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Background <p>The superior septal approach (SSA) was developed to improve mitral valve exposure during surgery, particularly in patients with complex anatomy. However, concerns regarding prolonged operative times and rhythm disturbances have limited its widespread adoption. This systematic review and meta-analysis aimed to compare SSA with conventional left atriotomy (CLA) in terms of perioperative outcomes, complications, rhythm disturbances, and mortality.</p> Methods <p>A systematic search of PubMed, Scopus, and Web of Science was performed up to August 2025 according to PRISMA guidelines. Outcomes assessed included postoperative cardiac rhythm outcomes (primary outcomes), perioperative metrics (secondary outcomes) -including pacemaker implantation, cardiopulmonary bypass (CPB) and cross-clamp times, intensive care unit (ICU) stay, and hospital stay, and complications (safety outcomes). Pooled risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CI) were calculated using a random-effects model.</p> Results <p>A total of 12 cohort studies were included. Postoperative sinus rhythm (RR = 0.86, 95% CI 0.71–1.04) and atrial fibrillation (AF) (RR = 1.12, 95% CI 0.83–1.49) did not differ between SSA and CLA; junctional rhythm and complete atrioventricular block (AVB) were also comparable. Within-group (pre–post) analyses showed sinus rhythm increased after both techniques, more with SSA (RR = 1.36) than CLA (RR = 1.20), while AF changes were non-significant. Meta-regression indicated more recent publication year and higher repair (vs. replacement) proportion were associated with greater sinus rhythm benefit favoring SSA. Secondary outcomes were similar overall; pacemaker implantation was borderline higher after SSA and became significant in sensitivity analysis. Safety endpoints were also comparable between approaches.</p> Conclusion <p>The SSA provides equivalent perioperative efficiency and clinical safety compared with CLA in mitral valve surgery. Concerns about rhythm disturbances and operative burden are not supported by pooled evidence, suggesting that SSA remains a safe and valuable option, particularly in cases requiring enhanced exposure. Further high-quality prospective studies are warranted to define long-term outcomes and refine patient selection.</p>

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Is the superior septal approach a safe alternative to conventional left atriotomy for mitral valve surgery? Evidence from a systematic review and meta-analysis

  • 期刊论文

  • 出版模式：

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  • 发表日期：

    2025年12月5日

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  • Alaa Maali,
  • Harald Hausmann,
  • Robert Flieger,
  • Mostafa Hossam El Din Moawad,
  • Mohamed Ismail,
  • Abdelrahman M. Elettreby,
  • Hamza A. Abdul-Hafez,
  • Osama Bisht

摘要

Background

The superior septal approach (SSA) was developed to improve mitral valve exposure during surgery, particularly in patients with complex anatomy. However, concerns regarding prolonged operative times and rhythm disturbances have limited its widespread adoption. This systematic review and meta-analysis aimed to compare SSA with conventional left atriotomy (CLA) in terms of perioperative outcomes, complications, rhythm disturbances, and mortality.

Methods

A systematic search of PubMed, Scopus, and Web of Science was performed up to August 2025 according to PRISMA guidelines. Outcomes assessed included postoperative cardiac rhythm outcomes (primary outcomes), perioperative metrics (secondary outcomes) -including pacemaker implantation, cardiopulmonary bypass (CPB) and cross-clamp times, intensive care unit (ICU) stay, and hospital stay, and complications (safety outcomes). Pooled risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CI) were calculated using a random-effects model.

Results

A total of 12 cohort studies were included. Postoperative sinus rhythm (RR = 0.86, 95% CI 0.71–1.04) and atrial fibrillation (AF) (RR = 1.12, 95% CI 0.83–1.49) did not differ between SSA and CLA; junctional rhythm and complete atrioventricular block (AVB) were also comparable. Within-group (pre–post) analyses showed sinus rhythm increased after both techniques, more with SSA (RR = 1.36) than CLA (RR = 1.20), while AF changes were non-significant. Meta-regression indicated more recent publication year and higher repair (vs. replacement) proportion were associated with greater sinus rhythm benefit favoring SSA. Secondary outcomes were similar overall; pacemaker implantation was borderline higher after SSA and became significant in sensitivity analysis. Safety endpoints were also comparable between approaches.

Conclusion

The SSA provides equivalent perioperative efficiency and clinical safety compared with CLA in mitral valve surgery. Concerns about rhythm disturbances and operative burden are not supported by pooled evidence, suggesting that SSA remains a safe and valuable option, particularly in cases requiring enhanced exposure. Further high-quality prospective studies are warranted to define long-term outcomes and refine patient selection.