Left Atrial Reduction Plasty: A Novel Technique
2012; Elsevier BV; Volume: 93; Issue: 3 Linguagem: Inglês
10.1016/j.athoracsur.2011.11.013
ISSN1552-6259
AutoresCorey Adams, Gian‐Marco Busato, Michael Chu,
Tópico(s)Cardiac Valve Diseases and Treatments
ResumoWe describe a novel technique of left atrial volume reduction in a patient presenting with severe dyspnea from severe mitral insufficiency, giant left atrium, and compressive symptoms of dysphagia and dysphonia. Resection involved circumferential excision of the left atrium anterior to the pulmonary venous vestibule and posterior to the mitral valve and fossa ovalis, including the left atrial appendage. A chordal-sparing bioprosthetic mitral valve replacement, tricuspid valve annuloplasty, and coronary bypass were also performed. Significant reduction of left atrial volume by 50% was achieved and clinical resolution of compressive symptoms was seen at 6-month follow-up. We describe a novel technique of left atrial volume reduction in a patient presenting with severe dyspnea from severe mitral insufficiency, giant left atrium, and compressive symptoms of dysphagia and dysphonia. Resection involved circumferential excision of the left atrium anterior to the pulmonary venous vestibule and posterior to the mitral valve and fossa ovalis, including the left atrial appendage. A chordal-sparing bioprosthetic mitral valve replacement, tricuspid valve annuloplasty, and coronary bypass were also performed. Significant reduction of left atrial volume by 50% was achieved and clinical resolution of compressive symptoms was seen at 6-month follow-up. Giant left atrium (GLA) is a rare condition defined by an atrial diameter exceeding 6.5 cm and is often associated with long-standing rheumatic mitral stenosis [1Apostolakis E. Shuhaiber J.H. The surgical management of giant left atrium.Eur J Cardiothorac Surg. 2008; 33: 182-190Crossref PubMed Scopus (66) Google Scholar, 2Kawazoe K. Beppu S. Takahara Y. et al.Surgical treatment of giant left atrium combined with mitral valvular disease Plication procedure for reduction of compression to the left ventricle, bronchus, and pulmonary parenchyma.J Thorac Cardiovasc Surg. 1983; 85: 885-892PubMed Google Scholar]. Compressive symptoms at the time of mitral valve surgery are the most common indication for surgical reduction [2Kawazoe K. Beppu S. Takahara Y. et al.Surgical treatment of giant left atrium combined with mitral valvular disease Plication procedure for reduction of compression to the left ventricle, bronchus, and pulmonary parenchyma.J Thorac Cardiovasc Surg. 1983; 85: 885-892PubMed Google Scholar]. Several approaches have been described; however the optimal surgical technique for achieving reduction and relief of symptoms remains unknown [3Yuasa S. Soeda T. Masuyama S. et al.Surgical treatment of giant left atrium using a combined superior-transseptal approach.Ann Thorac Surg. 2003; 75: 1985-1986Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 4Sugiki H. Murashita T. Yasuda K. Doi H. Novel technique for volume reduction of giant left atrium: simple and effective "spiral resection" method.Ann Thorac Surg. 2006; 81: 378-380Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 5Fujita T. Kawazoe K. Beppu S. Manabe H. Surgical treatment on mitral valvular disease with giant left atrium—the effect of para-annular plication on left atrium.Jpn Circ J. 1982; 46: 420-426Crossref PubMed Scopus (12) Google Scholar, 6Lessana A. Scorsin M. Scheuble C. Raffoul R. Rescigno G. Effective reduction of a giant left atrium by partial autotransplantation.Ann Thorac Surg. 1999; 67: 1164-1165Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar]. Risk of excessive bleeding, increased cardiopulmonary times, and unclear surgical efficacy raise many questions about the optimal approach to GLA reduction. We describe a novel surgical technique that was successful in achieving significant GLA reduction and relieving compressive symptoms.TechniqueAn 81-year-old woman presented with a 6-month history of New York Heart Association class IV dyspnea, dysphagia, hoarseness, and worsening chest discomfort. Her past medical history was significant for long-standing persistent atrial fibrillation. Transthoracic echocardiography revealed severe mitral regurgitation (posterior leaflet restriction with annular dilatation), ejection fraction of 50%, and left atrium dimensions of 9 × 16 ×12.5 cm (Fig 1A). Endoscopy revealed no obvious esophageal masses; however a modified barium swallow suggested external cardiac compression. Computed tomography showed midesophageal compression from the left atrium, with proximal esophageal dilatation. Coronary angiography revealed a significant stenosis in the left anterior descending artery.Standard midline sternotomy with aortic and bicaval cannulation was used. After coronary revascularization, the left atrium was circumferentially dissected from pulmonary veins to the mitral valve and fossa ovalis. This developed the interatrial groove on the right side and separated any attachments of the redundant left atrium superiorly, inferiorly, and laterally such that the majority of the left atrium could be easily exposed exteriorly from the pulmonary venous vestibule to the mitral annulus and fossa ovalis (Fig 2A). A wide transverse left atriotomy incision revealed a heavily redundant left atrium that was rolling on itself. The left atrial appendage and the posterior left atrial wall were prolapsing into the luminal area of the left atrium (Fig 2B). A circumferential left atrial reduction was performed internally by excising the left atrial wall from near the origin of the left superior pulmonary vein, clockwise toward and including the entire left atrial appendage, continuing posteriorly to the circumflex artery down to and along the posterior mitral annulus (Fig 2B). The gaping elliptical resection was reapproximated internally with running 4–0 polypropylene suture (Fig 2C). A complete chordal-sparing mitral valve replacement with a 31-mm porcine bioprosthesis was performed. The left atrial resection was completed on the right side by excising an ellipse from the left atrial roof, near the origin of the first resection, and removing all redundant tissue between the left-sided pulmonary veins and the fossa ovalis, extending down below the inferior vena cava and near the completion of the internal resection (Fig 2D). Through a vertical right atriotomy, a tricuspid annuloplasty with a 31-mm flexible band annuloplasty was performed. Cardiopulmonary bypass and cross-clamp times were 206 and 145 minutes, respectively.Fig 2(A) Left atrial resection line beveled around fossa ovalis and pulmonary veins, extending down below inferior vena cava near the completion of the internal resection. (B) Internal incisions: excising left atrial wall from above origin of left superior pulmonary vein, clockwise toward and including the entire left atrial appendage, and continuing posterior to circumflex artery down to and along posterior mitral annulus. (C) Closure of left atrial resection line between pulmonary vestibule and mitral valve. The pericardium (P), coronary sinus (CS) and atrioventricular groove are visible through left atrial resection lines. Care must be taken to avoid injury to coronary sinus or circumflex coronary artery when suturing near the atrioventricular groove. (D) inferior view of 1-cm bridge of left atrial tissue between the left-sided and right-sided suture line closure of left atrium (LA) under the inferior vena cava (IVC). (RA = right atrium.)View Large Image Figure ViewerDownload (PPT)ResultsPostoperative convalescence was uncomplicated and the patient was discharged home on postoperative day 6. Transthoracic echocardiography confirmed a well-functioning prosthetic mitral valve, trace tricuspid insufficiency, and reduction in left atrial dimensions from 115 to 54 cm2 (Fig 1). At 9-months' follow-up the patient described New York Heart Association class I-II symptoms, had no dysphagia, and experienced return to normal voice clarity.CommentThe clinical presentation of this patient was consistent with Ortner's syndrome, with recurrent laryngeal palsy, dysphagia, and severe dyspnea [7Morgan A. Mourant A. Left vocal cord paralysis and dysphagia in mitral valve disease.Br Heart J. 1980; 43: 470-473Crossref PubMed Scopus (24) Google Scholar]. This novel GLA reduction technique achieved significant left atrial size reduction, complete left atrial appendage resection, and relief of adjacent compressive symptoms. The left atrial resection lines are similar to the original Cox-Maze I or II procedure, isolating the pulmonary veins with 1 incision [8Cox J.L. Boineau J.P. Schuessler R.B. Jaquiss R.D.B. Lappas D.G. Modification of the maze procedure for atrial flutter and atrial fibrillation. I. Rationale and surgical results.J Thorac Cardiovasc Surg. 1995; 110: 473-484Abstract Full Text Full Text PDF PubMed Scopus (339) Google Scholar] but extending a second, more anterior incision to create a large sleeve resection of the body of the left atrium, including the left atrial appendage. Previously described techniques include partial plication, patterned excisions, and partial autotransplantation of the heart [1Apostolakis E. Shuhaiber J.H. The surgical management of giant left atrium.Eur J Cardiothorac Surg. 2008; 33: 182-190Crossref PubMed Scopus (66) Google Scholar, 2Kawazoe K. Beppu S. Takahara Y. et al.Surgical treatment of giant left atrium combined with mitral valvular disease Plication procedure for reduction of compression to the left ventricle, bronchus, and pulmonary parenchyma.J Thorac Cardiovasc Surg. 1983; 85: 885-892PubMed Google Scholar, 3Yuasa S. Soeda T. Masuyama S. et al.Surgical treatment of giant left atrium using a combined superior-transseptal approach.Ann Thorac Surg. 2003; 75: 1985-1986Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 4Sugiki H. Murashita T. Yasuda K. Doi H. Novel technique for volume reduction of giant left atrium: simple and effective "spiral resection" method.Ann Thorac Surg. 2006; 81: 378-380Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 5Fujita T. Kawazoe K. Beppu S. Manabe H. Surgical treatment on mitral valvular disease with giant left atrium—the effect of para-annular plication on left atrium.Jpn Circ J. 1982; 46: 420-426Crossref PubMed Scopus (12) Google Scholar, 6Lessana A. Scorsin M. Scheuble C. Raffoul R. Rescigno G. Effective reduction of a giant left atrium by partial autotransplantation.Ann Thorac Surg. 1999; 67: 1164-1165Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar]. The classic plication technique involves occluding the left atrial appendage and plicating just the inferior wall of the left atrium [1Apostolakis E. Shuhaiber J.H. The surgical management of giant left atrium.Eur J Cardiothorac Surg. 2008; 33: 182-190Crossref PubMed Scopus (66) Google Scholar]. This technique results in a modest left atrial volume reduction and may leave an uneven and potentially thrombogenic surface within the left atrium. Partial plication or resection of both inferior and superior atrial walls is a more extensive reduction, which combines both superior and transseptal approaches and the posterior-inferior wall and roof of the left atrium [1Apostolakis E. Shuhaiber J.H. The surgical management of giant left atrium.Eur J Cardiothorac Surg. 2008; 33: 182-190Crossref PubMed Scopus (66) Google Scholar, 2Kawazoe K. Beppu S. Takahara Y. et al.Surgical treatment of giant left atrium combined with mitral valvular disease Plication procedure for reduction of compression to the left ventricle, bronchus, and pulmonary parenchyma.J Thorac Cardiovasc Surg. 1983; 85: 885-892PubMed Google Scholar]. However it may result in an increased risk of bleeding and conduction abnormalities inherent to the transseptal exposure. The partial heart autotransplantation technique provides the most extensive reduction and excellent exposure of the mitral valve; however a major disadvantage includes the extensive additional suture lines in nondiseased anatomic structures (inferior vena cava, pulmonary artery, aorta) and prolonged cardiopulmonary bypass times [1Apostolakis E. Shuhaiber J.H. The surgical management of giant left atrium.Eur J Cardiothorac Surg. 2008; 33: 182-190Crossref PubMed Scopus (66) Google Scholar, 6Lessana A. Scorsin M. Scheuble C. Raffoul R. Rescigno G. Effective reduction of a giant left atrium by partial autotransplantation.Ann Thorac Surg. 1999; 67: 1164-1165Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar]. The "spiral" technique described by Sugiki and colleagues [4Sugiki H. Murashita T. Yasuda K. Doi H. Novel technique for volume reduction of giant left atrium: simple and effective "spiral resection" method.Ann Thorac Surg. 2006; 81: 378-380Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar] involves a combined transseptal approach that results in an extensive resection extending from the atrial septum to the right lateral wall of the left atrium through the atrial roof, and lateral, posterior, and inferior walls of the left atrium. However a potential disadvantage of this technique is a risk of bleeding along the extensive suture lines and possible distortion of right atrial anatomy [4Sugiki H. Murashita T. Yasuda K. Doi H. Novel technique for volume reduction of giant left atrium: simple and effective "spiral resection" method.Ann Thorac Surg. 2006; 81: 378-380Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar].Advantages of our described technique include avoidance of the right atrial incisions, complete excision of the left atrial appendage, aggressive left atrial reduction with a near circumferential resection pattern, relative simplicity, and avoidance of extensive suture lines. This novel technique, although only a single case report, achieved a 50% decrease in left atrial size, produced no significant postoperative complications, did not significantly increase operative time, and at 9 months' follow-up resulted in complete relief of compressive symptoms. Hypothetically, this patient may also experience a reduced stroke risk with reduced static blood flow in the left atrium secondary to the left atrial remodeling and complete left atrial appendage resection. Ongoing follow-up will be required to assess any long-term effects. Giant left atrium (GLA) is a rare condition defined by an atrial diameter exceeding 6.5 cm and is often associated with long-standing rheumatic mitral stenosis [1Apostolakis E. Shuhaiber J.H. The surgical management of giant left atrium.Eur J Cardiothorac Surg. 2008; 33: 182-190Crossref PubMed Scopus (66) Google Scholar, 2Kawazoe K. Beppu S. Takahara Y. et al.Surgical treatment of giant left atrium combined with mitral valvular disease Plication procedure for reduction of compression to the left ventricle, bronchus, and pulmonary parenchyma.J Thorac Cardiovasc Surg. 1983; 85: 885-892PubMed Google Scholar]. Compressive symptoms at the time of mitral valve surgery are the most common indication for surgical reduction [2Kawazoe K. Beppu S. Takahara Y. et al.Surgical treatment of giant left atrium combined with mitral valvular disease Plication procedure for reduction of compression to the left ventricle, bronchus, and pulmonary parenchyma.J Thorac Cardiovasc Surg. 1983; 85: 885-892PubMed Google Scholar]. Several approaches have been described; however the optimal surgical technique for achieving reduction and relief of symptoms remains unknown [3Yuasa S. Soeda T. Masuyama S. et al.Surgical treatment of giant left atrium using a combined superior-transseptal approach.Ann Thorac Surg. 2003; 75: 1985-1986Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 4Sugiki H. Murashita T. Yasuda K. Doi H. Novel technique for volume reduction of giant left atrium: simple and effective "spiral resection" method.Ann Thorac Surg. 2006; 81: 378-380Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 5Fujita T. Kawazoe K. Beppu S. Manabe H. Surgical treatment on mitral valvular disease with giant left atrium—the effect of para-annular plication on left atrium.Jpn Circ J. 1982; 46: 420-426Crossref PubMed Scopus (12) Google Scholar, 6Lessana A. Scorsin M. Scheuble C. Raffoul R. Rescigno G. Effective reduction of a giant left atrium by partial autotransplantation.Ann Thorac Surg. 1999; 67: 1164-1165Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar]. Risk of excessive bleeding, increased cardiopulmonary times, and unclear surgical efficacy raise many questions about the optimal approach to GLA reduction. We describe a novel surgical technique that was successful in achieving significant GLA reduction and relieving compressive symptoms. TechniqueAn 81-year-old woman presented with a 6-month history of New York Heart Association class IV dyspnea, dysphagia, hoarseness, and worsening chest discomfort. Her past medical history was significant for long-standing persistent atrial fibrillation. Transthoracic echocardiography revealed severe mitral regurgitation (posterior leaflet restriction with annular dilatation), ejection fraction of 50%, and left atrium dimensions of 9 × 16 ×12.5 cm (Fig 1A). Endoscopy revealed no obvious esophageal masses; however a modified barium swallow suggested external cardiac compression. Computed tomography showed midesophageal compression from the left atrium, with proximal esophageal dilatation. Coronary angiography revealed a significant stenosis in the left anterior descending artery.Standard midline sternotomy with aortic and bicaval cannulation was used. After coronary revascularization, the left atrium was circumferentially dissected from pulmonary veins to the mitral valve and fossa ovalis. This developed the interatrial groove on the right side and separated any attachments of the redundant left atrium superiorly, inferiorly, and laterally such that the majority of the left atrium could be easily exposed exteriorly from the pulmonary venous vestibule to the mitral annulus and fossa ovalis (Fig 2A). A wide transverse left atriotomy incision revealed a heavily redundant left atrium that was rolling on itself. The left atrial appendage and the posterior left atrial wall were prolapsing into the luminal area of the left atrium (Fig 2B). A circumferential left atrial reduction was performed internally by excising the left atrial wall from near the origin of the left superior pulmonary vein, clockwise toward and including the entire left atrial appendage, continuing posteriorly to the circumflex artery down to and along the posterior mitral annulus (Fig 2B). The gaping elliptical resection was reapproximated internally with running 4–0 polypropylene suture (Fig 2C). A complete chordal-sparing mitral valve replacement with a 31-mm porcine bioprosthesis was performed. The left atrial resection was completed on the right side by excising an ellipse from the left atrial roof, near the origin of the first resection, and removing all redundant tissue between the left-sided pulmonary veins and the fossa ovalis, extending down below the inferior vena cava and near the completion of the internal resection (Fig 2D). Through a vertical right atriotomy, a tricuspid annuloplasty with a 31-mm flexible band annuloplasty was performed. Cardiopulmonary bypass and cross-clamp times were 206 and 145 minutes, respectively.ResultsPostoperative convalescence was uncomplicated and the patient was discharged home on postoperative day 6. Transthoracic echocardiography confirmed a well-functioning prosthetic mitral valve, trace tricuspid insufficiency, and reduction in left atrial dimensions from 115 to 54 cm2 (Fig 1). At 9-months' follow-up the patient described New York Heart Association class I-II symptoms, had no dysphagia, and experienced return to normal voice clarity. An 81-year-old woman presented with a 6-month history of New York Heart Association class IV dyspnea, dysphagia, hoarseness, and worsening chest discomfort. Her past medical history was significant for long-standing persistent atrial fibrillation. Transthoracic echocardiography revealed severe mitral regurgitation (posterior leaflet restriction with annular dilatation), ejection fraction of 50%, and left atrium dimensions of 9 × 16 ×12.5 cm (Fig 1A). Endoscopy revealed no obvious esophageal masses; however a modified barium swallow suggested external cardiac compression. Computed tomography showed midesophageal compression from the left atrium, with proximal esophageal dilatation. Coronary angiography revealed a significant stenosis in the left anterior descending artery. Standard midline sternotomy with aortic and bicaval cannulation was used. After coronary revascularization, the left atrium was circumferentially dissected from pulmonary veins to the mitral valve and fossa ovalis. This developed the interatrial groove on the right side and separated any attachments of the redundant left atrium superiorly, inferiorly, and laterally such that the majority of the left atrium could be easily exposed exteriorly from the pulmonary venous vestibule to the mitral annulus and fossa ovalis (Fig 2A). A wide transverse left atriotomy incision revealed a heavily redundant left atrium that was rolling on itself. The left atrial appendage and the posterior left atrial wall were prolapsing into the luminal area of the left atrium (Fig 2B). A circumferential left atrial reduction was performed internally by excising the left atrial wall from near the origin of the left superior pulmonary vein, clockwise toward and including the entire left atrial appendage, continuing posteriorly to the circumflex artery down to and along the posterior mitral annulus (Fig 2B). The gaping elliptical resection was reapproximated internally with running 4–0 polypropylene suture (Fig 2C). A complete chordal-sparing mitral valve replacement with a 31-mm porcine bioprosthesis was performed. The left atrial resection was completed on the right side by excising an ellipse from the left atrial roof, near the origin of the first resection, and removing all redundant tissue between the left-sided pulmonary veins and the fossa ovalis, extending down below the inferior vena cava and near the completion of the internal resection (Fig 2D). Through a vertical right atriotomy, a tricuspid annuloplasty with a 31-mm flexible band annuloplasty was performed. Cardiopulmonary bypass and cross-clamp times were 206 and 145 minutes, respectively. ResultsPostoperative convalescence was uncomplicated and the patient was discharged home on postoperative day 6. Transthoracic echocardiography confirmed a well-functioning prosthetic mitral valve, trace tricuspid insufficiency, and reduction in left atrial dimensions from 115 to 54 cm2 (Fig 1). At 9-months' follow-up the patient described New York Heart Association class I-II symptoms, had no dysphagia, and experienced return to normal voice clarity. Postoperative convalescence was uncomplicated and the patient was discharged home on postoperative day 6. Transthoracic echocardiography confirmed a well-functioning prosthetic mitral valve, trace tricuspid insufficiency, and reduction in left atrial dimensions from 115 to 54 cm2 (Fig 1). At 9-months' follow-up the patient described New York Heart Association class I-II symptoms, had no dysphagia, and experienced return to normal voice clarity. CommentThe clinical presentation of this patient was consistent with Ortner's syndrome, with recurrent laryngeal palsy, dysphagia, and severe dyspnea [7Morgan A. Mourant A. Left vocal cord paralysis and dysphagia in mitral valve disease.Br Heart J. 1980; 43: 470-473Crossref PubMed Scopus (24) Google Scholar]. This novel GLA reduction technique achieved significant left atrial size reduction, complete left atrial appendage resection, and relief of adjacent compressive symptoms. The left atrial resection lines are similar to the original Cox-Maze I or II procedure, isolating the pulmonary veins with 1 incision [8Cox J.L. Boineau J.P. Schuessler R.B. Jaquiss R.D.B. Lappas D.G. Modification of the maze procedure for atrial flutter and atrial fibrillation. I. Rationale and surgical results.J Thorac Cardiovasc Surg. 1995; 110: 473-484Abstract Full Text Full Text PDF PubMed Scopus (339) Google Scholar] but extending a second, more anterior incision to create a large sleeve resection of the body of the left atrium, including the left atrial appendage. Previously described techniques include partial plication, patterned excisions, and partial autotransplantation of the heart [1Apostolakis E. Shuhaiber J.H. The surgical management of giant left atrium.Eur J Cardiothorac Surg. 2008; 33: 182-190Crossref PubMed Scopus (66) Google Scholar, 2Kawazoe K. Beppu S. Takahara Y. et al.Surgical treatment of giant left atrium combined with mitral valvular disease Plication procedure for reduction of compression to the left ventricle, bronchus, and pulmonary parenchyma.J Thorac Cardiovasc Surg. 1983; 85: 885-892PubMed Google Scholar, 3Yuasa S. Soeda T. Masuyama S. et al.Surgical treatment of giant left atrium using a combined superior-transseptal approach.Ann Thorac Surg. 2003; 75: 1985-1986Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 4Sugiki H. Murashita T. Yasuda K. Doi H. Novel technique for volume reduction of giant left atrium: simple and effective "spiral resection" method.Ann Thorac Surg. 2006; 81: 378-380Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 5Fujita T. Kawazoe K. Beppu S. Manabe H. Surgical treatment on mitral valvular disease with giant left atrium—the effect of para-annular plication on left atrium.Jpn Circ J. 1982; 46: 420-426Crossref PubMed Scopus (12) Google Scholar, 6Lessana A. Scorsin M. Scheuble C. Raffoul R. Rescigno G. Effective reduction of a giant left atrium by partial autotransplantation.Ann Thorac Surg. 1999; 67: 1164-1165Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar]. The classic plication technique involves occluding the left atrial appendage and plicating just the inferior wall of the left atrium [1Apostolakis E. Shuhaiber J.H. The surgical management of giant left atrium.Eur J Cardiothorac Surg. 2008; 33: 182-190Crossref PubMed Scopus (66) Google Scholar]. This technique results in a modest left atrial volume reduction and may leave an uneven and potentially thrombogenic surface within the left atrium. Partial plication or resection of both inferior and superior atrial walls is a more extensive reduction, which combines both superior and transseptal approaches and the posterior-inferior wall and roof of the left atrium [1Apostolakis E. Shuhaiber J.H. The surgical management of giant left atrium.Eur J Cardiothorac Surg. 2008; 33: 182-190Crossref PubMed Scopus (66) Google Scholar, 2Kawazoe K. Beppu S. Takahara Y. et al.Surgical treatment of giant left atrium combined with mitral valvular disease Plication procedure for reduction of compression to the left ventricle, bronchus, and pulmonary parenchyma.J Thorac Cardiovasc Surg. 1983; 85: 885-892PubMed Google Scholar]. However it may result in an increased risk of bleeding and conduction abnormalities inherent to the transseptal exposure. The partial heart autotransplantation technique provides the most extensive reduction and excellent exposure of the mitral valve; however a major disadvantage includes the extensive additional suture lines in nondiseased anatomic structures (inferior vena cava, pulmonary artery, aorta) and prolonged cardiopulmonary bypass times [1Apostolakis E. Shuhaiber J.H. The surgical management of giant left atrium.Eur J Cardiothorac Surg. 2008; 33: 182-190Crossref PubMed Scopus (66) Google Scholar, 6Lessana A. Scorsin M. Scheuble C. Raffoul R. Rescigno G. Effective reduction of a giant left atrium by partial autotransplantation.Ann Thorac Surg. 1999; 67: 1164-1165Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar]. The "spiral" technique described by Sugiki and colleagues [4Sugiki H. Murashita T. Yasuda K. Doi H. Novel technique for volume reduction of giant left atrium: simple and effective "spiral resection" method.Ann Thorac Surg. 2006; 81: 378-380Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar] involves a combined transseptal approach that results in an extensive resection extending from the atrial septum to the right lateral wall of the left atrium through the atrial roof, and lateral, posterior, and inferior walls of the left atrium. However a potential disadvantage of this technique is a risk of bleeding along the extensive suture lines and possible distortion of right atrial anatomy [4Sugiki H. Murashita T. Yasuda K. Doi H. Novel technique for volume reduction of giant left atrium: simple and effective "spiral resection" method.Ann Thorac Surg. 2006; 81: 378-380Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar].Advantages of our described technique include avoidance of the right atrial incisions, complete excision of the left atrial appendage, aggressive left atrial reduction with a near circumferential resection pattern, relative simplicity, and avoidance of extensive suture lines. This novel technique, although only a single case report, achieved a 50% decrease in left atrial size, produced no significant postoperative complications, did not significantly increase operative time, and at 9 months' follow-up resulted in complete relief of compressive symptoms. Hypothetically, this patient may also experience a reduced stroke risk with reduced static blood flow in the left atrium secondary to the left atrial remodeling and complete left atrial appendage resection. Ongoing follow-up will be required to assess any long-term effects. The clinical presentation of this patient was consistent with Ortner's syndrome, with recurrent laryngeal palsy, dysphagia, and severe dyspnea [7Morgan A. Mourant A. Left vocal cord paralysis and dysphagia in mitral valve disease.Br Heart J. 1980; 43: 470-473Crossref PubMed Scopus (24) Google Scholar]. This novel GLA reduction technique achieved significant left atrial size reduction, complete left atrial appendage resection, and relief of adjacent compressive symptoms. The left atrial resection lines are similar to the original Cox-Maze I or II procedure, isolating the pulmonary veins with 1 incision [8Cox J.L. Boineau J.P. Schuessler R.B. Jaquiss R.D.B. Lappas D.G. Modification of the maze procedure for atrial flutter and atrial fibrillation. I. Rationale and surgical results.J Thorac Cardiovasc Surg. 1995; 110: 473-484Abstract Full Text Full Text PDF PubMed Scopus (339) Google Scholar] but extending a second, more anterior incision to create a large sleeve resection of the body of the left atrium, including the left atrial appendage. Previously described techniques include partial plication, patterned excisions, and partial autotransplantation of the heart [1Apostolakis E. Shuhaiber J.H. The surgical management of giant left atrium.Eur J Cardiothorac Surg. 2008; 33: 182-190Crossref PubMed Scopus (66) Google Scholar, 2Kawazoe K. Beppu S. Takahara Y. et al.Surgical treatment of giant left atrium combined with mitral valvular disease Plication procedure for reduction of compression to the left ventricle, bronchus, and pulmonary parenchyma.J Thorac Cardiovasc Surg. 1983; 85: 885-892PubMed Google Scholar, 3Yuasa S. Soeda T. Masuyama S. et al.Surgical treatment of giant left atrium using a combined superior-transseptal approach.Ann Thorac Surg. 2003; 75: 1985-1986Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 4Sugiki H. Murashita T. Yasuda K. Doi H. Novel technique for volume reduction of giant left atrium: simple and effective "spiral resection" method.Ann Thorac Surg. 2006; 81: 378-380Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 5Fujita T. Kawazoe K. Beppu S. Manabe H. Surgical treatment on mitral valvular disease with giant left atrium—the effect of para-annular plication on left atrium.Jpn Circ J. 1982; 46: 420-426Crossref PubMed Scopus (12) Google Scholar, 6Lessana A. Scorsin M. Scheuble C. Raffoul R. Rescigno G. Effective reduction of a giant left atrium by partial autotransplantation.Ann Thorac Surg. 1999; 67: 1164-1165Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar]. The classic plication technique involves occluding the left atrial appendage and plicating just the inferior wall of the left atrium [1Apostolakis E. Shuhaiber J.H. The surgical management of giant left atrium.Eur J Cardiothorac Surg. 2008; 33: 182-190Crossref PubMed Scopus (66) Google Scholar]. This technique results in a modest left atrial volume reduction and may leave an uneven and potentially thrombogenic surface within the left atrium. Partial plication or resection of both inferior and superior atrial walls is a more extensive reduction, which combines both superior and transseptal approaches and the posterior-inferior wall and roof of the left atrium [1Apostolakis E. Shuhaiber J.H. The surgical management of giant left atrium.Eur J Cardiothorac Surg. 2008; 33: 182-190Crossref PubMed Scopus (66) Google Scholar, 2Kawazoe K. Beppu S. Takahara Y. et al.Surgical treatment of giant left atrium combined with mitral valvular disease Plication procedure for reduction of compression to the left ventricle, bronchus, and pulmonary parenchyma.J Thorac Cardiovasc Surg. 1983; 85: 885-892PubMed Google Scholar]. However it may result in an increased risk of bleeding and conduction abnormalities inherent to the transseptal exposure. The partial heart autotransplantation technique provides the most extensive reduction and excellent exposure of the mitral valve; however a major disadvantage includes the extensive additional suture lines in nondiseased anatomic structures (inferior vena cava, pulmonary artery, aorta) and prolonged cardiopulmonary bypass times [1Apostolakis E. Shuhaiber J.H. The surgical management of giant left atrium.Eur J Cardiothorac Surg. 2008; 33: 182-190Crossref PubMed Scopus (66) Google Scholar, 6Lessana A. Scorsin M. Scheuble C. Raffoul R. Rescigno G. Effective reduction of a giant left atrium by partial autotransplantation.Ann Thorac Surg. 1999; 67: 1164-1165Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar]. The "spiral" technique described by Sugiki and colleagues [4Sugiki H. Murashita T. Yasuda K. Doi H. Novel technique for volume reduction of giant left atrium: simple and effective "spiral resection" method.Ann Thorac Surg. 2006; 81: 378-380Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar] involves a combined transseptal approach that results in an extensive resection extending from the atrial septum to the right lateral wall of the left atrium through the atrial roof, and lateral, posterior, and inferior walls of the left atrium. However a potential disadvantage of this technique is a risk of bleeding along the extensive suture lines and possible distortion of right atrial anatomy [4Sugiki H. Murashita T. Yasuda K. Doi H. Novel technique for volume reduction of giant left atrium: simple and effective "spiral resection" method.Ann Thorac Surg. 2006; 81: 378-380Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar]. Advantages of our described technique include avoidance of the right atrial incisions, complete excision of the left atrial appendage, aggressive left atrial reduction with a near circumferential resection pattern, relative simplicity, and avoidance of extensive suture lines. This novel technique, although only a single case report, achieved a 50% decrease in left atrial size, produced no significant postoperative complications, did not significantly increase operative time, and at 9 months' follow-up resulted in complete relief of compressive symptoms. Hypothetically, this patient may also experience a reduced stroke risk with reduced static blood flow in the left atrium secondary to the left atrial remodeling and complete left atrial appendage resection. Ongoing follow-up will be required to assess any long-term effects.
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