Operative technique
Surgical approach was at the discretion of the operating surgeon.
Routine chest computed tomography was not obtained. Cardioplegia was
with high potassium 4:1 blood: crystalloid cardioplegia until July 2014,
after which time, cold Del Nido cardioplegia was used. Moderate
hypothermia (32° C) was used in all cases.
In the ST group, conventional median sternotomy, ascending aorta and
bicaval cannulation, and antegrade cardioplegia catheters were used
(coronary sinus catheters are no longer placed routinely). In the RAT
group, a small right anterior thoracotomy was made in the fifth
intercostal space. Double lumen endotracheal intubation routine.
Peripheral cannulation was preferentially utilized. Pericardial
retraction sutures were placed and secured on protective red rubber
“bumpers” on the chest wall. A left ventricular vent was inserted
through the right superior pulmonary vein and tunneled through the chest
wall. After MVr, two 32-French chest drains were placed in the
mediastinal and pericardial spaces for postoperative drainage. The
intercostal space was approximated with heavy suture. Use of subpleural
pain catheters was at the discretion of the surgeon.
MV exposure and the approach to MVr was similar in both groups. The MV
was typically accessed via the interatrial sulcus, although transseptal
and left atrial dome approaches were also utilized. Posterior leaflet
MVr generally involved resection of the diseased segment, annular
plication and reconstruction of the posterior leaflet. The anterior
leaflet was repaired by the placement of Gore-Tex neochordae (W.L. Gore
& Associates, Inc., Flagstaff, AZ, USA) or resection and
reconstruction. A true-sized, partial posterior MV annuloplasty was
primarily utilized.