Asian Cardiovasc Thorac Ann 2000;8:192-194
© 2000 Asia Publishing EXchange Pte Ltd
Closed Mitral Commissurotomy Utilizing Right Thoracotomy Approach
De Dang Hanh, MD,
A Thomas Pezzella, MD
Department of Cardiothoracic Surgery
Viet Duc Hospital
Hanoi, Vietnam
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For reprint information contact: A Thomas Pezzella, MD Tel: 1 508 798 6318 Fax: 1 508 798 1621 email: thomas.pezzella{at}banyan.ummed.edu Division Cardiothoracic Surgery, Department of Surgery, St. Vincent Hospital, 25 Winthrop Street, Worcester, MA 01604, USA.
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Abstract
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Right thoracotomy provides an alternative approach for commissurotomy in selected cases of mitral valve disease. From 1970 through 1985, over 300 patients underwent closed mitral commissurotomy by this approach, with satisfactory early results.
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Introduction
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For many years prior to the routine use of the heart-lung machine, closed mitral commissurotomy (CMC) was the mainstay for relief of severe rheumatic mitral stenosis. Since the first description by Souttar1 in 1925, the pioneering efforts of Harken and colleagues,2 Bailey,3 and Smithy and colleagues4 in the late 1940s laid the groundwork for a number of operations over subsequent years with gratifying short-term and long-term results. Although Souttar1 used a right thoracotomy approach, a left thoracotomy is the most common and conventional access modality. Contemporary experience of CMC via a right thoracotomy is described to highlight its modern application, particularly in situations where cardiopul-monary bypass or transvenous balloon mitral valvuloplasty are unavailable, prohibitively expensive, or hazardous.
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Technique
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Normally, the left atrium is the cardiac chamber lying posteriorly, close to the thoracic spine, and to the left. In rheumatic mitral stenosis, the left atrium enlarges to the right (Figure 1A
), forming a double shadow on the pos-teroanterior chest radiograph. It is this characteristic of location that allows increased visualization of the left atrium with the right thoracotomy approach. On the surface, the interatrial septum (Sondergaard groove) is a fatty longitudinal ridge extending behind both cavae and anterior to the right pulmonary veins. This area is so narrow that one has to enter the left atrium at the apex behind the superior vena cava or at the junction of the pulmonary veins and the left atrium. However, after incising this fatty groove or ridge down to the left atrial muscular wall, a plane is developed and the overlying fatty tissue and right atrial wall can be dissected anteriorly and to the left (Figure 1B).
The patient is rotated on the operating table to the left at 45 degrees. A right anterior thoracotomy is performed and the chest is entered through the 5th intercostal space. The pericardium is incised longitudinally, anterior to the phrenic nerve, from the superior vena cava to approxi-mately 2 cm from the inferior vena cava. With the pericardial edges retracted, the interatrial septal ridge is visualized with the right atrium anteriorly and the left atrium with the two pulmonary veins posteriorly. In the presence of tricuspid insufficiency with an enlarged right atrium, a clamp is used to retract the right atrium to the left, thus exposing the obscured left atrium (Figure 1B
). A 24-cm incision is made in the interatrial groove at the level of the pulmonary veins. A 3/0 silk pursestring suture is placed in the fatty tissue (Figures 1B and 1C). Traction sutures are placed superiorly and inferiorly. An incision is made to admit the index finger (Figure 1C). The mitral valve is palpated and the stenosis is dilated (Figure 1D). The posterior leaflet is easily separated because it lies in front of the examining finger (instead of the dorsum of the finger when performed via a left thoracotomy). On removing the finger, the pursestring suture is tied (Figure 1E). If there is continued bleeding, the two traction sutures can reinforce the closure. Finally, the dissected groove is closed with a continuous nonabsorbable suture (Figure 1F).
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Discussion
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This operation evolved following dissatisfaction with the left-sided approach. In reoperations for recurrent mitral stenosis, originally carried out from the left side, a redo left thoracotomy presented several problems. The lung was frequently adherent to the chest wall and adjacent structures, requiring tedious dissection and often com-plicated by parenchymal lung injury with troublesome bleeding and air leaks. In addition, with previous ampu-tation of the left atrial appendage at the original operation, there was inadequate room to insert the finger into the left atrium to dilate the valve or guide a Tubbs dilator introduced through the left atrium or left ventricle. In other patients, the presence of a left atrial appendage clot, either palpated or demonstrated with 2-dimensional echocardiography, increased the risk of systemic emboli with finger insertion through the left atrial appendage or the base of the left atrium.
From 1970 to 1985, over 300 patients with mitral stenosis underwent CMC via a right thoracotomy approach at Viet Duc Hospital, Hanoi, Vietnam. The majority were young with early fibrotic mitral stenosis and normal sinus rhythm. Finger dilatation alone was utilized, except in 5 cases where a Tubbs dilator was used directly through the left atrium because of inability to reach the valve directly with the finger. There was one death secondary to heart failure on the 2nd postoperative day. One patient suffered a nonfatal postoperative embolic stroke. Satisfactory results were obtained with the finger dilatation technique, however, specific details regarding demographics and long-term results are unavailable.
With the development of safe cardiopulmonary bypass, open mitral commissurotomy, repair, and valve replace-ment have supplanted CMC in most centers. Recently, closed percutaneous mitral balloon valvuloplasty has gained increased acceptance and popularity. However, in certain situations such as pregnancy, and in certain parts of the world, CMC remains a practical and effective modality. Commonly in developing countries, cardio-pulmonary bypass or percutaneous mitral balloon valvu-loplasty are unavailable, restricted, or costly. Herein, CMC remains a practical and valuable technique.
A considerable experience of CMC has been reported, usually via a left thoracotomy. However, use of a right thoracotomy is not a new concept; Neptune and Bailey5 described this approach in 1954 for mitral and associated tricuspid stenosis. With associated pulmonary pathology, combined lung resection and CMC has been carried out from the right side. A third indication was combined CMC and closure of an atrial septal defect with atrio-septopexy. Cooley and Stoneburner6 in 1959 described a bilateral thoracotomy approach for recurrent mitral stenosis. This allowed a right-sided digital approach and introduction of a Tubbs dilator through the left ventricular apex. Toumbouras and colleagues7 reviewed 754 patients undergoing CMC from 1958 to 1993; 53 underwent operation via the right chest. Unfortunately, no details of this approach were given. Suri and colleagues8 reviewed 113 cases of mitral restenosis approached through the left chest, with a 3.8% systemic embolization rate; 1 of the 3 deaths was secondary to a cerebral embolus. Technically, the approach was through the body of the left atrium.
There are distinct advantages in the right thoracotomy approach. Entry is easier in patients with previous left-sided CMC, thus avoiding adhesions, parenchymal tears, and air leaks. In the redo situation, the left atrial appendage is obliterated and the superior pulmonary vein may have been compromised and stenotic from the previous suture closure technique. There is decreased risk of embolism. However, it is recognized that intraoperative trans-esophageal echocardiographic guidance with entry below the appendage may improve the safety of the left thora-cotomy approach. The posterior mitral leaflet is more adherent than the anterior leaflet. From the right side, the pulp of the finger is against the posterior leaflet, in contrast to the dorsum of the dilating finger when the approach is from the left side. In young patients with early fibrotic mitral stenosis and normal sinus rhythm, the finger dilatation technique is certainly adequate.
There are certain disadvantages with the right thoracotomy approach. The mitral valve is further away or deeper. One has to insert the entire index finger in order to reach the orifice of the mitral valve. A vascular clamp cannot be used on the left atrium. If bleeding ensues, a Fogarty balloon or Foley balloon bladder catheter is used to obliterate the atriotomy and provide control. One cannot use a Tubbs dilator via the apex of the left ventricle. If the valve cannot be dilated with the finger, it is difficult and sometimes hazardous to use the Tubbs dilator directly through the left atrium. This method was used only 5 times in the entire series. In this situation, consideration of extension across the sternum, as described by Cooley and Stoneburner6 may have to be employed in order to access the left ventricular apex. It is also important to stress that in young patients with a small left ventricle, a smaller pediatric Tubbs dilator should be used.
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Acknowledgments
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Special thanks to Tuan Nguyenduy, MD, for his careful translation of the original manuscript.
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References
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Souttar HS. The surgical treatment of mitral stenosis. Br Med J 1925;2:603–6.[Free Full Text]
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Harken DE, Ellis LB, Ware PF, Norman LR. The surgical treatment of mitral stenosis. N Engl J Med 1948;239: 801–9.[Medline]
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Bailey CP. The surgical treatment of mitral stenosis. Dis Chest 1949;15:377–97.[Medline]
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Smithy HG, Boone JA, Stallworth JM. Surgical treatment of constrictive valvular disease of the heart. Surg Gynecol Obstet 1950;90:175–92.
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Neptune WB, Bailey CP. Mitral commissurotomy through the right thoracic approach. J Thorac Surg 1954;28:15–22.
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Cooley DA, Stoneburner JM. Transventricular mitral valvotomy. Surgery 1959;46:414–20.[Medline]
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Toumbouras M, Panagopoulos F, Papakonstantinou C, Bougioukos G, Rammos K, Sbarounis CN, et al. Long-term surgical outcome of closed mitral commissurotomy. J Heart Valve Dis 1995;4:247–50.[Medline]
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Suri RK, Pathania R, Jha NK, Singh H, Dhaliwal RS, Rana SS, et al. Closed mitral valvotomy for mitral restenosis. Experience in 113 consecutive cases. J Thorac Cardiovasc Surg 1996;112:727–30.[Abstract/Free Full Text]
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Abstract
Introduction
