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J Thorac Cardiovasc Surg 2003;126:287-288
© 2003 The American Association for Thoracic Surgery

Brief communication

A self-retaining retractor for the maze procedure

A. Marc Gillinov, MDa,*

a Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA

Received for publication September 17, 2002; accepted for publication September 24, 2002.

* Address for reprints: A. Marc Gillinov, MD, Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation/F25, 9500 Euclid Ave, Cleveland, OH 44195, USA
gillinom{at}ccf.org

Most surgical approaches for cure of atrial fibrillation require exposure of the pulmonary vein orifices and the posterior left atrium. Visualization of the left pulmonary veins and posterior left atrium is challenging, particularly in patients with left atrial enlargement. The maze procedure includes incisions that isolate the pulmonary veins, excise the left atrial appendage, and connect the pulmonary vein encircling incision to the mitral annulus.1 Recent modifications of the maze procedure recreate some or all of these lesions by using alternative energy sources that include microwave, radiofrequency, cryothermy, and laser sources.2,3 A new set of specially designed atrial retractor blades that affix to a standard sternal retractor attachment4 was designed to expose the pulmonary vein orifices and the posterior left atrium (Kapp Surgical, Cleveland, Ohio, and Medtronic, Inc, Minneapolis, Minn).

Technique

After median sternotomy, the patient is started on cardiopulmonary bypass, and the heart is arrested with cold blood cardioplegia. A standard lateral left atriotomy is constructed after dissection of the interatrial groove. The posterior left atrium is exposed by means of placement of 2 retractor blades that are affixed to the bar of a standard self-retaining mitral valve retractor (Figure 1).



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  		Figure 1. The left atrial blades affix to a standard sternal retractor attachment used for mitral valve surgery. Reprinted with the permission of The Cleveland Clinic Foundation.

 
The deeper blade is placed such that its leading edge is adjacent to the posterior mitral annulus; the blade is malleable and can be bent to obtain optimal exposure. This blade distracts the mitral valve toward the patient’s left, thereby exposing the orifices of the left pulmonary veins (Figure 2). A shorter angled blade is then positioned cephalad to the first blade. This blade retracts the superior portion of the left atrium, exposing the left superior pulmonary vein and the left atrial appendage. In a particularly large left atrium, the superior blade can be placed over the orifice of the left atrial appendage to expose the orifice of the left superior pulmonary vein. The left atrial portion of the operation is then completed.



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  		Figure 2. A malleable retractor blade distracts the mitral valve toward the patient’s left, thereby exposing the left pulmonary vein orifices. A second shorter blade retracts the superior portion of the left atriotomy, improving exposure of the left superior pulmonary vein and the left atrial appendage. Reprinted with the permission of The Cleveland Clinic Foundation.

 
From April 2002 through August 2002, this retractor system was used to perform 35 operations to treat atrial fibrillation. The malleable blades were easily adjusted to accommodate variability in left atrial size and orientation of the pulmonary veins.

Comment

Development of new operative procedures has caused a resurgence in the surgical treatment of atrial fibrillation. Like the Cox maze procedure, these new operations generally include isolation of the pulmonary veins and excision of the left atrial appendage. Exposure of these structures, particularly in a large left atrium, is challenging.

A series of new atrial retractor blades (Kapp Surgical Inc, Cleveland, Ohio) provides exposure of the posterior left atrium and pulmonary vein orifices. These blades, which are malleable and universally adjustable, attach to a standard mitral valve retractor. This system provides excellent and consistent exposure of the posterior left atrium and pulmonary veins without the need for surgical assistance, facilitating operations for atrial fibrillation.

Footnotes

The Cleveland Clinic Foundation has entered into a licensing agreement with Kapp Surgical, Inc.

References

  1. Cox JL, Ad N, Palazzo T, et al. Current status of the maze procedure of the treatment of atrial fibrillation. Semin Thorac Cardiovasc Surg. 2000;12:15–19[Medline]
  2. Gillinov A.M., Smedira N.G., Cosgrove D.M. Microwave ablation of atrial fibrillation during mitral valve surgery. Ann Thorac Surg. 2002;74:1259-61
  3. Gillinov A.M., Blackstone E.H., McCarthy P.M., Atrial fibrillation: current surgical options and their assessment. Ann Thorac Surg. 2002;74:2210-7
  4. Cosgrove DM. A self-retaining retractor for mitral valve operations. J Thorac Cardiovasc Surg. 1986;92:305–306[Abstract]




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