Sinus Node Function after Extended Transseptal Approach for Mitral Valve Surgery: 164 Clinical Cases

경중격 절개방식을 좌심방 상부까지 연장시킨 방법을 통한 승모판막 수술 후 동방 결절 기능부전에 대한 164예 임상분석

  • Ryu Se Min (Department of Thoracic and Cardiovascular Surgery, College of Medicine, Korea University) ;
  • Kim Hyun Koo (Department of Thoracic and Cardiovascular Surgery, College of Medicine, Korea University) ;
  • Cho Yang Hyun (Department of Thoracic and Cardiovascular Surgery, College of Medicine, Korea University) ;
  • Sim Jae Hoon (Department of Thoracic and Cardiovascular Surgery, College of Medicine, Korea University) ;
  • Sohn Young-sang (Department of Thoracic and Cardiovascular Surgery, College of Medicine, Korea University) ;
  • Choi Young Ho (Department of Thoracic and Cardiovascular Surgery, College of Medicine, Korea University) ;
  • Kim Hark Jei (Department of Thoracic and Cardiovascular Surgery, College of Medicine, Korea University)
  • 류세민 (고려대학교 의과대학 흉부외과학교실) ;
  • 김현구 (고려대학교 의과대학 흉부외과학교실) ;
  • 조양현 (고려대학교 의과대학 흉부외과학교실) ;
  • 심재훈 (고려대학교 의과대학 흉부외과학교실) ;
  • 손영상 (고려대학교 의과대학 흉부외과학교실) ;
  • 최영호 (고려대학교 의과대학 흉부외과학교실) ;
  • 김학제 (고려대학교 의과대학 흉부외과학교실)
  • Published : 2005.03.01

Abstract

Extended transseptal approach can provide an excellent view of the mitral valve but the safety of this approach is controversial because this incision requires transaction of the sinus node artery, which in most cases and can result postoperative arrhythmia. The purpose of this study was to evaluate perioperative and longterm conduction disturbances and the cardiac rhythms of patients who underwent an extended transseptal approach for mitral valve surgery. Material and Method: Postoperative cardiac rhythms were analyzed in the 164 consecutive patients who received mitral valve replacements with a extended transseptal approach between March 1992 and July 2003. Result: Of the 84 patients in normal sinus rhythm, 34 ($39\%$) had developed transient junctional rhythm and atrial fibrillation after operation, lasting less than 72 hours in most of cases. No intractable arrhythmias occurred. Most of these arrhythmia were not detected at the time of discharge and only 8 patients ($9\%$) had atrial fibrillation at discharge. Postoperative PR intervals increased for 1 week, then decreased within 2 weeks postoperatively, and returned to normal range by 6 months postoperatively. During the postoperative period, 4 of the 78 patients with preoperative atrial fibrillation developed normal sinus thythm. Conclusion: The post-operative arrhythmias were temporary and showed no significant complications after extended transseptal approach for the mitral valve surgery.

승모판막의 수술에 있어서 확장된 경중격 절개 방식을 좌심방까지 연장시킨 방법에 의한 술식은 시야의 우수성 및 노출이 용이하여 좋은 방법으로 알려져 있으나 동방 결절 동맥의 손상으로 인한 동방 결절 기능 장애와 심방 전도 장애등으로 수술 후 부정맥의 악화가 그 단점으로 제시된다. 이에 비교적 장기간에 걸친 다수의 환자를 대상으로 이 술기의 부정맥에 미치는 영향을 알아보고자 하였다. 대상 및 방법: 1992년부터 2003년까지 고려대학교 구로병원 흉부외과에서 이 술기를 이용하여 승모판막 치환술 및 좌심방 육종을 제거한 164명의 환자를 대상으로 후향적으로 연구하여 수술 후 심장율동에 미치는 영향을 알아보았다. 결과: 158명의 환자가 승모판 치환수술을 받았고 6명은 좌심방 점액종 제거수술을 받았다. 승모판 치환수술을 받은 158명중 71명의 환자가 동시에 대동맥판 치환수술(40명), 삼첨판 성형술(27명), 관상동맥 우회로 조성수술 (2명), 심실중격 결손증 교정수술(2명)등을 받았다. 술 전 동율동이던 86명 중 34명($39\%$)에서 술 후 심방 세동 또는 방실 접합력 율동(junctional arrhyamia)으로 필요한 경우 일시적 심장조율을 시행하였고 이중 8명($9\%$)을 제외하고는 모두 퇴원 전에 정상율동으로 회복되었고, 장기 추적 결과 10명($11\%$)에서 심방 세동을 보였다. 수술 후 1주일까지 PR interval 이 연장됐지만 2주경부터 감소하여 6개월 무렵엔 수술 전 수치로 회복되었다. 수술 전 심방 세동을 보이던 78명의 환자 중 4명이 수술 직후 정상 동조율로 전환되었고 장기 추적결과 3명이 정상 동조율을 보였다. 결론: 화장시킨 경중격 절개방식을 좌심방 상부까지 연장하여 시행한 승모판막 치환술에서 수술 후 동방 결절 동맥의 손상으로 올 수 있는 부정맥은 일시적이며 의의있는 합병증은 없었다.

Keywords

References

  1. Smith CR. Septal-superior exposure of the mitral valve: the transplant approach. J Thorac Cardiovasc Surg 1992;103: 623-8
  2. Masuda M, Tominaga R, Kawachi Y, et al. Postoperative cardiac rhythms with superior septal approach and lateral approach to the mitral valve. Ann Thorac Surg 1996; 62:1118-22 https://doi.org/10.1016/0003-4975(96)00379-7
  3. Takeshita M, Furuse F, Kotsuka Y, Kubota H. Sinus node function after mitral valve surgery via the transseptal superior approach. Eur J Cardiothorac Surg 1997;12:341-4 https://doi.org/10.1016/S1010-7940(97)01202-5
  4. Berreklouw E, Ercan H, Schonberger JP. Combined superior transseptal approach to the left atrium. Ann Thorac Surg 1991;51:293-5 https://doi.org/10.1016/0003-4975(91)90803-X
  5. Guiraudon GM, Ofiesh JG, Kaushik R. Extended vertical transatrial septal approach to the mitral valve. Ann Thorac Surg 1991;52:1058-62 https://doi.org/10.1016/0003-4975(91)91281-Y
  6. Utley JA, Leyland SA, Nguyenduy T. Comparison of outcomes with three atrial incisions for mitral valve operations. Right lateral, superior septal, and transseptal. J Thorac Cardiovasc Surg 1995;109:582-7 https://doi.org/10.1016/S0022-5223(95)70292-X
  7. Kim HJ, Hwang JJ, Shin JS, Joe SJ, Choi YH. Mitral valve operation via extended transseptal approach. Korean J Thorac Cardiovasc Surg 1993;26:909-14
  8. Kim HJ, Hwang JJ, Choi YH, et al. Clinical study of 80 cases of mitral valve operations via extended transseptal approach. Korean J Thorac Cardiovasc Surg 1998;31: 1037-42
  9. Jung SS, Park BR, Lee JS, Yang SS, Lee YH, Kim BC. Mitral valve replacement via an extended transseptal approach. Korean J Thorac Cardiovasc Surg 1995;28:579-82
  10. Na MH, Park SS, Yoon SY, et al. Evaluation on the extended transseptal approach in mitral valvular operations. Korean J Thorac Cardiovasc Surg 1998;31:855-60
  11. Busquet J, Fontan F, Anderson RH, Ho SY, Davis MJ. The surgical significance of the atrial branches of the coronary arteries. Int J Cardiol 1984;6:223-34 https://doi.org/10.1016/0167-5273(84)90357-7
  12. Drago F, Turchetta A, Calzolari A. Early identification of patients at risk for sinus node dysfunction after Mustard operation. Int J Cardiol 1992;35:27-32 https://doi.org/10.1016/0167-5273(92)90051-4
  13. Misawa Y, Fuse K, Kawahito K, Saito T, Konishi H. Conduction disturbances after superior septal approach for mitral valve repair. Ann Thorac Surg 1999;68:1262-5 https://doi.org/10.1016/S0003-4975(99)00666-9
  14. Sealy WC, Bache R, Seaber AV, Bhattacharga SK. The atrial pacemaking site after surgical exclusion of the sinoatrial node. J Thorac Cardiovasc Surg 1973;65:841-50
  15. Berdajs D, Patonay L, Turina MI. The clinical anatomy of the sinus node artery. Ann Thorac Surg 2003;76:732-6 https://doi.org/10.1016/S0003-4975(03)00660-X
  16. Ariswala S, Parikh P, Dixit S, Agney M, Kole S, Saksena D. Combined superior-transseptal approach to the mitral valve. Ann Thorac Surg 1992;53:180-2
  17. Shin H, Higashi S, Iseki H. Superior septal approach for mitral valve surgery. J Jpn Assoc Thorac Surg 1996;44: 111-4
  18. Shin H, Yozu R, Higashi S, Kawada S. Sinus node function after mitral valve surgery using the superior septal approach. Ann Thorac Surg 2001;71:587-90 https://doi.org/10.1016/S0003-4975(00)01945-7
  19. Kumar N, Saad E, Prabhaker G, De Vol E, Duran CMG. Extended transseptal versus conventional left atriotomy: early postoperative study. Ann Thorac Surg 1995;60:426-30 https://doi.org/10.1016/0003-4975(95)00449-U
  20. Alfieri O, Sandrelli L, Pardini A, et al. Optimal exposure of the mitral valve through an extended vertical transseptal approach. Eur J Cardiothorac Surg 1991;5:294-9 https://doi.org/10.1016/1010-7940(91)90038-L
  21. Kon ND, Tucker WY, Mills SA, Lavender SW, Cordell AR. Mitral valve operation via an extended transseptal approach. Ann Thorac Surg 1993;55:1413-7 https://doi.org/10.1016/0003-4975(93)91081-W
  22. Smith CR. In discussion of Misawa Y, Fuse K, Kawahito K, Saito T, Konishi H. Conduction disturbances after superior septal approach for mitral valve repair. Ann Thorac Surg 1999;68:1262-5 https://doi.org/10.1016/S0003-4975(99)00666-9