title: Revisiting the dome approach for partial sternotomy/minimally invasive mitral valve surgery.
abstract: BACKGROUND
  When partial upper sternotomy is used for minimal access mitral valve surgery, the valve is usually approached through an extended transseptal incision. Limiting the left atrial incision to the dome offers adequate visualization of the mitral valve for standard repairs or replacement. We describe the surgical technique and early experience with this dome approach.
  
  
  METHODS
  Forty-two patients had minimally invasive mitral valve surgery through partial upper sternotomy and incision in the left atrial dome. Surgical technique, operative findings, echocardiographic results, and complications are reported.
  
  
  RESULTS
  In all cases, the operation was completed without extending the sternotomy or atrial incision. Thirty patients (71%) underwent valve repair and 12 (29%) valve replacement. Repair techniques included ring anuloplasty, quadrangular posterior leaflet resection with or without sliding repair, commissural closure, and Alfieri repair. One patient had post-repair severe systolic anterior motion of the anterior mitral leaflet and underwent valve replacement. Thirty-nine had no or trivial mitral regurgitation and no systolic anterior motion; 3 had 1+ mitral regurgitation after repair. Six had concomitant aortic or tricuspid valve repair/replacement. There were no operative deaths. Two patients underwent reoperation for bleeding. Seven (17%) had postoperative bradycardia requiring temporary pacing, and 1 (2.4%) required permanent pacemaker insertion.
  
  
  CONCLUSIONS
  Combined with partial upper sternotomy, the left atrial dome incision offers adequate exposure of the mitral valve for standard procedures. This approach rarely divides the sinus node artery and is easy and fast to use.
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio 44195, USA.
authors.forename: Sherard
authors.initials: S
authors.lastname: Little
authors.forename: Michael
authors.initials: M
authors.lastname: Flynn
authors.forename: Gösta B
authors.initials: GB
authors.lastname: Pettersson
authors.forename: A Marc
authors.initials: AM
authors.lastname: Gillinov
authors.forename: Eugene H
authors.initials: EH
authors.lastname: Blackstone
mesh_terms: D000328:Adult; D000368:Aged; D006348:Cardiac Surgical Procedures / Q000379:methods; D005260:Female; D006325:Heart Atria / Q000601:surgery; D006349:Heart Valve Diseases / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D008943:Mitral Valve / Q000601:surgery*; D013249:Sternum / Q000601:surgery