Left Circumflex Artery Injury After Mitral Valve Surgery: An Algorithm Management Proposal

Abstract

Left circumflex coronary (LCx) artery injury during mitral valve surgery is a life-threatening complication. This report describes a series of patients with this complication in a high-volume mitral surgery center. Between January 2004 and December 2017, a total of 6501 mitral valve procedures were performed at the San Raffaele Scientific Institute in Milan, Italy. An LCx injury occurred in 10 patients (10 of 6501; 0.15%) after either mitral valve repair (n= 5) or replacement (n= 5). Coronary angiography was performed in 9 patients and showed 5 cases of left coronary artery dominance, 2 cases of right dominance, and 2 cases of codominance. All data were prospectively collected in the hospital database and were retrospectively reviewed. Suspicion of LCx injury was raised in the operating room in 5 patients and in the intensive care unit in the other 5 patients. Postoperative coronary angiography confirmed the LCx lesion. In the presence of total LCx occlusion, coronary artery bypass grafting (n= 3) or partial removal of the annuloplasty ring(n= 1) was performed. In cases of partial kinking (n= 4), percutaneous coronary intervention (PCI) was preferred. In the 2 patients with extrinsic subocclusion of the LCx, rescue PCI was initially attempted, but both procedures were complicated by artery disruption and stent underexpansion. In our series, LCx occlusion occurred more commonly in patients with left-dominant coronary artery circulation. Clinical presentation may be variable. Rescue PCI is a valid option in cases of kinking of the artery, but in other cases emergency coronary bypass grafting should be the first choice. Repositioning of the prosthesis may be an option in specific circumstances.