The superior approach for mitral valve replacement.

A consecutive series of 98 patients ranging from 2 1/2 to 79 years of age underwent mitral valve replacement using the superior approach that entails an atriotomy done between the superior vena cava and the ascending aorta prolonging it into the left superior pulmonary vein. The technique opens the roof of the left atrium without dissection, frequently without the need for double cannulation of the right atrium. No mobilization of the heart is involved, which is left in its normal position. There were 62 patients undergoing replacement alone, 22 combined with coronary bypass surgery, 10 with simultaneous aortic valve replacement, 2 with coronary bypass and left ventricular aneurysm resection, and 2 others combined with ventricular septal defect (VSD) closure and placement of an extracardiac conduit. Forty-six were done for stenosis and 52 for regurgitation. No technical difficulties were encountered, and the valve can easily be replaced through an incision slightly larger than the diameter of the prosthesis being implanted. Since the heart is not mobilized, the ventricles remain immersed in the cold topical solution (4 degrees C) in addition to the administration of cardioplegia for myocardial protection. The access is simple and offers better exposure for the assisting surgeon than the usual inter-atrial groove approach. Important steps of the technique are clarified.