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Objective: Mitral valve surgery is commonly performed through a left atriotomy at the level of the inter-atrial groove or through a trans-septal approach. Both approaches require full sternotomy and bicaval cannulation. In order to perform mitral surgery through a J-shaped ministernotomy we performed a 4 cm vertical incision of the left atrial roof (LAR) between the SVC and the ascending aorta using a single atrio-caval cannula for the venous return. Because of the proximity of LAR incision line to the aortic root, concomitant aortic valve/root surgery could be performed through the same minimally invasive approach.
Methods: Between 2007 and 2011, 512 patients underwent mitral procedures (460 MR / 52 MS) using LAR approach. A J shaped ministernotomy was performed in 189 patients and 61 of these had concomitant aortic valve/root procedures. A standard sternotomy was performed in 323 patients and 126 of these had concomitant aortic valve/root procedures. Repair rate in patients with mitral regurgitation 398/460 (86.5%). The incidence of isolated posterior, isolated anterior and bileaflet repair were 62%, 9% and 29%. Pulmonary vein RF isolation and external left atrial appendage ligation were performed in 20.3% of patients because of paroxysmal of persistent AF.
Results: in-hospital mortality was 2.3%. An adjunctive pericardial patch to repair the LAR was necessary in 1.9%. Re-exploration for bleeding was 4.8%. Permanent pacemaker implant occurred in 3.1% of patients. Four-year survival was 91±4.2%. In patients undergone mitral repair four-year freedom from MR > 2+ was 97.4%. Four-year AF ablation success rate was 75%.
Conclusions: LAR approach was a safe and effective option to perform mitral valve surgery. The proximity of the LAR incision to the aortic root and the possibility to use a single venous cannula make this approach suitable for minimally invasive mitro-aortic procedures.