title: Comparative endoscopic anatomic description of the mitral valvular complex: a cadaveric study.
abstract: BACKGROUND
  We compared the aortic, left atrial, and apical approaches to visualize the mitral valve with the goal to investigate the endoscopic anatomy and give exact step-by-step descriptions of these views.
  
  
  METHODS
  The mitral valvular complex of human cadaveric fresh hearts was investigated from three approaches using 0, 30, and 70 degrees rigid endoscopic optics. In 30 cases after the removal of the hearts, the endoscopes were introduced directly into the aortic root through an aortotomy, left atrium through a standard atriotomy, and apex of the heart through a transmural incision. In 10 cases, the in situ visualization was performed using standard surgical approaches, such as partial upper ministernotomy, right and left minithoracotomy. The investigation was performed first with the mitral valve open, then the left ventricle was filled with saline, and the valve was closed by clamping the aorta.
  
  
  RESULTS
  For the visualization of ventricular surfaces of the mitral leaflets and the subvalvular apparatus, the apical approach was most optimal. The aortic approach had limitations at the posterior leaflet. Using the atrial approach, we did not obtain any direct visual information about the subvalvular apparatus with the valve closed. The atrial surfaces of the leaflets were best visible using both the atrial and apical approaches with the mitral valve open. In the case of a closed valve, the apical approach did not allow for an investigation of the atrial surfaces. The aortic approach was useful to visualize the atrial surface of the posterior leaflet with an opened valve.
  
  
  CONCLUSIONS
  In mitral valve repairs through the left atrium, an additional aortic or apical view could be useful to obtain functional information about the subvalvular apparatus by the sealing probe.
authors.affiliation: Department of Cardiac Surgery, Sana Cardiac Surgery Stuttgart GmbH, Stuttgart, Germany.
authors.forename: Tamas
authors.initials: T
authors.lastname: Ruttkay
authors.affiliation: Department of Anatomy, Histology and Embryology, Laboratory for Applied and Clinical Anatomy, Semmelweis University, Budapest, Hungary.
authors.forename: Gabor
authors.initials: G
authors.lastname: Baksa
authors.affiliation: Department of Cardiac Surgery, Sana Cardiac Surgery Stuttgart GmbH, Stuttgart, Germany.
authors.forename: Julia
authors.initials: J
authors.lastname: Gotte
authors.affiliation: 2nd Department of Pathology, Semmelweis University, Budapest, Hungary.
authors.forename: Tibor
authors.initials: T
authors.lastname: Glasz
authors.affiliation: Department of Anatomy, Histology and Embryology, Laboratory for Applied and Clinical Anatomy, Semmelweis University, Budapest, Hungary.
authors.forename: Lajos
authors.initials: L
authors.lastname: Patonay
authors.affiliation: Department of Cardiac and Vascular Surgery, University of Debrecen, Debrecen, Hungary.
authors.forename: Zoltan
authors.initials: Z
authors.lastname: Galajda
authors.affiliation: Department of Cardiac Surgery, Sana Cardiac Surgery Stuttgart GmbH, Stuttgart, Germany.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Doll
authors.affiliation: Department of Cardiac Surgery, Sana Cardiac Surgery Stuttgart GmbH, Stuttgart, Germany.
authors.forename: Markus
authors.initials: M
authors.lastname: Czesla
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001011:Aorta / Q000601:surgery; D004724:Endoscopy; D005260:Female; D006325:Heart Atria / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000033:anatomy & histology*