Limited transseptal approach to the mitral valve: a practical step-by-step surgical tutorial

The mitral valve is conventionally accessed through a left atriotomy; however, adequate visualization may be challenging in selected patients, particularly those undergoing redo surgery, minimally invasive procedures, or with a small or non-compliant left atrium. In such cases, a transseptal interatrial approach can provide improved exposure of the mitral apparatus while facilitating concomitant tricuspid valve procedures. The limited transseptal (LTS) approach represents a partial, anatomy-preserving modification of the classic extended vertical transatrial septal incision. By confining the septal incision to the region of the fossa ovalis, and avoiding superior extension toward the atrial roof, this technique provides sufficient mitral valve exposure while minimizing the risk of injury to the sinus node artery and atrial conduction tissue. Alternative strategies, including the superior transseptal approach and the extended vertical transseptal incision have been associated with a higher incidence of atrial conduction disturbances and postoperative pacing requirements. In contrast, the LTS approach preserves atrial anatomy and reduces surgical trauma while maintaining excellent access to both atrioventricular valves. This video tutorial outlines the anatomical principles, indications and step-by-step surgical technique of the LTS approach, highlighting technical pearls and potential pitfalls to facilitate its safe and reproducible application in contemporary mitral valve surgery.