Intraoperative Assessment of Circumflex Artery Occlusion During Mitral Valve Operation

Abstract

Suture injury of the circumflex coronary artery (CX) and infarction are considered a major complication after a mitral valve operation [1Virmani R. Chun P.K. Parker J. McAllister Jr, H.A. Suture obliteration of the circumflex coronary artery in three patients undergoing mitral valve operation Role of left dominant or codominant coronary artery.J Thorac Cardiovasc Surg. 1982; 84: 773-778PubMed Google Scholar]. Herein we present a procedure that illustrates the opportunity of direct intraoperative coronary angiography in the hand of the cardiac surgeon for immediate reaction without time delay and myocardial ischemia.A 62-year-old woman with symptomatic aortic and mitral valve stenosis was referred to our institution for a double-valve operation. Coronary angiography revealed no lesions. Through a median sternotomy, the massively calcified mitral valve was replaced with a mechanical prosthesis. Due to the intensely calcified annulus, deep “U” sutures had to be made to avoid paravalvular leakage. In regard to a possible injury of the CX and after replacement of both valves, a direct intraoperative coronary angiography with a digital C arm (BV Pulsera [Philips BV Medical Systems, Eindhoven, The Netherlands]) was performed through the still open aortic root. The contrast medium was delivered through the cardioplegic solution catheters under visual control to the coronary ostia, as previously described [2Kilian E. Beiras-Fernandez A. Bauerfeind D. Reichart B. Lamm P. Intraoperative coronary angiography in the management of patients with acute aortic dissection and endocarditis.J Thorac Cardiovasc Surg. 2008; 136: 792-793Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar] This showed a proximal occlusion of the CX (Fig 1; LAD = left anterior descending artery); therefore, we anastomosed a venous bypass to the first marginal branch. The further surgical procedure and hospital stay was uneventful. The patient's latest echocardiogram showed good ventricular function. Electrocardiograph and laboratory results showed no signs of ischemia.The herewith presented technique demonstrates the potency of the intraoperative coronary angiography during heart operations showing the possibility of immediate reaction to complications without major delay and extended ischemia. Suture injury of the circumflex coronary artery (CX) and infarction are considered a major complication after a mitral valve operation [1Virmani R. Chun P.K. Parker J. McAllister Jr, H.A. Suture obliteration of the circumflex coronary artery in three patients undergoing mitral valve operation Role of left dominant or codominant coronary artery.J Thorac Cardiovasc Surg. 1982; 84: 773-778PubMed Google Scholar]. Herein we present a procedure that illustrates the opportunity of direct intraoperative coronary angiography in the hand of the cardiac surgeon for immediate reaction without time delay and myocardial ischemia. A 62-year-old woman with symptomatic aortic and mitral valve stenosis was referred to our institution for a double-valve operation. Coronary angiography revealed no lesions. Through a median sternotomy, the massively calcified mitral valve was replaced with a mechanical prosthesis. Due to the intensely calcified annulus, deep “U” sutures had to be made to avoid paravalvular leakage. In regard to a possible injury of the CX and after replacement of both valves, a direct intraoperative coronary angiography with a digital C arm (BV Pulsera [Philips BV Medical Systems, Eindhoven, The Netherlands]) was performed through the still open aortic root. The contrast medium was delivered through the cardioplegic solution catheters under visual control to the coronary ostia, as previously described [2Kilian E. Beiras-Fernandez A. Bauerfeind D. Reichart B. Lamm P. Intraoperative coronary angiography in the management of patients with acute aortic dissection and endocarditis.J Thorac Cardiovasc Surg. 2008; 136: 792-793Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar] This showed a proximal occlusion of the CX (Fig 1; LAD = left anterior descending artery); therefore, we anastomosed a venous bypass to the first marginal branch. The further surgical procedure and hospital stay was uneventful. The patient's latest echocardiogram showed good ventricular function. Electrocardiograph and laboratory results showed no signs of ischemia. The herewith presented technique demonstrates the potency of the intraoperative coronary angiography during heart operations showing the possibility of immediate reaction to complications without major delay and extended ischemia.