Surgic_al Approaches to the Mitral Valve

SENGODA G. BALASUNDARAM, M.S. and CARLOS DURAN, M.O.,-PH.D.

Department of Cardiovascular Diseases, King Faisal Specialist Hospital and
Research Centre, Riyadh, Kingdom of Saudi Arabia
Different approaches to the left atrium and varioustechniques of the atriotomy are
practiced by cardiac surgeons according to the need -for a particular patient and preference of
the individual surgeon. Their basic methods, advantages and disadvantages, and our present
day techniques are discussed.

ABSTRACT

A correct approach and good exposure plays

a key role in the success of any surgical procedure. This is particularly true in mitral valve
surgery, especially if a repair is envisaged.1 2
Mitral valve exposure is often less than ideal for
many surgeons and more so in the presence of
a small left atrium. Various techniques of left
atriotomy have been described to expose the
mitral valve. This article is aimed at describing
the various approaches to the mitral valve, the
advantages, disadvantages, and our present day
preferred techn ique.

METHODS
The left atrium can be exposed through: (1)
right thoracotomy; (2) left thoracotomy; (3) trknsverse sternotomy; and (4) median sternotomy.

Right anterolateral thoracotomy

By a right anterolateral , lateral or posterolateral thoracotomy incision, through the folurth
intercostal space, the right pleural cavity is
entered .3 If necessary, the right anterolateral
incision can be extended across the ster~um
after division of the internal mammary vasc ular
1
bundle. The groin is also prepared for cannulation of the femoral artery. The ascending aorta is
palpated and the pericardium over it is incised
Address for correspondence: Dr. S. Balasundaram , De'part
ment of Cardiovascular Diseases, King Faisal Specialist
Hospital , PO Box 3354, Riyadh 11211 , Saudi Arabia .

Vol. 5, No.3, 1990

vertically, anterior to the phrenic nerve. After

heparinization the aorta or femoral artery is
cannulated for arterial return . Venous drainage
is establ ished by cannulation of both cavae
through pursestrings in the right atrial wall or
through the right femoral vein (Fig . 1)
This approach is particularly useful for
reoperations, for the third time (or more), or for
patients with patent coronary bypass grafts or
sternotomy complication~ where freeing the
universal pericardia! adhesions can be
dangerous or at least time consuming. In difficult
cases, caval cannulations can be done through
the adherent pleura, pericardium, and the atrial
wall. The left atriotomy is carried out longitudinally anterior to the insertion of the right
pulmonary veins. De-airing must be carried out
by a Foley catheter across the mitral valve and
repeated needle aspiration of the left atrium and
aortic vent on suction .

Left anterolateral thoracotomy

Through the fourth intercostal space, the left
pleural cavity is entered. 5 The left groin is also
prepared for cannulation -- of--the femoral ..artery------.. ~- --
and vein. The pericardium is opened anteriorly
to the phrenic nerve. After heparinization ,
arterial return and venous drainage are achieved
through femoral cannulations. Arterial return can
also be achieved through cannulation of the left
subclavian artery.6 The main pulmonary or right
ventricle outflow tract is cannulated for addition-

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BALASUNDARAM AND DURAN

Midsternotomy
After a midline sternotomy, the pericardium is
opened vertically and slinged to the sternal
edges. After heparinization, an aortic cannula is
placed in the ascending aorta through pursestrings. Venous drainage is obtained, through cannulation of both cavae. Left ventricular venting
can be established through an apical sump,
pulmonary artery, or through the mitral valve. All
the approaches to the left atrium through a
median sternotomy beside giving access to
other valves and coronary arteries have the
great advantage of representing a standard
- cardiac surgical approach with standard cannulation techniques. 8
Figure 1. Right anterolateral thoracotomy through
the fourth intercostal space and standard left
atriotomy.

Standard left atriotomy

The interatrial groove can be dissected by

blunt dissection and the right atrium can be
retracted medially and anteriorly. The right supeal venous drainage if required. The left atriotomy
rior pulmonary vein at its junction to the left
is achieved anteriorly to the insertion of the left
atrium is exposed. The left atrium is opened at
the midpoint between the right superior pulpulmonary veins. Alternatively the incision can
be started at the base of the left atrial apmonary vein insertion and interatrial groove. This
pendage superiorly and directed toward the left
incision is extended longitudinally both supeinferior pulmonary vein posteriorly and inferiorriorly and inferiorly to give enough exposure of
ly.6 This approach, frequently used in the past
the mitral valve. Care must be taken at the time
for closed commissurotomies, beside the
of incising, so as not to inadvertently injure the
dangers involved in not being a routine proce~
posteri(:>r wall of the left atrium . When closing,
dure, represents a more difficult venous cancare must be taken not to include the posterior
nulation. Furthermore, it provides limited access
wall of the right pulmonary veins in the suture,
to the other cardiac chambers and affords poor
which would result in their occlusion. If the
visibility of the mitral apparatus which in fact is
exposure of the mitral valve is not adequate, th.e
directed toward the right. Right and left
left atriotomy can be extended superiorly below
thoracotomies are more traumatic and painful
the superior vena cava and inferiorly posterior to
for the patient than a median sternotomy.
the inferior vena cava after entering the oblique
sinus by freeing its pericardia! reflection .
Further exposure can be achieved by sectionTransverse sternotomy
ing the pericardia! reflection on both venae
A bilateral anterior thoracotomy carried out
cavae and by blunt dissection freeing the lateral
through the .fourth .l!l_t.ercosta[_ space has_. ~.eeo____aspects of both veins for about 2-3 em. These
described? The sternum is transsected
maneuvers allow a further anterior displacement
transversely across the fourth space. Both interof the right atrium and therefore a better exnal mammary bundles must be ligated and
posure. If necessary, the azygos vein can also be
divided. The pericardium is incised longitudinalligated and dividecfl When extending the
ly. The left atrium is usually approached through
atriotomy superiorly, care must be taken to avoid
its right aspect. This approach is rarely used due
injuring the closely related inferior aspect of the
to its cumbersome nature.
right pulmonary artery.

164

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MITRAL VALVE EXPOSURE

Superior

approach

mitral valve procedures in orqer to avoid these

problems'' .

Recently a superior approach to the left atrium

has been proposed by Saksena.10 The
anterosuperior aspect of the left atrium is exposed between the superior vena cava laterally
and the ascending aorta medially. The aorta is
cross-clamped and the card ioplegia is infused .
The ascending aorta is retracted medially and
the superior vena cava laterally. A transverse
incision is made in the superior aspect of the left
atrium and extended to the left, posterior to the
aorta and just beneath the right pulmonary
artery branch (Fig . 2). This approach gives a
good exposure and view for the surgeon and
assistant. However, extension of the atriotomy
both medially and laterally is limited and there is
the possibility of damage to the aortic root, left
coronary artery, and superior vena cava. Any
residual leak is difficult to control and surgeons
have reported the need to reinstitute cardiopulmonary bypass, packing the area with gauze,
and reexploring to control bleeding after 24
hours.11 This approach as suggested by Hirt et
al. 12 and Molina13 Should be attempted by surgeons who already have some experience in

- -- - - --

Figure 2. The superior approach to the left atrium.

Vol. 5, No. 3, 1990

Right atrial approach

The mitral valve can be seen easily through a
large atrial septal defect that constitutes the
standard approach in cases of cushion defects
where a right atriotomy is always performed.
Although acquired mitral lesions are rarely
treated follow ing this technique, some authors
have proposed this route, which in our opinion
must be kept as a useful alternative.3 14 In these
cases, both cavae must be cannulated and
snared . The interatrial septum must be incised
starting at the fossa ovalis and directed either
horizontally toward the free atrial wall, which will
result in the section of conduction pathways and
postoperative arrhythmia or vertically upward for
a few centimeters. The last one, as described by
Kreitmann et al. 14 can be useful in cases of redo
operations as i.t minimizes the amount of dissection required .

Biatrial

atriotomy

This approach known as the Dubost incision

was described at a time where rheumatic heart
valve disease was prevalent and most cases
requ ired mitral and tricuspid surgery (Fig . 3).
The incision is started in the left atrium at its
junction with the right superior pulmonary vein.
This incision is extended medially across the left
atrium, interatrial septum, and right atrial wall. In
the original description by Dubost et al.15 the
incision could be extended posteriorly along the
right superior pulmonary vein . Latter experience
has shown that it is better to initiate the left
atriotomy between both pulmonary veins; and if
extended it is done toward the posterior atrial
wall between both veins. This extension is far
easier to close and less dangerous. Both mitral
and tricuspid valves -are exposed: However;
closure time is long and the transverse section
of the septum may give rise to postoperative
arrhythmia. Brawley1 6 has described, for those
cases where after the standard atriotomy shows
to give an inadequate exposure, its extension
transversely across the right atrium and interatrial septum . A modification of this approach is

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BALASUNDARAM AND DURAN

Figure 3. Biatrial atriotomy.

Figure 4. Transverse division of interatrial septum after vertical right and left atriotomy.

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MITRAL VALVE EXPOSURE

to make a parallel right atriotomy and enter the

left atrium through a separate incision in the
intra-atrial septum 17 or after making the parallel
right atriotomy divide the interatrial septum perpendicular to the left atriotomy (Fig. 4). This
extension is started at the midpoint of the
standard left atriotomy and ends in the fossa
ovalis. The exposure is excellent, easier to close
than Dubosts' but carries the risk of all
transverse septostomies.
~

Left

ventriculotomy

In cases where a left ventriculotomy is required the mitral valve is well exposed from its
ventricular aspect. Valve replacement is performed easily and the superb view of the subvalvular apparatus makes simple some techniques
such as chordal shortening and papillary muscle
repair and reimplantation. The incision is made
in the scar area and directed toward the
atrioventricular groove. Once the papillary
muscles are identified the incision can be extended toward the apex. Closure is done, as in
any aneurysmectomy, over felt strips with or
without the use of a Dacron patch according to
the size of the ventricular wall resected.

introduced through the right a'pp~-~d~g~ is n~t

only faster and easier to place but also provides
a satisfactory venous return and does not 'kink
when a retractor is placed in the atriotomy.
Most surgeons also use a vertical left
atriotomy. Some dissect the interatrial groove
before opening the left atrium. We consider this
measure unnecessary and closure is made more
difficult particularly in an atria with t~in walls.
The point of incision should be immediately
posterior to the groove and as far anteriorly to
the pulmonary veins as possible. The incision is _
then prolonged superiorly and inferiorly. A
retractor is then placed in the atriotomy and
pulled anteriorly. Unless in the presence of a
large atrium , this atriotomy does not provide a
satisfactory view of the mitral valve. The section
of the pericardia! reflections on both cavae and
the dissection of their lateral aspects will free
them for a few centimeters and allow their
forward displacement (Fig . 5). The azygos vein
entrance into the superior vena cava is posterior
and therefore does not requ ire to be exposed or
ligated. Th is maneuver clearly exposes the -

Aortotomy

For the sake of completeness, occasionally a discreet lesion of the anterior leaflet of the mitral
valve can be repai red through an aortotomy.
Preferred technique

A. Incise pericardia! reflections

Although, as we have seen , the mitral valve

can be approached in many different ways, each
having some advantages, the majority of surgeons use a standard midsternotomy because it
provides easy access to most cardiac structures
with -minimal tissue damage and postoperative
--- pain , Its daily use considerably reduces uncertainties and therefore risks. Individual air venting
techniques are applied routinely.
The majority of surgeons use individual caval
connections on the basis that the anterior retraction on the right atri um might interfere with the
superior vena cava drainage. It has been our
experience that a single, dual-stage cannula

Vol. 5, No. 3, 1990

B. Atrlotomy incision extended

Figure 5. (A) Left atriotomy before resecting the

pericardia/ reflection. (B) Extended left atriotomy
after resecting the pericardia/ refle ctions.

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BALASUNDARAM AND DURAN

.l -~yJ~l~fd~~angles of the atriotomy that can then

1
I
1

1
1

i
1

. 1

be extended toward the roof and floor of the left atrium

for a considerable distance along the transverse
sinus superiorly and the oblique sinus inferiorly.
Care must be taken to identify and sometimes
separate by blunt dissection the lower aspect of
the right pulmonary artery superiorly. Inferiorly,
the incision must curve posteriorly and medially
before the entrance of the inferior vena cava into
the right atrium. The end result is a "C" shaped
atriotomy not unlike a transplant. Closure is
achieved by a single 3/0 prolene running suture
where its extremities, once completed, can be
inspected, superior end, from the medial aspect
of the superior vena cava and with the heart
luxated , inferior end in the oblique sinus. No
bleeding problems have been encountered with
this technique provided that both extremities of
the incision were securely sutu red. However,
because both cavae are free, it is easy to place
extra sutures if required.
In some case, where the left atrium is particularly small such as in acute regurgitant
lesions we transsect Gompletely the superior
vena cava ..18 In such cases, before right atrial
cannulation, the superior vena cava is dissected

upward, and a pursestring placed about 2-3 em

above the entrance into the right atrium and
cannulated with a right angle metal tip cannula
(Fig. 6) . Selle19 suggested that the superior vena
cava can be divided between two vascular
clamps and then cannulate the transsected
cephalic end of the superior vena cava. Reanastomosis is carried out by reapplying the vascular
clamps and then by continuous suture with
intermittent release of the clamp to avoid venous
hypertension in the upper extremities. An alternate way to divide the superior vena cava is to
cannulate the left innominate vein. 20 The inferior
vena cava is cannulated separately through a
pu rsestring in the right atrial wall. Once on
cardiopulmonary bypass both venae cavae are
snared . The superior vena cava is divided at
least 1 em from its entrance into the atrium (Fig.
6) . A standard left atriotomy immediately behind
the interatrial groove is done and prolonged
inferiorly and superiorly. The atrial retractors are
placed displacing the right atrium anteriorly and
showing the upper extremity of the atriotomy
that can then be extended toward the roof of the
left atrium . Th is combined standard and superior
approach provides a good vis ibility of the mitral
apparatus. After closure of the atriotomy, the
superior vena cava is anastomosed easily with a
running 4/0 prolene suture. The absence of a
cannula at that level considerably simplifies this
suture, which is done after unclamping the aorta
during the rewarming period .

REFERENCES
1. Rankin JS, Feneley MP, Hickey MSTJ, et al: A clinical
comparison of mitral valve repair versus valve
replacement in ischemic mitral regurgitation . J
Thorac Cardiovasc Surg 95:165 , 1988.
2. Kerth WJ, Sharma G, Hill JD, et al : A comparison of
the late results of replacement and of reconstructive
procedures for acquired mitral valve disease. J
Thorac Cardiovasc Surg 61 (1 ):14, 1971 .
3. Effler DB, Groves LK, Martinez WV, et al. Open heart
...----------- surgery for mitral insufficiency. J Thorac Surg
36:665, 1958.
4. Cohn LH , Peigh PS, Sell J, et al : Right thoracotomy,
femora-femoral bypass, and deep hypothermia for
replacement of the mitral valve. Ann Thorac Surg
48:69 , 1989.
Figure 6. Combined superior and lateral left
5. Clowes GHA Jr, Neville WE, Sancetta SM, et al:
atriotomy after a temporary division of the superior
Results of open surgical correction of mitral valvular
vena cava.

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MITRAL VALVE EXPOSURE

--

insufficiency and description of technique for approach from left side. Surgery 51:138, 1962.
6. Rumel WR , Vaughn CC, Guibone RA: Surgical
reconstruction of the mitral valve. Ann Thorac Surg
8(4):289, 1969.
7. Cleland W, Goodwin J, McDonald L, et al: Principles
and techniques in cardiac surgery. Medical and
Surgical Cardiology. Oxford, Blackwell Scientific
Publications, 1969, p 288
8. Elkins RC, Bender HW, Brawley RK, et al: Technique for prosthetic replacement of the mitral valve.
Surg Gynec Obst 134:485, 1972.
9. Zacharias A: Alternative method to improve exposure for difficult mitral valve procedures. Ann
Thorac Surg 42:336, 1986.
10. Saksena DS, Tucker BL, Lindesmith GC, et al: The
superior approach to the mitral valve. Ann Thorac
Surg 12(2):146, 1971.
11. Robinson G: The superior approach to the mitral
valve. Eur J Cardiol Thorac Surg 3:378, 1989.
12. Hirt SW, Frimpong-Boateng, Borst HG: The superior
approach to the mitral valve, is it worthwhile? Eur J
Cardiol Thorac Surg 2:372, 1988.
13. MolinaJE: The superior approach to the mitral valve
is it worthwhile? Eur J Cardiol Thorac Surg 3:188,
1989.
14. Kreitmann P, Jourdan J, Saab M, et al: Abord de Ia

Vol. 5, No. 3, 1990

15.

16.

17.

18.

19.

20.

valve mitrale par voie transatriale, interet particulier

dans les remplacements valvulaires iteratifs. Ann
Chir Thorac Cardiovasc 40(8):557, 1986
Dubost C, Guilmet D, Parades B, et al: Nouvelle
technique d'ouverture de l'oreillette gauche en
chirurgie a coeur ouvert: t.:abord biauriculaire
transseptal. Press Med 74:1607, 1966.
Brawley RK: Improved exposure of the mitral valve
in patients with a small left atrium. Ann Thorac Surg
29(2):179, 1980.
Pezzella T, Effler DB, Levy IE: Operative approaches
to the left atrium and mitral valve apparatus. Tex
Heart lnst J 10(2): 119, 1983.
Barner HB: Combined superior and right lateral left
atriotomy with division of the superior vena cava for
exposure of the mitral valve. Ann Thorac Surg
40(4):365, 1985.
Selle JG: Temporary division of the superior vena
cava for exceptional mitral valve exposure. J Thorac
Cardiovasc Surg 88:302, 1984.
Kyger ER (Ill), Coselli M, Kalchoff WP: A method for
improved exposure of the mitral valve: Cannulation
of innominate vein and division of superior vena
cava for extended left atriotomy in mitral valve
operations. J Thorac Cardiovasc Surg 91(1)143,
1986.

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