Research Centre Riyadh   Kingdom o Saudi Arabia
ABSTRACT Different approaches to the left atrium and various·
techniques of the atriotomy are
practiced by cardiac surgeons according to the need-for a parti cular patient and preference of
the individual surgeon.
day
a key role in the success of any surgical proce
dure. This is particularly true in mitral valve
surgery, especially if a repair is envisaged.
 
·
a small left atrium. Various techniques of left
atriotomy have been described
advantages, disadvantages, and our present day
preferred technique.
verse sternotomy; and
entered.
3
If necessary, the right anterolateral
incision can be extended across the s t r ~ u m
after division of the internal mammary vasc
1
ular
ti
on
palpated
and
Address for correspondence : Dr.
Hospital ,
PO
heparinization the aorta
through pursestrings in the right atri
al
wall
or
This approach is particularly useful for
reoperations, for the third time (or more),
or
for
patients with patent coronary bypass grafts or
sternotomy c o m p l i c a t i o n ~ where freeing the
universal pericardia adhesions
In
difficult
pulmonary veins.
and
aortic vent on suction .
pleural cavity
..
· · -
to
arterial return and venous drainage are achieved
through femoral cannulations. Arterial return
can
also
be
subclavian artery.
Vol. 5, No 3 , 1990
Journal of Cardiac Surgery
the fourth intercostal space and standard left
atriotomy
is achieved anteriorly to the insertion of the left
pulmonary veins. Alternatively the incision can
be started at the base of the left atrial ap
pendage superiorly and directed toward the left
inferior pulmonary vein posteriorly and inferior
ly.6 This approach, frequently used
in
dangers involved in not being a routine
p r o c e ~
dure, represents a more difficult venous can
nulation. Furthermore,
visibility of the mitral apparatus which
in
thoracotomies are more traumatic and painful
for the patient than a median sternotomy.
Transverse sternotomy
is
is
placed
in
ings. Venous drainage is obtained, through can
nulation 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 can
nulation techniques.
blunt dissection and the right atrium can be
retracted medially and anteriorly. The right supe
rior pulmonary vein at its junction to the left
atrium is exposed. The left atrium is opened at
the midpoint between the right superior pul
monary vein insertion and interatrial groove. This
incision is extended longitudinally both supe
riorly and inferiorly to give enough exposure of
the mitral valve. Care must be taken at the time
of incising, so as not to inadvertently injure the
posteri :>r wall of the left atrium. When closing,
care must be taken not to include the posterior
wall of the right pulmonary veins
in
exposure of the mitral valve
is
the superior vena cava and inferiorly posterior to
the inferior vena cava after entering the oblique
sinus by freeing its pericardia reflection.
Further exposure can be achieved by section
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_.ercosta _space h s   e e o
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 inter- of the right atrium and therefore a better ex-
nal mammary bundles must be ligated and posure. If necessary, the azygos vein can also be
divided. The pericardium
incised longitudinal- ligated and dividecfl When extending the
ly. The left atrium is usually approached through atriotomy superiorly, care mustbe 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
has been proposed by Saksena .
1
The
posed 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
atr ium 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
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 cardiopul
monary bypass, packing the area with gauze,
and reexploring to control bleed ing after
24
hours.
11
al.
1
2
geons who already have some experience in
mitral valve procedures in orqer to avoid these
problems .
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 following this technique, some authors
have proposed this route, which in our opinion
must be kept as a useful
alternative.3·
14
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.
operations as i.t minimizes the amount of dissec
tion required.
Biatrial atriotomy
was described at a time where rheumatic heart
valve disease was prevalent and most cases
requ ired mitral and
- -- - - -- The incision is started in the left atrium at its
igure 2 he superior approach to the left atrium 
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
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
and tr icuspid valves -are exposed: However;
closure time is long and the transverse section
of the septum may give rise to postoperative
arrhythmia. Brawley1
to give
atrial septum. A modification of this approach is
Vo l.
nd
 
to make a pa rallel right atriotomy and enter the
left atrium through a separate incision in the
intra-atrial septum
right atriotomy divide the interatrial septum per
pendicular to the left atriotomy (Fig. 4 . This
extension
is
started
at
ovalis. The exposure is excellent, eas ier to close
than Dubosts' but carries the risk of
all
is re
ventricular aspect. Valve replacement is per
formed easily and the superb view of the subval
vular apparatus makes simple some techniques
such
as
repair and reimplantation. The incision is made
in the scar area
muscles are identifi
in
ng
to
ortotomy
discreet lesion of the anterior leaflet of the mitral
valve can
referred technique
having some advantages, the majority of sur
geons 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 uncer
ta inties and therefore risks. Individual air venting
techniques are applied routinely.
connections on the basis that the anterior retrac
tion
on
superior vena cava drainage. It has
been
our
~
a satisfactory venous return and does not 'kink
when a retractor
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 ~ i n walls.
The point of incision should be immediately
posterior to the groove and as far anteriorly to
the pu lmonary veins as possible. The incision is _
then prolonged superiorly and inferiorly. A
retractor is then placed
forward displacement (Fig. 5 . The azygos vein
entrance into the superior vena
cava
re
A. Incise pericardia reflections
B. Atrlotomy incision extended
pericardia/ reflection. B) Extended left atriotomy
after resecting the pericardia/ refle ctions.
Vol. 5, No. 3, 1990
Journal of Cardiac Surgery
DURAN
I
. ~ y J ~ l ~ f d ~ ~ a n g l e s
of the atriotomy that can then be ex-
1 tended toward the roof and floor of the left atrium
I for a considerable distance along the transverse
1
j Care must be taken to identify and sometimes
l separate by blunt dissection the lower aspect of
1 the right pulmonary artery superiorly. Inferiorly,
1 the incision must curve posteriorly and medially
I
i before the entrance of the inferior vena cava into
1
C
shaped
. 1
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.
ticularly small such as in acute regurgitant
lesions we transsect Gompletely the superior
vena cava
is
dissected
above the entrance into the right atrium and
cannulated with a right angle metal tip cannula
Fig.
6
. Selle
19
cava can be divided between two vascular
clamps and then cannulate the transsected
cephalic end of the superior vena cava. Reanas
tomosis 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 alter
nate way to divide the superior vena cava is to
cannulate the left innominate ve in.
20
pursestring in the right atrial wall. Once on
cardiopulmonary bypass both venae cavae are
snared. The superior vena cava is divided at
least 1
6
the interatri
inferiorly and superiorly. The atrial retractors are
placed displacing the right atrium anteriorly and
showing the upper ext remity of the atriotomy
that can then be extended toward the roof of the
left atrium. This 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 eas ily with a
running 4/0 prolene suture. The absence of a
cannula at that level considerably simplifies this
suture, which
during the rewarming period.
MSTJ
et
al:
Thorac Cardiovasc
procedures for acquired mitral
3. Effler DB,Groves LK, MartinezWV, et al. Open heart
. surgery
for
atriotomy after a temporary division of the superior
vena cava
gh PS
femora-femoral
bypass
48 :69, 1989.
Results of
168
Journal
 
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
Publications, 1969, p 288
8. Elkins RC Bender HW Brawley RK, et al: Techni
que for prosthetic replacement of the mitral valve.
Surg Gynec Obst 134:485, 1972.
9. Zacharias
posure for difficult mitral valve procedures. Ann
Thorac Surg 42:336, 1986.
superior approach to the mitral valve. Ann Thorac
Surg 12(2):146, 1971.
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
valve mitrale par voie transatriale, interet particulier
dans les remplacements valvulaires iteratifs. Ann
Chir Thorac Cardiovasc 40(8):557, 1986
15. 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.
16. Brawley RK: Improved exposure of the mitral valve
in patients with a small left atrium . Ann Thorac Surg
29(2):179, 1980.
to the left atrium and mitral valve apparatus. Tex
Heart lnst J 10(2): 119, 1983.
18. 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.
cava for exceptional mitral valve exposure.J Thorac
Cardiovasc Surg 88:302, 1984.
M
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.