Asian Cardiovasc Thorac Ann 2001;9:123-124
© 2001 Asia Publishing EXchange Pte Ltd
Extensive Left Atrial Tear During Mitral Valve Replacement: a Word of Caution
Harinder Singh Bedi, MCh,
Maninder Singh Kalkat, MCh,
Ashwani Nayyar, MD
Department of Cardiac Surgery
Tagore Heart Care & Research Centre
Jalandhar, Punjab, India
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For reprint information contact: Harinder Singh Bedi, MCh Tel: 91 172 67 1323 Fax: 91 172 21 5054 email: harinders{at}fortis.co.in Department of Cardiovascular Surgery, Fortis Heart Institute, 562 Phase I, Mohali, Punjab 160055, India.
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Abstract
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An extensive left atrial tear was encountered in a 70-year-old woman undergoing valve surgery. This potentially fatal complication was successfully repaired with autologous pericardium.
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Introduction
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A left atrial tear may occur during mitral valve surgery. It is a potentially fatal complication that can be difficult to repair when the atrial wall is friable.
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Case Report
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A 70-year-old frail female who was known to have chronic rheumatic heart disease, presented with dyspnea on exertion. She was in New York Heart Association functional class III with moderately severe calcified mitral stenosis, moderate mitral regurgitation, severe calcified aortic stenosis, severe tricuspid regurgitation, a clot in the left atrium (LA), and pulmonary artery hypertension. She was in chronic atrial fibrillation. There was no history suggestive of previous infective endocarditis. Two-dimensional echocardiography and angiography con-firmed the diagnosis and revealed normal coronary arteries. Double valve replacement and tricuspid valve repair was required.
Since the patient had a small LA, atrial fibrillation, and needed concomitant tricuspid valve repair, a superior transseptal biatrial approach was used (Figures 1A & 1B
).1 The right atrium was opened parallel to, and 3 to 4 cm behind the atrioventricular groove going across the right atrial appendage. The interatrial septum was opened at the fossa ovalis and extended inferiorly to the inferior limbus. The incision was extended superiorly and the 2 incisions (right atrial and interatrial septal) joined at the roof of the LA. This was opened for 4 to 5 cm. Stay sutures were used to retract the interatrial septum and right atrial wall; no retraction instruments were required for exposure. A standard transaortic approach was used for aortic valve replacement. On opening the LA, a friable but densely adherent clot was seen. It was stuck to the left atrial appendage and atrial wall. It was removed piecemeal with difficulty as no plane of cleavage could be dissected. The rest of the procedure was carried out in the standard fashion. Specifically, no excessive traction was required at any stage of the mitral procedure as the exposure was excellent. Continuous 4/0 propylene was used to close the roof of the LA and interatrial septum. The LA was thoroughly de-aired. The 2 sutures were tied where they met and then continued to close the right atrium.
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Figure 1 (A & B). Line diagram and operative photograph of the superior transseptal approach, showing the incision in the right atrium (RA), interatrial septum (IAS), and left atrium (LA). The prosthetic mitral valve (MV) is visible. The white arrow points to the potential start of a tear in the roof of the LA. IVC = inferior vena cava, SVC = superior vena cava.
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On coming off cardiopulmonary bypass (CPB), excessive bleeding from the roof of the LA was noticed. CPB was reinstituted, the heart was arrested, and the incision was reopened. A ragged tear was found in the roof of the LA, going towards the left atrial appendage (Figure 2). The tear was repaired by direct suturing and the incision was closed. There was concern about the friability of the tissues. When CPB was discontinued, bleeding was again observed coming from the left side. CPB was reinstituted and the LA was opened at the conventional site: from just in front of the right pulmonary veins. The tear was noted to have spread across the left atrial appendage and extended almost up to the mitral annulus. A large piece of autologous pericardium was prepared and used to exclude the whole of the friable torn area by suturing it to a relatively healthy area far away from the friable LA, using 5/0 polypropylene. On coming off CPB again, no excessive bleeding occurred. The patient made an uneventful recovery.
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Figure 2. Operative photograph of a similar case to that reported (double valve replacement with tricuspid valve repair), showing the right atrium (RA), interatrial septum (IAS), left atrium (LA), prosthetic mitral valve (MV) and prosthetic aortic valve (AV). The white arrow points to the area where a tear in the roof of LA can start.
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Discussion
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In the superior transseptal approach, the chances of tearing the LA are low as the exposure is good without the need for excessive traction. It is nevertheless important to close the highest point of the incision (in the roof of the LA) carefully as this area becomes almost inaccessible once the heart is full and beating.2 The potential for a LA tear exists in all methods of exposure of the mitral valve, in spite of a meticulous technique. Generally, the repair is simple and involves reinstitution of CPB and placing a few sutures.3 However, if the LA is friable as in our case (possibly because the patient was an elderly female and had an adherent clot in the LA, which had been removed with difficulty), the repair may not be straightforward. In such a case, we recommend our technique as it is based on the sound surgical principle of staying away from friable areas that will not tolerate direct suturing.
Presented as a poster at the Standards and Concepts in Valve Surgery Conference, Vienna, Austria, October 7, 1999, and awarded the Best Presentation Award.
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References
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Berreklouw E, Ercan H, Schönberger JP. Combined superior-transseptal approach to the left atrium. Ann Thorac Surg 1991;51:293–5.[Abstract]
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Kon ND, Tucker WY, Mills SA, Lavender SW, Cordell AR. Mitral valve operation via an extended transseptal approach. Ann Thorac Surg 1993;55:1413–7.[Abstract]
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Gaudino M, Alessandrini F, Glieca F, Martinelli L, Santarelli P, Bruno P, et al. Conventional left atrial versus superior septal approach for mitral valve replacement. Ann Thorac Surg 1997;63:1123–7.[Abstract/Free Full Text]
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Abstract
Introduction
