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

Abstract

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.

Incidence and outcomes of early percutaneous coronary intervention after isolated valve surgery

“…To our knowledge, this study is the first to systematically assess the incidence and outcomes of acute coronary injury requiring early PCI after isolated valve surgery . In our cohort of 135,611 patients who underwent isolated aortic or mitral valve surgery in the United States over a 12‐year period, 0.8% needed early PCI prior to discharge.…”

“…The mechanism by which iatrogenic injuries occur differ between aortic and mitral valve surgeries. After mitral valve surgery, the circumflex coronary artery is the culprit artery in most iatrogenic injuries, which may result from entrapment with an encircling fixation suture, external compression by the Annuloplasty ring, or coronary perforation during decalcification of the mitral annulus . However, coronary injuries during aortic valve interventions are usually caused by severe intimal hyperplasia due to damage from the antegrade cardioplegia cannula or by an immunological reaction to bioprothestic materials in the aortic annulus .…”

“…Postoperative coronary ischemia is an uncommon but serious complication of isolated valve surgery. In the vast majority of cases, this issue results from an iatrogenic coronary injury during the operation, and are treated by means of percutaneous coronary intervention (PCI) . Various mechanisms have been proposed for this complication including direct vascular damage due to suturing or decalcification techniques, external mechanical compression, or immunological reaction to surgical prostheses .…”

“…In the vast majority of cases, this issue results from an iatrogenic coronary injury during the operation, and are treated by means of percutaneous coronary intervention (PCI) . Various mechanisms have been proposed for this complication including direct vascular damage due to suturing or decalcification techniques, external mechanical compression, or immunological reaction to surgical prostheses . This might manifest intraoperatively with difficulty weaning from cardiopulmonary bypass, postoperatively with myocardial infarction, electrical or hemodynamic instability, or later after discharge with insidious anginal symptoms .…”

“…Various mechanisms have been proposed for this complication including direct vascular damage due to suturing or decalcification techniques, external mechanical compression, or immunological reaction to surgical prostheses . This might manifest intraoperatively with difficulty weaning from cardiopulmonary bypass, postoperatively with myocardial infarction, electrical or hemodynamic instability, or later after discharge with insidious anginal symptoms . However, the literature on early PCI after valve surgery are limited to small case series.…”