Approach for primary mitral valve surgery: right anterolateral thoracotomy or median sternotomy

Although both right anterolateral thoracotomy and median sternotomy have been used for mitral valve surgery (repair/replacement), the latter approach is considered standard for primary mitral valve surgery. We hypothesized that primary mitral valve surgery, if performed through a right anterolateral thoracotomy, would not only be better accepted cosmetically by patients, but also make redo surgery through a median sternotomy easy and trouble free from re-entry bleeding.

A right anterolateral thoracotomy was used for primary mitral valve surgeries in 52 patients (group A; 22 males, 30 females) of mean age 30.3 +/- 09.14 years (range: 14 to 50 years). Equal numbers of cases operated on during the same period by via median sternotomy were selected retrospectively from hospital records to serve as controls (group B). Groups were matched with respect to age, body weight, body surface area, sex, cardiac rhythm, functional status, type of mitral valve pathology and associated lesions.

Operative mortality was similar in both groups, but fewer postoperative complications occurred in group A. Total hospital stay, intensive care unit stay, postoperative bleeding, inotrope requirement and ventilatory support postoperatively was significantly less in group A.

Right anterolateral thoracotomy provides excellent exposure of the mitral valve, even with a small left atrium, and offers a better cosmetic lateral scar which is less prone to keloid formation. In addition, right anterolateral thoracotomy is as safe as median sternotomy for primary mitral valve repair/replacement, and should be used as an initial approach to mitral valve surgery, while median sternotomy be kept for repeat mitral valve or other open-heart surgery required later in life.