Left Atrial Reduction Plasty: A Novel TechniqueCorey Adams, MD, Gian-Marco Busato, MS, and Michael W. A. Chu, MD

Division of Cardiac Surgery, Department of Surgery, University of Western Ontario, Lawson Health Research Institute, andSchulich School of Medicine, University of Western Ontario, London, Ontario, Canada

We describe a novel technique of left atrial volumereduction in a patient presenting with severe dyspneafrom severe mitral insufficiency, giant left atrium, andcompressive symptoms of dysphagia and dysphonia.Resection involved circumferential excision of the leftatrium anterior to the pulmonary venous vestibule andposterior to the mitral valve and fossa ovalis, including

the left atrial appendage. A chordal-sparing bioprosthetic

Campus, LHSC, 339 Windermere Rd, London, Ontario, Canada, N6A5A5; e-mail: michael.chu@lhsc.on.ca

© 2012 by The Society of Thoracic SurgeonsPublished by Elsevier Inc

mitral valve replacement, tricuspid valve annuloplasty,and coronary bypass were also performed. Significantreduction of left atrial volume by 50% was achieved andclinical resolution of compressive symptoms was seen at6-month follow-up.

(Ann Thorac Surg 2012;93:e77–9)

© 2012 by The Society of Thoracic Surgeons

Giant left atrium (GLA) is a rare condition defined byan atrial diameter exceeding 6.5 cm and is often

associated with long-standing rheumatic mitral stenosis[1, 2]. Compressive symptoms at the time of mitral valvesurgery are the most common indication for surgicalreduction [2]. Several approaches have been described;however the optimal surgical technique for achievingreduction and relief of symptoms remains unknown[3–6]. Risk of excessive bleeding, increased cardiopulmo-nary times, and unclear surgical efficacy raise manyquestions about the optimal approach to GLA reduction.We describe a novel surgical technique that was success-ful in achieving significant GLA reduction and relievingcompressive symptoms.

Technique

An 81-year-old woman presented with a 6-month historyof New York Heart Association class IV dyspnea, dyspha-gia, hoarseness, and worsening chest discomfort. Herpast medical history was significant for long-standing per-sistent atrial fibrillation. Transthoracic echocardiographyrevealed severe mitral regurgitation (posterior leaflet re-striction with annular dilatation), ejection fraction of 50%,and left atrium dimensions of 9 � 16 �12.5 cm (Fig 1A).Endoscopy revealed no obvious esophageal masses; how-ever a modified barium swallow suggested external cardiaccompression. Computed tomography showed midesopha-geal compression from the left atrium, with proximalesophageal dilatation. Coronary angiography revealed asignificant stenosis in the left anterior descending artery.

Standard midline sternotomy with aortic and bicavalcannulation was used. After coronary revascularization,the left atrium was circumferentially dissected from pul-monary veins to the mitral valve and fossa ovalis. Thisdeveloped the interatrial groove on the right side and

Accepted for publication Nov 7, 2011.

Address correspondence to Dr Chu, Division of Cardiac Surgery, Depart-ment of Surgery, University of Western Ontario, B6-106 University

separated any attachments of the redundant left atrium

superiorly, inferiorly, and laterally such that the majority

Fig 1. (A) Preoperative transthoracic echocardiogram showing a giantleft atrium measuring 9 � 16 � 12.5 cm with a left atrial area of 115cm2. (B) Postoperative transthoracic echocardiogram demonstrating sig-nificant reduction in left atrial dimensions from 115 to 54 cm2.

of the left atrium could be easily exposed exteriorly from

0003-4975/$36.00doi:10.1016/j.athoracsur.2011.11.013

e78 HOW TO DO IT ADAMS ET AL Ann Thorac SurgLA REDUCTION SURGERY 2012;93:e77–9

the pulmonary venous vestibule to the mitral annulusand fossa ovalis (Fig 2A). A wide transverse left atriotomyincision revealed a heavily redundant left atrium thatwas rolling on itself. The left atrial appendage and theposterior left atrial wall were prolapsing into the luminalarea of the left atrium (Fig 2B). A circumferential leftatrial reduction was performed internally by excising theleft atrial wall from near the origin of the left superiorpulmonary vein, clockwise toward and including theentire left atrial appendage, continuing posteriorly to thecircumflex artery down to and along the posterior mitralannulus (Fig 2B). The gaping elliptical resection wasreapproximated internally with running 4–0 polypropyl-ene suture (Fig 2C). A complete chordal-sparing mitralvalve replacement with a 31-mm porcine bioprosthesiswas performed. The left atrial resection was completedon the right side by excising an ellipse from the left atrialroof, near the origin of the first resection, and removingall redundant tissue between the left-sided pulmonaryveins and the fossa ovalis, extending down below theinferior vena cava and near the completion of the internalresection (Fig 2D). Through a vertical right atriotomy, atricuspid annuloplasty with a 31-mm flexible band annu-loplasty was performed. Cardiopulmonary bypass andcross-clamp times were 206 and 145 minutes,respectively.

ResultsPostoperative convalescence was uncomplicated and thepatient was discharged home on postoperative day 6.Transthoracic echocardiography confirmed a well-functioning prosthetic mitral valve, trace tricuspid insuf-ficiency, and reduction in left atrial dimensions from 115to 54 cm2 (Fig 1). At 9-months’ follow-up the patientdescribed New York Heart Association class I-II symp-

Fig 2. (A) Left atrial resection line beveledaround fossa ovalis and pulmonary veins, ex-tending down below inferior vena cava nearthe completion of the internal resection. (B)Internal incisions: excising left atrial wallfrom above origin of left superior pulmonaryvein, clockwise toward and including the en-tire left atrial appendage, and continuing pos-terior to circumflex artery down to and alongposterior mitral annulus. (C) Closure of leftatrial resection line between pulmonary vesti-bule and mitral valve. The pericardium (P),coronary sinus (CS) and atrioventriculargroove are visible through left atrial resectionlines. Care must be taken to avoid injury tocoronary sinus or circumflex coronary arterywhen suturing near the atrioventriculargroove. (D) inferior view of 1-cm bridge ofleft atrial tissue between the left-sided andright-sided suture line closure of left atrium(LA) under the inferior vena cava (IVC).(RA � right atrium.)

toms, had no dysphagia, and experienced return tonormal voice clarity.

Comment

The clinical presentation of this patient was consistentwith Ortner’s syndrome, with recurrent laryngeal palsy,dysphagia, and severe dyspnea [7]. This novel GLAreduction technique achieved significant left atrial sizereduction, complete left atrial appendage resection, andrelief of adjacent compressive symptoms. The left atrialresection lines are similar to the original Cox-Maze I or IIprocedure, isolating the pulmonary veins with 1 incision[8] but extending a second, more anterior incision tocreate a large sleeve resection of the body of the leftatrium, including the left atrial appendage. Previouslydescribed techniques include partial plication, patternedexcisions, and partial autotransplantation of the heart[1–6]. The classic plication technique involves occludingthe left atrial appendage and plicating just the inferiorwall of the left atrium [1]. This technique results in amodest left atrial volume reduction and may leave anuneven and potentially thrombogenic surface within theleft atrium. Partial plication or resection of both inferiorand superior atrial walls is a more extensive reduction,which combines both superior and transseptal ap-proaches and the posterior-inferior wall and roof of theleft atrium [1, 2]. However it may result in an increasedrisk of bleeding and conduction abnormalities inherentto the transseptal exposure. The partial heart autotrans-plantation technique provides the most extensive reduc-tion and excellent exposure of the mitral valve; howevera major disadvantage includes the extensive additionalsuture lines in nondiseased anatomic structures (inferiorvena cava, pulmonary artery, aorta) and prolonged car-

e79Ann Thorac Surg HOW TO DO IT ADAMS ET AL2012;93:e77–9 LA REDUCTION SURGERY

diopulmonary bypass times [1, 6]. The “spiral” techniquedescribed by Sugiki and colleagues [4] involves a com-bined transseptal approach that results in an extensiveresection extending from the atrial septum to the rightlateral wall of the left atrium through the atrial roof, andlateral, posterior, and inferior walls of the left atrium.However a potential disadvantage of this technique is arisk of bleeding along the extensive suture lines andpossible distortion of right atrial anatomy [4].

Advantages of our described technique include avoid-ance of the right atrial incisions, complete excision of theleft atrial appendage, aggressive left atrial reduction witha near circumferential resection pattern, relative simplic-ity, and avoidance of extensive suture lines. This noveltechnique, although only a single case report, achieved a50% decrease in left atrial size, produced no significantpostoperative complications, did not significantly in-crease operative time, and at 9 months’ follow-up re-sulted in complete relief of compressive symptoms. Hy-pothetically, this patient may also experience a reducedstroke risk with reduced static blood flow in the leftatrium secondary to the left atrial remodeling and com-plete left atrial appendage resection. Ongoing follow-up

will be required to assess any long-term effects.

References

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3. Yuasa S, Soeda T, Masuyama S, et al. Surgical treatment ofgiant left atrium using a combined superior-transseptal ap-proach. Ann Thorac Surg 2003;75:1985–6.

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