Superior Septal Approach Research Articles

Ectopic atrial rhythm after superior septal approach to the mitral valve - an often under-reported entity.

Very few reports elaborate on the changes in P wave following superior septal approach to the mitral valve. We aimed to describe the changes in the P wave axis and other electrocardiographic changes following this approach among patients preoperatively in sinus rhythm. We did a retrospective review of medical records among all our patients undergoing superior septal approach for mitral valve surgery from September 2014 to September 2019. Electrocardiograms during hospital stay and until 6-month follow-up were analyzed. A deviation in P wave axis from the normal range of + 30 to + 60° was classified as ectopic atrial rhythm. In the study population of 47 patients (age 16-75years, 51.3 ± 13.6years; M:F ratio 3.7:1), who were in normal sinus rhythm preoperatively, 34 patients (72.3%) had a visible P wave on electrocardiogram (ECG) at discharge. Among them, the P wave axes of 17 patients (36.2%) were within normal range (normal sinus rhythm), whereas 17 patients (36.2%) had ectopic atrial rhythm at discharge. The most frequent abnormal P wave axis was between 0 and - 30° (12 patients). At 6months, 8 patients (17.0%) had a persistent ectopic atrial rhythm. These patients underwent a Holter test at 6months and were followed up for symptomatic bradycardia for 3years. None of the patients with ectopic atrial rhythm required pacemaker insertion. Persistence of ectopic atrial rhythm at 6months is common (17%) after superior septal approach. Documentation of P wave axis after this approach will help avoid missing it. These patients may be kept on follow-up to look for symptomatic bradycardia.

Huge asymptomatic left atrial myxoma resected through a superior septal approach.

Huge asymptomatic left atrial myxoma resected through a superior septal approach.

Mitral valve surgery: comparison between superior septal and left atrial approaches

Background Mitral valve (MV) is one of the most complex structures in human heart with a challenging exposure. Traditionally, MV is approached via left atriotomy (LAA) while superior septal approach (SSA) is an alternative.Objective: is to highlight the merits and demerits of these two approaches in providing access to the MV in term of the aortic cross clamp time (ACCT), quality of exposure, and potential complications in view of the published literature.
 Patients and Method: Over an 18-month period ending at June 30th, 2019, 56 patients with MV disease ± other cardiac diseases were enrolled in this study. Twenty patients had surgery via LAA (one surgeon) whereas 36 were operated upon via SSA (another surgeon). Standard surgery was done via median sternotomy, cardiopulmonary bypass and hypothermia of 32 0C. Perioperative events were recorded.
 Results In SSA group (males=25; age ranged 23-74 years; mean=57.4), patients had chest pain and breathlessness for a mean of 3 months (>LAA) besides low ejection fraction (EF) in 44%, atrial fibrillation (AF) in 38.9% and dilated LA in 19.4%. They underwent 25 MV replacements (MVR), 11 MV repairs (0 in LAA), 11 coronary artery bypass grafts (CABGs) (2.6 graft per patient vs. 1.3 in LAA; significant) and 2 aortic valve replacement. Mean ACCT was 81.6 minutes (˂LAA). Postoperatively, 32 patients (88.9%) had a normal or improved EF, 11 of 14 AF patients (78.6%) reverted to sinus rhythm and no hospital death was recorded. Conclusion Besides excellent exposure, the SSA enabled us to perform MVR or repair ± additional interventions within a short time and without a heart block. Hence, our results matched the international literature.

Superior Septal Approach for Mitral Valve Surgery Incase of Better Left Atrial Exposure

Superior Septal Approach for Mitral Valve Surgery Incase of Better Left Atrial Exposure

Sinus node dysfunction with interatrial conduction delay observed after left atrial myxoma resection through the superior septal approach

We report on a 64-year-old female patient who underwent cardiac surgery for left atrial myxoma, using the superior septal approach with large atrial septal wall resection and patch closure. The superior septal approach is reported to be a relatively safe method for preventing the development of sinus node dysfunction after cardiac surgery. However, this patient developed sinus node dysfunction after surgery and required the implantation of a permanent pacemaker. Moreover, in this case, determining the appropriate positions of the pacemaker leads was difficult because of the presence of a large conduction delay in the interatrium. Selecting the appropriate atrioventricular delay settings was important in order to achieve proper sequential contractions between the left atrium and the left ventricle.

Using the superior septal approach to excise a giant left atrial myxoma: A case report

Using the superior septal approach to excise a giant left atrial myxoma: A case report

Right posterior sinoatrial node artery showing a pericaval course: a previously undescribed mode of termination

The left posterior sinus node artery (PSNA) originates from the posterolateral left circumflex artery, is quite common and shows more frequently a retrocaval mode of termination. In contrast, the right PSNA that arises from the terminal right coronary artery has been rarely described while information on its mode of termination is generally lacking. The PSNA courses close to the ostia of the superior pulmonary veins; hence, it may get injured during surgical or catheter ablation procedures performed for the treatment of atrial fibrillation. The left PSNA terminates retrocavally more frequently than the usual SNAs; hence, it may be at a greater risk of transection during the popular superior septal approach to the mitral valve. We present a case of right PSNA which terminated in a previously unreported course, i.e., the pericaval. Discussion pertains to the anatomic features of the PSNA that render it susceptible to the aforementioned complications.

Intraseptal biatrial myxoma excised via the superior septal approach

A 72-year-old man suffering from exertional dyspnea was admitted to our hospital. A computed tomography scan revealed a huge tumor occupying the interatrial septum and growing toward both the right and left atria. The tumor was successfully excised via the superior septal approach. Histological examination of the surgical specimen revealed that it was a myxoma. The patient recovered uneventfully and was discharged from our hospital 28 days after surgery. He received a permanent pacemaker implant due to sick sinus syndrome 12 months after surgery. To our knowledge, this is the first report of resection of intraseptal biatrial myxoma.

Superior septal approach for excision of large myxomas: the early KIMS experience

Superior septal approach for excision of large myxomas: the early KIMS experience

Superior septal approach for mitral valve surgery: a word of caution.

Superior septal approach provides excellent exposure of the mitral valve and the subvalvular structures. The unavoidable section of the sinus node artery is in relationship with this technique. We have studied the electrical changes associated after using this approach. We studied 247 cases of mitral valve surgery from 1996 to 2003. The patient population was divided into two comparative groups: group I (128 cases) was represented by the superior septal approach and group II (119 cases) composed the conventional right lateral approach through the left atrium. Preoperatively, 48 patients (37.5%) in group I and 46 (38.6%) in group II were in a normal sinus rhythm. Mean follow-up was 30.7 months in group I and 33.5 months in group II. There was no mortality in group I and eight cases (6.7%) in group II. A high incidence of changes as junctional rhythm was observed in group I, especially after weaning of cardiopulmonary bypass and on the first day after surgery (P>0.001). Postoperative P-R interval of the patients in sinus rhythm was 100+/-30 ms in group I and 148+/-24 ms in group II (P>0.05). P-R interval in group I was shorter than normal. P-wave morphology changed becoming inverted in leads II, III and aVF after surgery in these cases in group I. A full recuperation in P-R interval and the P-wave axis was seen in 52 cases (87.5%) in patients in group I after the third postoperative month. A definitive pacemaker implantation was need in two cases (1.5%) in group I and in six (5%) in group II (P>0.05). A superior septal approach is directly related with the loss of normal sinus rhythm because of the section of the sinus node artery. After a brief period of transient electrical changes, a new low atrial or coronary sinus rhythm slower than normal sinus rhythm appears. In consequence, a word of caution must be strongly considered in patients critically dependent on normal sinus rhythm, despite the low incidence of definitive electrical changes. Normal sinus rhythm appears again after the third postoperative month.

Early and late arrhythmias in patients in preoperative sinus rhythm submitted to mitral valve surgery through the superior septal approach

Background It has been hypothesized that the use of the superior septal approach to the mitral valve can lead to postoperative loss of sinus rhythm. This study was undertaken to evaluate the early and mid-term alterations of the cardiac rhythm in patients with preoperative sinus rhythm (SR) submitted to mitral valve surgery through the superior septal approach Methods Seventy-five cases in preoperative SR submitted to primary isolated mitral valve surgery through the superior septal approach constitute the study population. All patients underwent 12-lead electrocardiography on admission, every day after surgery until discharge and every year during the follow-up period. Results On admission in the intensive care unit, 46 cases maintained their preoperative rhythm, whereas 18 developed a junctional rhythm (JR) and 7 had a first- or second-degree atrio-ventricular block (AVB). Four cases arrived in the unit in atrial fibrillation (AF). On the first postoperative day, these proportions were substantially unchanged, with the only exception being a slight increase in the number of patients in AF. The day before discharge, only 35 of the 74 surviving cases maintained the preoperative SR, whereas 13 developed AF, 10 were in JR, and 16 were in AVB. During the follow-up period (mean, 26 ± 14 months), the majority of cases (47/74) regained SR; 11 patients had AVB, 3 were in JR, and the remaining 13 were in AF. Conclusions The use of the superior septal approach for mitral valve procedures in patients in preoperative SR is associated with minor, transient cardiac rhythm disturbances.

Endoscope-assisted superior septal approach for resection of left atrial myxoma

J Thorac Cardiovasc Surg 2002;123:357-358 Yoshio Misawa, Tsutomu Saito, Katsuo Fuse and Yasunori Sohara Endoscope-assisted superior septal approach for resection of left atrial myxoma http://jtcs.ctsnetjournals.org/cgi/content/full/123/2/357 the World Wide Web at: The online version of this article, along with updated information and services, is located on

Sinus node function after mitral valve surgery using the superior septal approach

Background. Sinus node function after the superior septal approach (SSA) in mitral valve surgery is controversial. We assessed sinus node function after this approach based on electrophysiological examinations and electrocardiographic change. Methods. Forty-six patients underwent successful mitral valve surgery via the SSA. Preoperatively, 25 patients were in atrial fibrillation (AF), 20 were in normal sinus rhythm (SR), and 1 patient was paced. Thirteen patients who demonstrated no sinus node dysfunction preoperatively underwent postoperative electrophysiological studies. Peripostoperative cardiac rhythm was monitored using a portable four-lead electrocardiograph, and late cardiac rhythm was examined using standard 12-lead electrocardiography in the outpatient clinic. Results. Twelve of 20 patients with preoperative SR experienced early postoperative supraventricular arrhythmias, but all spontaneously recovered SR. Electrophysiological studies revealed a basic cycle length of 767 ± 74 ms, sinoatrial conduction time of 72 ± 34 ms, sinus node recovery time of 1,119 ± 139 ms, and corrected sinus node recovery time of 349 ± 114 ms, thus demonstrating a lack of sinus node dysfunction. During the postoperative period (34 ± 24 months), 2 of the 20 patients with preoperative SR developed persistent AF, and 3 of the 25 patients with preoperative AF achieved normal SR. Conclusions. The SSA does not appear to cause long-term adverse effects on sinus node function, although temporary effects may occur.

Conduction disturbances after superior septal approach for mitral valve repair

Background. The superior septal approach sacrifices the sinus node artery, and it requires more invasive incisions into the right and left atria. Therefore, postoperative rhythm disturbances could be troublesome in patients with SSA. In this study, we evaluated perioperative and midterm conduction disturbances in the cardiac rhythms of patients who had a SSA for mitral valve repair. Methods. Fifty-two patients had mitral valve operations by the superior septal approach, and cardiac rhythm status was assessed. The mean follow-up period was 15 ± 8 months. In patients with normal sinus rhythms preoperatively, serial changes in PR intervals were also assessed. Holter electrocardiograms were used 6 to 12 months postoperatively. Twelve patients who had mitral valve operations by conventional left atriotomy from the right side of the left atrium served as the control group. Results. There were no operative deaths, but one patient in the experimental group died of cerebral hemorrhage 4 months postoperatively. No intractable arrhythmias occurred. Of the 25 patients who maintained sinus rhythms, preoperative PR interval on electrocardiogram was 155 ± 20 milliseconds. Postoperative PR intervals increased for 1 week, had decreased within 2 weeks postoperatively, and returned to the normal range by 6 months postoperatively. Holter electrocardiograms of 17 patients did not show supraventricular arrhythmias exceeding 3% of the total beats. None of the patients needed pacemaker implantation. The PR intervals of 5 patients with normal sinus rhythms in the control group did not show significant changes perioperatively. Conclusions. The superior septal approach is excellent for mitral valve operations because it overcomes postoperative dysrhythmias.

Conventional Left Atrial Versus Superior Septal Approach for Mitral Valve Replacement

Background. This study was designed to evaluate the safety and effectiveness of the superior septal approach for routine mitral valve replacement.Methods. One hundred forty-six consecutive patients undergoing mitral valve replacement at our institution were randomly assigned to undergo the procedure using either the conventional left atriotomy or the superior septal approach. Postoperatively and during the follow-up, 12-lead electrocardiography, 24-hour Holter monitoring, and transthoracic and transesophageal echocardiography were performed in all patients.Results. The cardiopulmonary bypass and cross-clamp times were significantly higher in the superior septal group. No significant difference in blood loss was found between the two groups, and no residual atrial septal defect was found in patients in whom we used the superior septal approach. The maintainance of sinus rhythm at late follow-up and the incidences of postoperative arrhythmias and newly developed atrioventricular block were not significantly different between the two groups.Conclusions. The use of the superior septal approach to the mitral valve is not associated with a greater incidence of rhythm disturbances or other complications. Because this approach provides optimal exposure of the valve and the subvalvular apparatus, it has been routinely adopted for use in patients undergoing mitral valve replacement at our institution.(Ann Thorac Surg 1997;63:1123–7)

Postoperative cardiac rhythms with superior septal approach and lateral approach to the mitral valve

The superior-septal approach provides an excellent view of the mitral valve and therefore has received considerable interest. However, the safety of this approach is controversial because it requires division of the sinus node artery in most cases. Postoperative cardiac rhythms were analyzed in 152 consecutive patients who underwent mitral valve procedures between January 1992 and February 1995 with a conventional right lateral left atriotomy (group 1, n = 69) or the superior-septal approach (group 2, n = 83). Follow-up ranged from 2 to 38 months, and the mean follow-up was 16.1 months in group 1 and 13.8 months in group 2. The mortality rate was similar in the two groups (1.4% in group 1 and 1.2% in group 2), and the causes of death were not related to the left atriotomy. At discharge, 96% of the patients in group 1 who were in sinus rhythm preoperatively and 78% of those in group 2 remained in sinus rhythm. At the last follow-up, 88% of these patients in group 1 and 83% in group 2 remained in sinus rhythm. Among the patients in atrial fibrillation or junctional rhythm before operation, 12% in group 1 and 11% in group 2 had regained sinus rhythm at the last follow-up. There were no significant differences in these values. Although the incidence of dysrhythmias was higher with the superior-septal approach in the early postoperative period, this approach provides an excellent operative view of the mitral valve and similar results in terms of late postoperative cardiac rhythms as the right lateral left atriotomy.

Severe left ventricular outflow tract obstruction despite sliding leaflet technique for repair of the mitral valve

Reconstructive surgery of the mitral valve has become the procedure of choice for mitral valve disease. In our center, the prevalence of reconstructive mitral valve surgery increased to 30% (42/139) in 1994. Systolic anterior motion of the mitra] valve causing left ventricular outflow tract obstruction (LVOTO) after repair of the valve occurs in 1% to 6% of cases. 1-5 Risk factors for the occurrence of LVOTO include degenerative mitral insufficiency with excess leaflet tissue, nondilatated left ventricular cavity, narrow mitral valve-aorta angle, use of a rigid mitroplasty ring, and nonuse of the sliding leaflet technique) -5 We report a case in which LVOTO occurred in a high-risk patient despite our use of the sliding leaflet technique, with severe consequences. A 59-year-old woman was referred to our surgical unit with a long-standing history of mitral insufficiency. Echocardiography had revealed prolapse of both anterior and posterior mitral leaflets, with myxomatous degenerative changes resulting in severe mitral regurgitation. Angiography confirmed these findings and also showed smooth coronary arteries and preserved left ventricular function. A narrow left ventricular outflow tract was noted, but no gradient was measured. On May i8, 1995, a reconstructive mitral valve operation was performed. The mitral valve was exposed through a superior septal approach, and retrograde bloodcardioplegia was used for myocardial protection. Because of prolapse of the posterior leaflet and rupture of one chorda, two quadrangular resections of the posterior leaflet were necessary. The defect was closed with the sliding leaflet technique. In addition, a prolonged chorda of the anterior leaflet was shortened by invagination of its excess length in the papillary muscle. The repair was concluded with a size 32 Carpentier annuloplasty ring (Baxter, Healthcare Corp., Deerfield, Ill.). Perioperative surgical and echocardiographic control showed no remaining insufficiency. The patient was easily weaned from the extracorporeal circulation but while she was still in the operating room, low cardiac output developed (cardiac index 2.38 L. min~ • m -2) and was initially treated with positive inotropic support. Echocardiography revealed septal anterior motion with narrowing of the left ventricular outflow