The dome of the left atrium: An alternative approach for mitral valve repair

Objective: Surgical repair of mitral insufficiency is most commonly performed through a left atriotomy via the inter-atrial groove or trans-atrial (septal) approach. While the dome of the left atrium approach has been described for mitral replacement concerns have been raised about its adequacy for complex repairs. We report our experience with mitral valve repair carried out through the dome of the left atrium, in comparison with more standard approaches. Methods: One hundred and thirty-one consecutive patients undergoing mitral valve repair for regurgitation were reviewed retrospectively between 1995 and 2001. Three groups were created based on their surgical approach: inter-atrial groove group (n=43), trans-atrial group (n=18), and dome of the left atrium group (between the superior vena cava and the ascending aorta; n=70). Results: The three groups were similar in terms of pre-operative variables except for significantly older patients in the inter-atrial groove group (P<0.001). The etiology of MR was 24% ischemic (P=ns between groups) and 52% of patients had a concomitant procedure, most commonly coronary artery bypass grafting (P=ns). Valve repairs were achieved using Carpentier techniques including: ring annuloplasty (n=130), isolated posterior leaflet resection (n=69), isolated anterior leaflet (n=11), or bi-leaflet repair (n=19). The overall mortality was 4% with a median length of hospitalization of 7 days and these did not differ significantly between groups. However, longer CPB times (P<0.01) and requirement for prolonged mechanical ventilation (P=0.002) were more frequent in the inter-atrial groove group. Conclusion: We report a simple, alternative approach for mitral valve repair via the dome of the left atrium that provides similar outcome to other commonly used approaches.