Intervencionismo coronario en la oclusión iatrogénica de circunfleja tras anuloplastia mitral

Circumflex Coronary Artery Injury during Modern Mitral Valve Surgery-A Review of Current Concepts and Perspectives

The devastating impact of a circumflex coronary artery (CX) injury during mitral valve (MV) surgery is well reported. Despite significant improvements in preoperative risk assessment, intraoperative diagnosis and perioperative treatment strategies of CX injury during MV surgery, recent reports re-emphasize the variability in presentation, the unpredictable mechanisms of injury and the conflicting evidence regarding perioperative management. The progressive transition from conventional sternotomy access to minimally invasive surgical and transcatheter (TC) interventions for MV disease are associated with significant learning curves and require additional single-shaft and robotic console suture manipulation skills with special attentiveness to the potential risk of CX injury. The introduction of hybrid theatres that facilitate single stage surgical and TC interventions also provides new intraoperative diagnostic and therapeutic options without transporting unstable patients for percutaneous coronary intervention (PCI) assessment. By utilizing a MeSH terms-based PubMed search, a total of 89 patients with CX injury that occurred during MV surgery was identified from 49 reports between 1967 and 2022. MV surgery was performed by conventional sternotomy (n = 76, 85.4%), endoscopic (n = 12, 13.4%) and robotic access (n = 1, 1.1%), with 35 injuries (39.3%) resulting in total CX occlusion. Rescue PCI was utilized in 40 patients (44.9%). This manuscript provides a systematic overview of all available historic and contemporary reports on CX injury during MV surgery, outlines recent refinements in CX injury mechanisms, describes current MV surgery associated CX injury prevention and diagnosis and treatment strategies and highlights important MV procedural aspects that may minimize the risk and consequences of CX injury.

Percutaneous treatment of left circumflex coronary artery injury related to mitral valve surgery: Case series and systematic review of the literature

Left circumflex coronary artery (LCx) injury related to mitral valve surgery is a rare complication. The best treatment option is not defined, and percutaneous coronary intervention (PCI) may represent an effective treatment to avoid prolonged myocardial ischemia. To evaluate feasibility and efficacy of PCI treatment, all records of LCx injury related to mitral valve surgery and treated with PCI were included after a systematic PubMed searching. Moreover, we retrospectively analyzed our single-center PCI database and patients fulfilling the inclusion criteria were included. Patients undergoing transcatheter mitral valve intervention, non-mitral valve surgery, conservatively or surgically treated after LCx injury were excluded. Data about patient characteristics, procedural details, PCI success, and in-hospital mortality were collected. Fifty-six patients were included, 58.9% were male (n = 33) and the median age was 60.5 years (IQR = 21.75). The majority had left dominant or codominant coronary system (62.2%, n = 28 and 15.6%, n = 7, respectively). Clinical manifestations ranged from hemodynamic stability (21.1%, n = 8) to hemodynamic instability (42.1%, n = 16) and cardiac arrest (18.4%, n = 7). On ECG, 23.5% of patients (n = 12) presented ST-segment depression, 58.8% (n = 30) ST-segment elevation, 7.8% (n = 4) atrioventricular block, and 29.4% (n = 15) ventricular arrhythmias. Left ventricle dysfunction was present in 52.3% (n = 22) of patients and wall motion abnormalities in 71.4% (n = 30). PCI success rate was 82.1% (n = 46) and in-hospital mortality 4.5% (n = 2). LCx injury related to mitral surgery is a rare complication characterized by an increased risk of mortality. PCI seems a feasible treatment option, still burdened by suboptimal results, probably related to the technical challenges posed by the surgical failure.

Iatrogenic left circumflex coronary occlusion following mitral valve replacement surgery: A case report

Injury to epicardial coronary arteries following mitral valve replacement surgery, albeit rare, could have fatal complications. In this case, we suggest conservative medical treatment as a safe approach in patients who are not suitable to undergo revascularization.

How far is the left circumflex coronary artery from the mitral annulus?

INTRODUCTION

The relationship between the distance from the mitral annulus to the left circumflex coronary artery (LCX) and iatrogenic LCX injury has been questioned. This study was designed to determine the high-risk sites of LCX injury with an anatomical approach using multiple detector-computed tomography (MDCT) scanning taken before mitral valve annuloplasty (MVA). The purpose of this study is to prevent LCX injury in patients unable to receive MDCT before mitral valve surgery.

METHODS

In 2018, we performed MVA on 59 patients, 52 of whom had undergone preoperative MDCT scanning. We retrospectively analyzed the MDCT images of these 52 patients and measured the shortest distance from the mitral annulus to the LCX in three dimensions. Also, we divided the mitral annulus into 12 clockwise areas (A0-A11) to identify the exact location.

RESULTS

The site of closest proximity and their numbers of patients were as follows: A6, 1 patient; A8, 2 patients; A9, 32 patients; and A10, 17 patients. Nine (17.3%) of the 52 patients had the shortest distance of less than 2 mm. The shortest distance according to the dominance of coronary artery showed no significant difference (p = 0.81).

CONCLUSION

The site of closest proximity from the mitral annulus to the LCX was concentrated on the A8 to A10 areas and it is an interesting result that as many as 17% of patients have their coronary arteries less than 2 mm away from the annulus.

Mitral valve annulus and circumflex artery: In vivo study of anatomical zones

Objective

To provide, with the use of preoperative coronary computed tomography angiography, an in vivo anatomical characterization of the relationship between the circumflex artery and mitral valve annulus to identify different risk classes and to increase the surgical awareness of those anatomical relations.

Methods

Ninety-five (mean age: 64.2 ± 11.7) consecutive patients, initially referred for elective minimally invasive mitral valve surgery, underwent preoperative coronary computed tomography angiography. The distance between the circumflex artery and mitral annulus was assessed using 6 points designed on the posterior mitral annulus, starting from the anterolateral to the posteromedial commissure; this design created an ideal 5-zone system. High-risk anatomy was defined as a distance less than 3 mm between the circumflex artery and the mitral valve annulus.

Results

The shortest distance between the circumflex artery and mitral valve annulus was observed at the area between the anterolateral commissure and the midpoint of P1 scallop, so-called zone 1 (5.49 ± 3.13 mm), whereas the longest distance occurred at zone 5 (12.03 ± 4.93). Twenty-four patients (25%) were identified with high-risk anatomy (mean distance 1.94 ± 0.8 mm). Left dominant and co-dominant hearts demonstrated a shorter circumflex artery-mitral valve annulus distance at all the zones. At multinomial logistic regression, the pattern of coronary dominance and the size of the circumflex artery were independent factors for high-risk anatomy.

Conclusions

Coronary computed tomography angiography is a useful investigation to identify patients at risk of circumflex artery flow disturbance; for high-risk anatomy, this knowledge may enhance a safer operative technique.

Acute Circumflex Occlusion After a Successful Mitral Valve Repair

We herein present an interesting case of acute iatrogenic coronary artery occlusion after a successful mini mitral valve repair in a young patient with Barlow's disease. It was successfully managed with percutaneous coronary intervention. This is a well-recognized complication of mitral valve surgery and is often misdiagnosed or late recognized. Implementation of non-invasive and intracoronary imaging is pivotal in-patient management.

Mitral Valve Repair and Anomalous Origin of Circumflex Artery: To Ring or Not to Ring

We describe a case of an adult patient with mitral valve regurgitation and the anomalous origin and course of the left circumflex coronary artery. Use of a ringless procedure or a microinvasive approach, such as transapical neochordae implantation, would have possibly avoided a life-threatening post-operative complication. (Level of Difficulty: Advanced.).

Left circumflex artery injury postmitral valve surgery, single center experience

The left circumflex (LCX) artery is located close to the mitral valve (MV), making it susceptible to injury during MV surgery. We are reporting our experience in the diagnosis and management of this complication. We retrospectively reviewed our surgical and coronary angiography databases for patients with documented LCX artery injury during MV surgery between January 2000 and December 2016. The complication was associated with MV replacement (9/1313, 0.7%) but not MV repair (0/393, 0.0%). Eight patients (88.9%) were female and the mean age was 40.4 ± 14.2 years. There was roughly similar distribution of left and right dominant coronary circulations (5 and 4 patients, respectively). Eight patients (88.9%) had ischemic changes on electrocardiogram and ventricular arrhythmias were documented on six patients (66.7%). Three patients (33.3%) were treated with percutaneous coronary intervention while six patients (66.7%) required redo surgery to graft the LCX artery. The 30-day mortality was high (33.3%). A high index of suspicion is required to diagnose this injury. At the moment, no consensus is available on the optimal treatment strategy. We propose percutaneous approach as the first option to spare the patients from undergoing open-heart surgery for the second time.

Circumflex coronary artery injury after mitral valve surgery: A report of four cases and comprehensive review of the literature

As the LCx is closely related to the mitral valve annulus, it is susceptible to perioperative injury. Various underlying mechanisms, predisposing factors, and therapeutic strategies have been suggested but disagreement exists. Using a MeSH terms-based PubMed search, 44 cases of mitral valve surgery-related LCx injury were detected, including our 4 cases. We provide a comprehensive review of current knowledge regarding mitral valve surgery-related left circumflex coronary artery (LCx) injury. Preoperative coronary angiography was performed in 55% (n = 24). Coronary abnormalities were present in 11% (n = 5). Coronary dominance was reported in 73% (n = 32), predominantly showing left (69%, n = 22) or balanced (19%, n = 6) circulations. Right coronary dominance was present in 12% (n = 4). Ischemia was detected in the perioperative or early postoperative phase in 86% (n = 30). Delayed symptoms were present in 14% (n = 5). Echocardiography demonstrated new regional wall motion abnormalities in 80% (n = 24), but was negative in 20% (n = 6) despite coronary compromise. Electrocardiography showed myocardial ischemia in 97% (n = 34), including regional ST-segment elevations in 68% (n = 23). Primary treatment was surgical in 42% (n = 15) and percutaneous in 58% (n = 21), reporting success ratios of 87% (n = 13) and 81% (n = 17), respectively. We confirm an augmented risk of mitral valve surgery-related LCx injury in balanced or left-dominant coronary circulations. Preoperative knowledge of coronary anatomy does not preclude LCx injury. An anomalous LCx arising from the right coronary cusp was identified as a possible specific high-risk entity. Electrocardiographic monitoring and intraoperative echocardiography remain paramount to ensure a timely diagnosis and treatment. © 2016 Wiley Periodicals, Inc.

Anomalous Origin of the Circumflex Artery: An Underestimated Threat During Mitral Valve Operation

Ischemic iatrogenic lesions can complicate surgical procedures on the mitral valve. One of the causative mechanisms is direct injury to or distortion of the circumflex coronary artery. The risk of damaging the circumflex coronary artery depends mainly on the proximity of that vessel to the posterior segment of the mitral annulus, and this varies from patient to patient. Herein, we report the case of an iatrogenic circumflex coronary artery lesion after mitral annuloplasty in a patient with an anomalous origin of the circumflex artery.

Morphometric study of the human mitral annulus: guide for mitral valve surgery

BACKGROUND

during mitral valve surgery, it is important for surgeons to understand the anatomy of the mitral valve annulus to prevent surgical complications. This study aimed to perform morphometry of the mitral annulus to facilitate secure suturing during ring annuloplasty or replacement of the mitral valve.

METHODS

an anatomical study was carried out on 7 human hearts. We divided the mitral valve annulus into sections containing 8 different points. It was noted that the annulus was a complex structure which has fibrous continuity with the mitral leaflets, and with or without the aortic annulus.

RESULTS

there was always a segment of the annular fibrous structure which was facing directly toward the left ventricular cavity. The length of the segment ranged from 1.0 to 3.4 mm. In terms of the size of the annulus, there were large variations within the subject and among the subjects. The shortest distance between the mitral annulus and left circumflex coronary artery was at the anterolateral commissure, and the length was 3.3 mm.

CONCLUSION

this study has improved understanding of the anatomy of the mitral annulus, which could help surgeons to avoid operative complications. Based on this study, several suggestions are made for placing sutures for mitral valve replacement and mitral ring annuloplasty.