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Case Report
The Best Exposure of the Mitral Valve: The Pulmonary Veins Isolation Approach

  Ovidio A Garcia-Villarreal*   

Department of Cardiac Surgery, Hospital of Cardiology UMAE 34, IMSS, Monterrey, Nuevo Leon, Mexico

*Corresponding author: Dr. Ovidio A, Sierra Nayarita 143, Col. Virginia Tafich, 66374, Santa Catarina, Nuevo León, México, Tel: +52 81 83 88 89 17; E-mail:


Optimal exposure is one of the key factors for a successful MV surgery. Because the left atrium is located at the back of the heart, MV exposure may be very difficult. This article describes an approach which consists in sectioning the antrum of the pulmonary veins. By rotating and pulling out the heart, the mitral valve can be fully exposed. This technique is highly recommended for those cases with small left atrium.


Cardiac surgical procedures; Heart atria; Mitral valve; Pulmonary veins


Perfect exposure of the mitral valve (MV) is crucial to perform any type of MV surgery. Small left atrium (LA), posterior location of the LA in the heart, a very deep thoracic cavity and median sternotomy as preferred usual approach are factors affecting the MV visualization. Sometimes, the conventional LA incision through Sondergaard’s groove does not give ideal exposure. Taking into account that the LA is located at the back of the heart, disconnection of the pulmonary veins (PV) antrum from the LA and twisting the heart by clockwise rotation offers an excellent solution for MV exposure.

Surgical Technique

Operation is performed through a full median sternotomy. Ascending aorta and bicaval cannulation is used. Cardiopulmonary bypass is established to moderate hypothermia. The aorta is cross-clamped and cold anterograde cardioplegic solution is administered. The LA is opened vertically from the right side in front of the right PV as usual. Two median Deaver retractors are placed under the MV. This manoeuvre makes it possible to identify the bulging between the PV antrum and the rest of the LA. The incision is extended inferiorly through the mitral itsmus until reaching the area between the base of the LA appendage and the left PV. Then, the incision is prolonged behind the superior vena cava and all around the LA roof encompassing the other end of this one. Two landmark sutures are placed in both sides of the LA before its division in order to facilitate the future anastomosis while preventing some malalignment. PV are now completely isolated. At this point, Deaver retractors are removed, and the heart is twisted by clockwise rotation. By a translation of the sectioned plane of the LA to another one more horizontal and anterior making a turn of almost 180 degrees, the surgeon can work on both the MV and LA at ground level. A very exceptional view of the MV is obtained (Figure 1). After MV surgery has been made, the heart is repositioned into place and the LA is sewn with a 3-0 prolene over-and-over running suture, begining at the most posterior point, according to the two marking sutures.

Figure 1. Different stages of operation. A: Panormic view of the mitral valve approach. B: Once the pulmonary veins have been isolated, the heart is twisted by clockwise rotation. With this maneuver, the posterior border of the left atrium becomes the most anterior structure in the operative field. The arrows indicate the sectioned posterior border of the left atrium. C: Mitral valve bioprosthesis has been inserted under vision of all the native mitral annulus.

IVC: Inferior Vena Cava, LA: Left Atrium, RA: Right Atrium, SVC: Superior Vena Cava.


Optimal visualization of the MV is required for any MV surgery. Several factors such as the space orientation of the MV pointing backwards, the location of the LA at the back of the heart and the median sternotomy as preferred approach may adversely affect the correct visualization of the MV. Moreover, a small LA and a very deep thoracic cavity can exacerbate the lack of MV exposure. All these factors may make the classic conventional LA incision inadequate to address the MV. Several alternative MV approaches have been described [1-6].


We must keep in mind that the LA can be divided into two main parts, viz, one section containing the MV and LA appendage, and another one containing the PV (also called PV antrum). In this technique described here, the surgeon totally cuts the LA into those two halves described above.

PV isolation approach for MV surgery proposed in this paper has the advantage of working at ground level. This is thanks to the twisting of the heart by clockwise rotation after the PV has been isolated. Making a turn of almost 180 degrees, the sectioned plane of the LA is translated to another more anterior and horizontal one. As a result, the surgeon can work on the MV at floor level. A spectacular view of the MV is obtained by this technique.

It is sometimes difficult to choose the most appropiate MV approach, and opening the LA is mandatory. Most of the time, the LA is initially opened in a conventional fashion parallel to the Sondergaard´s groove. If additional exposure is needed, the original incision is simply extended into the LA. This technique is also useful when a Cox-maze III procedure is performed in addition to the MV surgery. An excellent surgical view of both, the LA appendage as well as the MV itsmus is achieved with this technique.

This approach described here was initially performed as a part of atrial fibrillation surgery [7,8]. It has been successfully used by the author in more than 150 cases of MV disease since 1998 (Table 1).

Cases 179
Age 62 ± 17 years
Gender, Female 127(70.9%)
Mitral valve pathology
Pure Stenosis 8 (4.5%)
Pure Regurgitation 70(39.1%)
Combined stenosis and regurgitation 101(56.4%)
NYHA 2.7 ± 1.3
LVEF 0.51± 0.07
Leftatrial diameters
Supero-inferior 6.1 ± 2.3 cm
Antero-posterior 7.6 ± 2.1 cm
Transversal 5.8 ± 2.0 cm
PASP 61 ± 13 mm Hg
LVESD 39 ± 1.1 mm
LVEDD 49 ± 0.7 mm
Sinus rhythm 87(48.6%)
Atrial fibrillation 86 (48%)
Other rhythm 06(3.4%)
Intraoperative results
Operative mortality 09 (5.02%)
In-hospital mortality 08 (4.5%)
CBP time 140 ± 15 min
Aortic cross-clamp time 115 ± 18 min
Mitral valve procedures
Biological prosthesis 116 (64.8%)
Mechanical prosthesis 43  (24%)
Mitral valve repair 20 (11.2%)
Associated procedures
Tricuspid valve repair 35 (19.6%)
Tricuspid valve replacement 02 (1.11%)
Aortic valve replacement 12 (6.7%)
Coronary artery bypass grafting 05(2.8%)
Left atrial reduction 27 (15%)
Left atrial appendage removal 136 (75.9%)
Postoperative results
Bleeding in 24 hrs 480 ± 75 mL
Reoperation for bleeding 9 (5.02%)
Definitive pacemaker 6 (3.4%)
Use of vasoactive agents 130 (72.7%)
Acute renal failure 13 (7.3%)
Extubation in OR 125 (69.8%)
Prolonged intubation  > 8 hours 42 (23.4%)
LOS in ICU 3.4 ± 2.2 days
LOS in-hospital (postoperative) 9 ± 5 days

Table 1: Preoperative, intraoperative and postoperative data of all patients undergoing mitral valve surgery by the pulmonary veins isolation approach.

In conclusion, the PV isolation approach for MV surgery is a good solution for cases with not optimal MV exposure. It addresses the issue of the posterior location of the LA and MV at the back of the heart. This approach is highly recommended in cases with small LA.

Conflict of Interest:

None declared

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Article Information

Article Type: Case Report

Citation: Garcia-Villarreal OA (2015) The Best Exposure of the Mitral Valve: The Pulmonary Veins Isolation Approach. J Surg Open Access 1(1): doi

Copyright: © 2015 Garcia-Villarreal OA This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Publication history: 

  • Received date: 17 August 2014

  • Accepted date: 22 August 2015

  • Published date: 30 August 2015