Skip to main content

Advertisement

SpringerLink
Log in

Ectopic atrial rhythm after superior septal approach to the mitral valve — an often under-reported entity

  • Original Article
  • Published:
Indian Journal of Thoracic and Cardiovascular Surgery Aims and scope Submit manuscript

Abstract

Purpose

Very few reports elaborate on the changes in P wave following superior septal approach to the mitral valve. We aimed to describe the changes in the P wave axis and other electrocardiographic changes following this approach among patients preoperatively in sinus rhythm.

Methods

We did a retrospective review of medical records among all our patients undergoing superior septal approach for mitral valve surgery from September 2014 to September 2019. Electrocardiograms during hospital stay and until 6-month follow-up were analyzed. A deviation in P wave axis from the normal range of + 30 to + 60° was classified as ectopic atrial rhythm.

Results

In the study population of 47 patients (age 16–75 years, 51.3 ± 13.6 years; M:F ratio 3.7:1), who were in normal sinus rhythm preoperatively, 34 patients (72.3%) had a visible P wave on electrocardiogram (ECG) at discharge. Among them, the P wave axes of 17 patients (36.2%) were within normal range (normal sinus rhythm), whereas 17 patients (36.2%) had ectopic atrial rhythm at discharge. The most frequent abnormal P wave axis was between 0 and − 30° (12 patients). At 6 months, 8 patients (17.0%) had a persistent ectopic atrial rhythm. These patients underwent a Holter test at 6 months and were followed up for symptomatic bradycardia for 3 years. None of the patients with ectopic atrial rhythm required pacemaker insertion.

Conclusion

Persistence of ectopic atrial rhythm at 6 months is common (17%) after superior septal approach. Documentation of P wave axis after this approach will help avoid missing it. These patients may be kept on follow-up to look for symptomatic bradycardia.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

Data Availability

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request, after permission from Sree Chitra Tirunal institute of Medical Sciences, Thiruvananthapuram, India.

References

  1. Alfieri O, Sandrelli L, Pardini A, Fucci C, Zogno M, Ferrari M, Caradonna E. Optimal exposure of the mitral valve through an extended vertical transeptal approach. Eur J Cardiothorac Surg. 1991;5:294–9.

    Article  CAS  PubMed  Google Scholar 

  2. Takeshita M, Furuse A, Kotsuka Y, Kubota H. Sinus node function after mitral valve surgery via the transseptal superior approach. Eur J Cardiothorac Surg. 1997;12:341–4.

    Article  CAS  PubMed  Google Scholar 

  3. Gaudino M, Alessandrini F, Glieca F, Martinelli L, Santarelli P, Bruno P, et al. Conventional left atrial versus superior septal approach for mitral valve replacement. Ann Thorac Surg. 1997;63:1123–7.

    Article  CAS  PubMed  Google Scholar 

  4. Boulemden A, Nadarajah D, Szafranek A, Richens D. Atrial approaches to the mitral valve: is there a difference in postoperative rhythm disturbance and permanent pacemaker implantation? Interact Cardiovasc Thorac Surg. 2018;27:536–42.

    Article  PubMed  Google Scholar 

  5. García-Villarreal OA, González-Oviedo R, Rodríguez-González H, Martínez-Chapa HD. Superior septal approach for mitral valve surgery: a word of caution. Eur J Cardiothorac Surg. 2003;24:862–7.

    Article  PubMed  Google Scholar 

  6. Aydin E, Arslan A, Ozkokeli M. Comparison of superior septal approach with left atriotomy in mitral valve surgery. Rev Bras Cir Cardiovasc. 2014;29:367–73.

    PubMed  PubMed Central  Google Scholar 

  7. Utley JR, 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.

    Article  CAS  PubMed  Google Scholar 

  8. Smith CR. Septal-superior exposure of the mitral valve: the transplant approach. J Thorac Cardiovasc Surg. 1992;103:623–8.

    Article  CAS  PubMed  Google Scholar 

  9. Guiraudon GM, Ofiesh JG, Kaushik R. Extended vertical transatrial septal approach to the mitral valve. Ann Thorac Surg. 1991;52:1058–60.

    Article  CAS  PubMed  Google Scholar 

  10. Nguyen HU. Improved combined superior-transseptal approach to the mitral valve. Asian Cardiovasc Thorac Ann. 2009;17:171–4.

    Article  PubMed  Google Scholar 

  11. Berreklouw E, Ercan H, Schönberger JP. Combined superior-transseptal approach to the left atrium. Ann Thorac Surg. 1991;51:293–5.

    Article  CAS  PubMed  Google Scholar 

  12. Sealy WC, Bache RJ, Seaber AV, Bhattacharga SK. The atrial pacemaking site after surgical exclusion of the sinoatrial node. J Thorac Cardiovasc Surg. 1973;65:841–50.

    Article  CAS  PubMed  Google Scholar 

  13. Lazzeroni D, Bini M, Camaiora U, Castiglioni P, Moderato L, Ugolotti PT, et al. Predictive role of P-wave axis abnormalities in secondary cardiovascular prevention. Eur J Prev Cardiol. 2017;24:1994–9.

    Article  PubMed  Google Scholar 

  14. 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.

    Article  CAS  PubMed  Google Scholar 

  15. Masiello P, Triumbari F, Leone R, Itri F, Del Negro G, Di Benedetto G. Extended vertical transseptal approach versus conventional left atriotomy for mitral valve surgery. J Heart Valve Dis. 1999;8:440–4.

    CAS  PubMed  Google Scholar 

  16. Kumar N, Saad E, Prabhakar G, De Vol E, Duran CM. Extended transseptal versus conventional left atriotomy: early postoperative study. Ann Thorac Surg. 1995;60:426–30.

    Article  CAS  PubMed  Google Scholar 

  17. Tenpaku H, Wariishi S, Kanemitsu N, Okabe M, Nakamura T. Combined superior-transseptal approach versus conventional approach for mitral valve surgery. Jpn J Thorac Cardiovasc Surg. 2000;48:688–92.

    Article  CAS  PubMed  Google Scholar 

  18. 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.

    Article  CAS  PubMed  Google Scholar 

  19. Lukac P, Hjortdal VE, Pedersen AK, Mortensen PT, Jensen HK, Hansen PS. Superior transseptal approach to mitral valve is associated with a higher need for pacemaker implantation than the left atrial approach. Ann Thorac Surg. 2007;83:77–82.

    Article  PubMed  Google Scholar 

  20. Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, et al. 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay: executive summary: a report of the American college of cardiology/American heart association task force on clinical practice guidelines, and the heart rhythm society. Circulation. 2019;140:e333–81.

    PubMed  Google Scholar 

Download references

Acknowledgements

Dr Biju Soman MD, Dr Gurpreet Singh MD, Dr Biju George MD, Dr Vincy Sabu MD, Jayakumar, for help with statistical analysis.

Funding

None.

Author information

Authors and Affiliations

  1. Department of Cardiovascular and Thoracic Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India, 695011

    Atul Abraham, Varghese Thomas Panicker & Jayakumar Karunakaran

  2. Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India, 695011

    Krishna Kumar Mohanan Nair

Authors
  1. Atul Abraham
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Varghese Thomas Panicker
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Krishna Kumar Mohanan Nair
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jayakumar Karunakaran
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Atul Abraham. The first draft of the manuscript was written by Atul Abraham and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Atul Abraham.

Ethics declarations

Ethics approval

Approval was obtained from the Ethics Committee at SCTIMST, which waived the need for patient consent.

Informed Consent

Waived off by the Ethics Committee as no patient identifying material was used.

Statement on human and animal rights

There was no infringement of human or animal rights in this study.

Conflict of interest

The authors have no competing interests to declare that are relevant to the contents of this article.

Additional information

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Abraham, A., Panicker, V.T., Mohanan Nair, K.K. et al. Ectopic atrial rhythm after superior septal approach to the mitral valve — an often under-reported entity. Indian J Thorac Cardiovasc Surg 39, 340–349 (2023). https://doi.org/10.1007/s12055-022-01471-7

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12055-022-01471-7

Keywords

Search

Navigation