Right coronary occlusion during tricuspid band annuloplasty

Abstract

CLINICAL SUMMARY A 38-year-old man was referred to the University of Catania for severe mitral regurgitation caused by bacterial endocarditis in a myxomatous mitral valve, with prolapse and chordal rupture of the posterior leaflet. The patient was symptomatic for effort dyspnea. A preoperative echocardiogram showed a dilated left ventricle with 62% ejection fraction. Moderate to severe tricuspid regurgitation was present, with a dilated annulus (37 mm) and right ventricle (43 mm). Coronary angiography results were normal. The surgical procedure included mitral repair (longitudinal plication of the posterior leaflet, suturing P1-P2 and P2-P3, positioning of artificial chords and mitral annuloplasty with a 50-mm band, the SMB50, Sorin, Saluggia, Italy). Tricuspid repair was obtained with a 40-mm band (SMB40), positioned from the anteroseptal to the posteroseptal commissures. When the aorta was unclamped, severe ST elevation appeared immediately. Because air embolism in the RCA was suspected, systemic pressure was increased by means of vasopressors. The ST modifications were reduced, the pump was stopped, and the postoperative echocardiogram showed no mitral or tricuspid regurgitation and only mild hypokinesia in the inferior wall. During the sternal closure, ventricular fibrillation occurred; defibrillation was successful, but global hypokinesia was evident with severe ST elevation in the inferior leads. The patient was again cannulated, a segment of saphenous vein was harvested, and, under cardioplegic arrest, the 3 distal branches of the RCA were grafted and the proximal anastomosis was performed. ST modifications immediately disappeared, and the pump was stopped with good hemodynamics without inotropes. Peak enzymatic release was 193 creatine kinaseMB UI/L. The patient was extubated on the first postoperative day, and the postoperative course was uneventful. The echocardiogram before discharge showed no mitral or tricuspid regurgitation, ejection fraction lower than the preoperative value (50%), and mild inferior hypokinesia. The coronarography, performed before the patient’s discharge, showed complete RCA occlusion just before the posteromedial tricuspid commissure (Figure 1) and a widely patent saphenous vein graft. The level of RCA occlusion was immediately before the crux cordis.