incision may be extended anteriorly to make a flap of the fossa ovalis, based on the anterior limbus, if necessary for exposure (Fig. I, dotted lines). Stay sutures are placed on the edge of the fossa ovalis to expose the mitral valve (Fig. 2). The stay sutures alone are usually satisfactory to allow visualization of the left atrial structures, Two small right angled retractors may be used, although when these are used care must be taken to avoid traction on the area of the atrioventricular node (Fig. 3). After the mitral valve procedure is performed, the incision in the fossa ovalis is closed primarily with a continuous 3-0 monofilament suture. The tricuspid valve repair is then performed. The right atriotomy incision is closed and the caval tapes are released. The patient is weaned from cardiopulmonary bypass after air bubbles are removed from the heart.
Volume 96 Number 5 November 1988
Right atrial approach to mitral, tricuspid valves 7 5 7
Fig. I. Stay sutures are placed on right atrial wall and incision is made in posterior aspect of fossa ovalis. Dotted lines indicate site for anterosuperior and anteroinferior extension of septotorny, if required for exposure.
Fig. 2. Stay sutures are placed on cut edge of fossa ovalis and mitral valve is exposed.
Results
Exposure of the mitral and tricuspid valves was satisfactory with this method. No technical problems were encountered. One reentry for bleeding was necessary (5.9%) because of diffuse coagulopathy. There was one hospital death (5.9%: 70% confidence limits 0.76% to 18.6%) as a result of renal failure on postoperative
day 21. There was one reoperation (5.9%) at 27 days postoperatively for prosthetic valve endocarditis. The latter patient, who had initially undergone MVR for native valve endocarditis, successfully underwent transseptal reoperation. There were no episodes of transient or permanent atrioventricular dissociation noted (0%: 70% confidence
The Journal of Thoracic and Cardiovascular Surgery
7 5 8 McGrath, Levett, Gonzalez-Lavin
suture line. In those patients in whom multiple previous mitral valve operations have been performed, we believe that this may be a safer operation, because redissection and reclosing of the left atrium and pulmonary veins is not necessary. In conclusion, we affirm that the right atrial approach to the mitral and tricuspid valves is a satisfactory technique and that it carries a low risk of complications. REFERENCES
Fig. 3. Small retractors may be placed on anterior limbus to improve exposure of left atrium. Gentle retraction is used to avoid injury to atrioventricular node.
limits 0% to 10.7%). The 12 patients who were in atrial fibrillation preoperatively remained in atrial fibrillation after operation. The five patients who were in normal sinus rhythm preoperatively remained in sinus rhythm after repair. There have been no episodes of thromboembolism during the short follow-up period. All patients were followed up from 32 to 372 days postoperatively, with a mean of 116 days. Discussion Many routes of surgical access to the mitral valve have been described.':" Generally these different techniques are recommended when there is a difficult mitral valve exposure. The approach to the mitral valve through the right atrium and interatrial septum has been variously described previously."!' Recent reports have claimed that this technique affords poor visualization when there is a small left atrium and that it results in an increased risk of conduction system disturbances,":" although no supporting data have been presented. We have found that this method provides good exposure and ease of operation on the mitral valve, even when there is a small left atrium. It is an especially convenient technique in those patients in whom concomitant tricuspid valve operation is necessary to either repair or replace the tricuspid valve. The incision in the interatrial septum is easily closed and provides a secure
1. Lillehei CW, Gott VL, De Wall RA, Varco RL. Surgical correction of pure mitral insufficiency by annuloplasty under direct vision. Lancet 1957;77:446-9. 2. Clowes GHA Jr, Neville WE, Sancetta SM, et al. Results of open surgical correction of mitral valvular insufficiency and description of technique for approach from left side. Surgery 1962;51: 138-54. 3. Meyer BW, Verska JJ, Lindesmith GG, Jones Jc. Open repair of mitral valve lesions: the superior approach. Ann Thorac Surg 1965;1:453-7. 4. Grunwald RP, Attai-Lari A, Robinson G. Left-sided cannulation of the right atrium for mitral surgery. Ann Thorac Surg 1966;2:601-6. 5. Saksena OS, Tucker BL, Lindesmith GG, Nelson RM, Stiles QR, Meyer BW. The superior approach to the mitral valve. Ann Thorac Surg 1971;12:146-53. 6. Brawley RK. Improved exposure of the mitral valve in patients with a small left atrium. Ann Thorac Surg 1980;29: 179-83. 7. Cohn LH. Mitral valve replacement. In: Cohn LH, ed. Modern technics in surgery. Volume 29: Cardiac/thoracic surgery. New York: Futura, 1980:29-1-10. 8. Pifarre R, Balderman S, Sullivan HJ, Montoya A, Bakhos M. Technique to facilitate mitral valve exposure. Ann Thorac Surg 1982;33:92-3. 9. Richi AA, Sade RM, May MG, Hohn AR. Repair of left atrial abnormalities in children by the superior approach. Ann Thorac Surg 1981;31:433-6. 10. Pezzella AT, Effler DB, Levy IE. Operative approaches to the left atrium and mitral valve apparatus. Tex Heart Inst J 1983;10:119-23. 11. Selle JG. Temporary division of the superior vena cava for exceptional mitral valve exposure. J THoRAc CARDlOVASC SUliG 1984;88:302-4. 12. Zacharias A. Alternative method to improve exposure for difficult mitral valve procedures. Ann Thorac Surg 1986;42:336-7. 13. Julian OC, Lopez M, Dye WS, et al. Simultaneous repair of mitral and tricuspid valves through right atrium and intraatrial septum. Arch Surg 1959;78:745-54. 14. Bowman FO Jr, Maim JR. The transseptal approach to mitral valve repair. Arch Surg 1965;90:329-31.
Volume 96 Number 5 November 1988
15. Patel Jc. Technique chirurgicale. Presse Med 1966; 74:1607-16. 16. lonescu MI, Cohn LH. Cardio-pulmonary by-pass. In: Mitral valve disease: diagnosis and treatment, Glasgow, Scotland: Butterworth, 1985:194. 17. Kirklin JW, Barratt-Boyes BG. Alternative surgical
Right atrial approach to mitral. tricuspid valves
7 59
approaches to the mitral valve. In: Starek PJK, ed. Cardiac surgery. New York: John Wiley, 1986:364-5. 18. Starek PJK. Technical aspects of uncomplicated valve replacement. In: Heart valve replacement and reconstruction. Chicago: Year Book Medical Publishers, 1987: 61-79.
Bound volumes available to subscribers Bound volumes of THE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY are available to subscribers (only) for the 1988 issues from the Publisher, at a costof $51.00 ($68.00 international) for Vol. 95 (January-June)and Vol. 96 (July-December). Shipping charges are included. Each boundvolume containsa subjectand author indexand all advertising is removed. Copies are shipped within 60 days after publication of the last issue of the volume. The binding is durable buckram with the JOURNAL name, volume number, and year stamped in goldon the spine. Payment must accompany all orders. Contact The C.V. Mosby Company, Circulation Department, 11830 Westline Industrial Drive, St. Louis, Missouri 63146-3318, USA; phone (800) 325-4177, ext. 351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular JOURNAL subscription.