Left Circumflex Artery Injury after Mitral Valve Surgery: an algorithm management proposal

Background. Atrial fibrillation surgical radiofrequency ablation (AFSA) during mitral valve surgery (MVS) has almost completely superseded the Cox-Maze procedure for the treatment of atrial fibrillation. Methods. We retrospectively analyzed 100 patients who underwent MVS + AFSA in our institution from January 2008 to June 2017. We compared the effectiveness of AFSA in patients who underwent LAA exclusion to those who did not. Moreover, we analyzed the role of preoperative AF duration (≤ or >1 year) and medial-lateral left atrial dimensions (ML-LAD) (≤ or >6 cm). The efficacy endpoint was freedom from AF at discharge and at 2-year follow-up. The safety endpoints were need of a permanent pacemaker (PMK), surgical re-exploration, occurrence of stroke, and left circumflex artery or esophageal lesions. Results. Overall, the rate of AF freedom was 69% at discharge and 80% at 2-year follow-up. LAA exclusion did not influence AF freedom at 2-year follow-up, and 84.6% of patients who underwent LAA exclusion were in the sinus rythm (SR) at 2 year compared to 75% of those who did not receive LAA exclusion free from AF as well ( p = 0.230 ). AF duration ≤1 or >1 year did not influence sinus rhythm (SR) maintenance (85.7% vs. 75.8%; p = 0.224 ), and in these two groups, LAA exclusion did not change the efficacy of AFSA. ML-LAD ≤ 6 cm was associated with better results in terms of SR maintenance. A statistically significant association between LAA exclusion and SR maintenance at 2-year follow-up ( p = 0.017 ) was found among patients with ML-LAD ≤ 6 cm. Complications included 7 cases of PMK implantation, 2 cases of surgical re-exploration, and 1 case of stroke. No circumflex artery or esophageal lesions occurred after surgical procedures. Conclusions. In our experience, AFSA during isolated MVS resulted in good outcomes in terms of SR maintenance and incidence of complications. AF duration ≤ 1 year did not influence results, while patients with ML-LAD ≤ 6 cm had significantly better results regarding SR at follow-up. In patients with ML-LAD ≤ 6 cm, LAA exclusion significantly increased the success rate of SR maintenance at 2-year follow-up.

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Situation Awareness for Circumflex Artery Injury During Mitral Valve Surgery

The Annals of Thoracic Surgery ◽

10.1016/j.athoracsur.2019.02.054 ◽

2019 ◽

Vol 108 (5) ◽

pp. e329-e332

Author(s):

Germán A. Fortunato ◽

Martin Misfeld ◽

Roberto Battellini ◽

Alberto Domenech ◽

Jens Garbade ◽

...

Keyword(s):

Mitral Valve ◽

Situation Awareness ◽

Mitral Valve Surgery ◽

Valve Surgery ◽

Circumflex Artery ◽

Artery Injury

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CASE 3—2012: Iatrogenic Circumflex Artery Injury During Minimally Invasive Mitral Valve Surgery

Journal of Cardiothoracic and Vascular Anesthesia ◽

10.1053/j.jvca.2012.01.010 ◽

2012 ◽

Vol 26 (3) ◽

pp. 512-519 ◽

Cited By ~ 6

Author(s):

Jennifer Banayan ◽

Richa Dhawan ◽

William J. Vernick ◽

Patrick M. McCarthy

Keyword(s):

Mitral Valve ◽

Minimally Invasive ◽

Mitral Valve Surgery ◽

Valve Surgery ◽

Circumflex Artery ◽

Artery Injury

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Takotsubo syndrome after mitral valve surgery: a case report

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytaa327 ◽

2020 ◽

Author(s):

Ana Devesa ◽

Rafael Hernández-Estefanía ◽

José Tuñón ◽

Álvaro Aceña

Keyword(s):

Mitral Valve ◽

Fatal Outcome ◽

Mitral Valve Surgery ◽

Left Ventricular ◽

Valve Surgery ◽

Lv Function ◽

Partial Recovery ◽

Takotsubo Syndrome ◽

Left Circumflex Artery ◽

Coronary Syndrome

Abstract Background Takotsubo syndrome is a frequent entity; however, it has never been described after a mitral valve surgery. Case summary We present the case of a 79-year-old woman, with background of atrial fibrillation and a left atrial appendage closure device, who was admitted for elective mitral valve replacement, because of asymptomatic severe primary mitral regurgitation. Biologic mitral valve was implanted without incidences, but in the postoperative, she developed cardiogenic shock. Electrocardiogram (ECG) showed inverted T waves in precordial leads and an echocardiography showed severe left ventricular (LV) dysfunction with mid to distal diffuse hypokinesis, and better contractility in basal segments. Troponin levels were mildly elevated. With the suspicion of a postoperative acute coronary syndrome, a coronary angiography was performed and showed no significant coronary lesions. The haemodynamic situation was compromised for the next 48 h, in which vasoactive support and intra-aortic balloon counterpulsation were implemented. After 48 h, the haemodynamic situation suddenly improved. The ECG was normalized, and a control echocardiogram showed partial recovery of the LV function with resolution of regional wall motion abnormalities. The patient could be discharged at 1 week. The clinical picture was interpreted as a stress cardiomyopathy after mitral valve surgery. Discussion Takotsubo syndrome is a threatening condition; complications in acute phase could lead to a fatal outcome. Mitral valve surgery has to be considered as a trigger for this entity, after excluding coronary involvement, specially of left circumflex artery.

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Establishing an Anatomical Proximity Between the Coronary Circumflex Artery and the Mitral Valve Annulus: Implications for Mitral Valve Surgery

The FASEB Journal ◽

10.1096/fasebj.29.1_supplement.552.7 ◽

2015 ◽

Vol 29 (S1) ◽

Author(s):

Eliot Winkler ◽

Bayan Malakouti‐Nejad ◽

Marjorie Johnson ◽

Jorge Catrip ◽

Jeevan Nagendran ◽

...

Keyword(s):

Mitral Valve ◽

Mitral Valve Surgery ◽

Valve Surgery ◽

Circumflex Artery ◽

Valve Annulus

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0360 : Iatrogenic circumflex artery occlusion during mitral valve surgery: a retrospective study on 8 patients and a medical review

Archives of Cardiovascular Diseases Supplements ◽

10.1016/s1878-6480(15)30221-4 ◽

2015 ◽

Vol 7 (2) ◽

pp. 213

Author(s):

Grégoire Cauchois ◽

Matthieu Godin ◽

Fabien Doguet ◽

Hélène Eltchaninoff ◽

Jean-Paul Bessou ◽

...

Keyword(s):

Retrospective Study ◽

Mitral Valve ◽

Artery Occlusion ◽

Mitral Valve Surgery ◽

Valve Surgery ◽

Medical Review ◽

Circumflex Artery

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Management of late onset recurrent ventricular tachycardia following circumflex artery injury during minimally invasive mitral valve replacement surgery – Clinical case report

Acta Marisiensis - Seria Medica ◽

10.2478/amma-2021-0013 ◽

2021 ◽

Vol 67 (2) ◽

pp. 127-129

Author(s):

Timea Magdolna Szabo ◽

Mihaela Ispas ◽

Ayman Elkahlout

Keyword(s):

Myocardial Infarction ◽

Ventricular Tachycardia ◽

Mitral Valve ◽

Minimally Invasive ◽

Valve Replacement ◽

Mitral Valve Surgery ◽

Valve Surgery ◽

Circumflex Artery ◽

Replacement Surgery ◽

Valve Replacement Surgery

Abstract Introduction: A rare complication of mitral valve surgery is the injury of the circumflex artery due to their close anatomical proximity resulting in a perioperative myocardial infarction and subsequent fibrosis with increased risk of developing ventricular arrhythmias. Case presentation: We hereby describe the case of a 74-year-old male patient who underwent minimally invasive mitral valve replacement surgery for severe mitral regurgitation two weeks prior to presenting to the emergency department with dyspnea, palpitations and slight thoracic discomfort. He was diagnosed with recurrent sustained monomorphic ventricular tachycardia due to inferior wall myocardial infarction. Angioplasty of the culprit lesion was attempted, but the procedure failed due to the elastic recoil of the vessel. Our patient received antiarrhythmic therapy and an implantable cardioverter-defibrillator for secondary prevention of sudden cardiac death, with no further recorded episodes of ventricular tachycardia. Conclusion: Although injury of the circumflex coronary artery during mitral valve surgery is described as rare, we strongly believe that increasing awareness of the potential risks involved can further prevent fatal complications.

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