The Extended Transseptal Approach in Complex Mitral Valve Surgery - Evaluation of Risks and Benefits

Abstract

The extended transseptal approach to the mitral valve was used in 32 patients undergoing isolated or combined mitral valve surgery. In all cases exposure of the entire mitral valvular apparatus was excellent. Two patients died of low output within 30 days of surgery. No cause of death was related to the extended transseptal approach. In one early patient reexploration revealed arterial bleeding from the right atrial suture line which was caused by damage to the sinus nodal artery. In 7 patients temporary atrial conduction disturbances occurred which completely resolved within 10 days after responding well to dual-chamber pacing. Temporary ventricular pacing was necessary in two patients with preoperative bradyarrhythmia. In two patients undergoing mitral re-do surgery a permanent ventricular pacer was implanted. The extended transseptal approach offers an excellent exposure of the entire mitral valve both in primary isolated or combined mitral surgery particularly in re-do surgery where the primary standard vertical left atriotomy is impeded or the conventional transseptal approach gives only limited access. Temporary atrial dysrhythmia is not crucial and is easily controlled by short-term dual-chamber pacing.

Improved Combined Superior-Transseptal Approach to the Mitral Valve

“…[1][2][3][4][5]9,10 Our results showed that although the operative field was smaller than that of the classic approach, the modified approach was always closer to the edge of the mitral valve, so its exposure was relatively simple in all cases. Furthermore, closure after this approach was much simpler than after the classic approach.…”

“…This modified approach does not cut through the right atrial appendage and part of the right atrium, therefore, although it may damage the superior right atrial artery (one blood source for the sinus node) and bundle branches, it can better nourish the sinus region from the collateral system around the sinus node, and increase the number of atrial muscle fibers that connect the sinus node with the atrioventricular node, thus reinforcing sinoatrial conduction. 1 –5,9,10 Our results showed that although the operative field was smaller than that of the classic approach, the modified approach was always closer to the edge of the mitral valve, so its exposure was relatively simple in all cases. Furthermore, closure after this approach was much simpler than after the classic approach.…”

“…In mitral valve surgery, the approach to LA influences the quality of the operation, especially in difficult anatomical situations such as a small LA, pericardial adhesions in reoperations, a deep thorax, dilated right cardiac chambers, or technically difficult operations including mitral valve repair. 1 –10 The combined superior-transseptal approach facilitates improved expose to the mitral valve apparatus in these situations. However, in our experience, this approach has drawbacks including large incisions cutting long sections of atrial muscle, and a complex closure process.…”