Partial transplant cardiectomy mitral exposure

Abstract

Case Previous operation Index operation Outcome Although a traditional groove of Sondergaard left atriotomy incision gives adequate mitral valve exposure in most instances, for difficult cases alternative approaches can be helpful. Radical approaches to the difficult mitral valve through sternotomy have included azygos division with superior vena cava mobilization, superior vena cava transection, and the superior transseptal approach. Drawbacks to these approaches include loss of azygos venous drainage, possible stenosis of the reconstructed superior vena cava, and possible sinoatrial node dysfunction. In a difficult mitral case, however, possible transient sinus node dysfunction is a small trade-off in light of the generally excellent exposure the transseptal exposure provides, and so this approach has become relatively common. Occasionally, though, even the transseptal incision does not provide good mitral exposure through a sternotomy. The partial cardiectomy approach begins with a standard superior transseptal incision, with bicaval cannulation and caval snares. After aortic crossclamping, the right atrium is opened on the appendage, the dome of the left atrium is identified, and a transatrial septal incision through the fossa ovalis is carried onto the dome, leaving enough atrium toward the aorta for easy reconstruction, as depicted by Smith and Guiraudon and colleagues. The right atrial and atrial septal incisions are carried down toward but short of the inferior vena cava and coronary sinus, respectively. If this transseptal exposure is insufficient, the aorta is transected just above the sinotubular junction, the atrial dome incision is extended, and the heart is retracted anteriorly. If mitral exposure is still inadequate, the pulmonary artery is also transected just above the sinotubular junction, and the dome atriotomy is continued leftward in front of the left pulmonary veins and behind the left atrial appendage. The heart is rolled toward the feet, exposing all 4 valves (Figure 1). After the mitral operation, closure proceeds similarly to a heart transplant: the left atrium, followed by the medial right atrium (the free wall of the right atrium can be left unsewn until after crossclamp release), the