Septal-superior exposure of the mitral valve. The transplant approach.

The technique used for transplant recipient cardiectomy can be modified to improve exposure of the mitral valve in patients with difficult anatomy. Right atrial and septal incisions are joined at the superior end of the interatrial septum and extended across the dome of the left atrium to the base of the left atrial appendage. Retraction of the right ventricle to the left bivalves the left atrium along an axis extending from the appendage to the inferior end of the septum, producing uniquely anterosuperior exposure of the mitral apparatus. This approach provided excellent exposure in seven patients in whom there were a variety of obstacles to a conventional approach. Four (57%) had complex reoperations. There were no bleeding complications. At late follow-up there was no change in rhythm or conduction in four patients with atrial fibrillation preoperatively. A change in P wave axis and morphology was seen at late follow-up in two patients with normal sinus rhythm preoperatively, possibly related to division of the sinus node artery. A third patient with normal sinus rhythm preoperatively remained in normal sinus rhythm at late follow-up. A septal-superior approach can be useful in complex reoperations, in procedures requiring right atriotomy for other reasons, and in patients with a small or inaccessible left atrium.