Left circumflex coronary artery injury following mitral valve replacement with late presentation: A case report and literature review

Abstract

Mitral valve replacement complications are more and more recognized due to the novel surgical techniques and the tendency to report such complications by young cardiologists and surgeons. Circumflex coronary artery injury is a rare complication that occurs during mitral valve replacement or repair by multiple mechanisms. We present the case of a 57-year-old female who underwent mitral valve replacement and ended up with heart failure after circumflex artery occlusion and failure of percutaneous coronary intervention.

Circumflex Coronary Artery Injury during Modern Mitral Valve Surgery—A Review of Current Concepts and Perspectives

“…The documented incidence of CX injury secondary to MV surgery varies between 0.15% and 4.0% [ 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 ], but various authors suggest that the true incidence is probably significantly higher due to underreporting. Danielson and colleagues [ 1 ] were the first to document 3 patients with CX injury in their series of 178 MV procedures in 1967, followed by Roberts [ 2 ], Morin [ 3 ], Virmani [ ...…”

“…The reported decrease in MV replacement procedures performed in developed countries [ 78 ] parallels modern international guidelines [ 74 , 75 ] that strongly advocate MV repair whenever possible. Various reports describe CX injury during MV repair [ 6 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 26 , 27 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 38 , 39 , 41 , 42 , 44 , 46 , 48 , 49 ] and emphasize the importance of accurate and meticulous annuloplasty needle entry angle, direction, depth, instrument manipulation and exteriorization in areas where the CX–CS–MV complex is at risk. Wide posterior leaflet quadrangular resection, extensive posterior sliding plasty and the use of excessively small or large annuloplasty rings should be avoided to minimize the risk of tissue traction, distortion or external compression of the CX in high-risk areas [ 79 , 80 , 81 , 82 , 83 ].…”

“…Once suspected, urgent confirmation of CX injury and the rapid identification of the responsible mechanism by TEE and/or coronary angiography are crucial to expedite the appropriate treatment strategy [ 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 ]. Flow-limiting CX injuries diagnosed intraoperatively require emergency revascularization and restoration of distal perfusion by either emergency empiric coronary artery bypass grafting (CABG) of the obtuse marginal branches utilizing saphenous vein [ 6 , 10 , 14 , 15 , 19 , 27 , 31 , 37 , 38 , 48 ], by revising the prosthesis sutures [ ...…”

“…Revascularization by PCI is feasible and preferred in a stable intraoperative setting where CX injury is confirmed to be the result of a partial CX occlusion and where transfer and ischemic reperfusion times are minimal. The inability to cross totally occluded CX injuries with guidewires, stent under-expansion and potential CX rupture are amongst the immediate risks reported with PCI [ 43 , 48 , 49 ]. The recent advances in hybrid theatre technology, which facilitate combined single-stage surgical MV and TC interventions [ 65 ], may decrease CX ischemic reperfusion time by providing the option of rapid on-table coronary angiography and attempts at PCI as an alternative to CABG once the clinical suspicion and mechanism of CX injury is confirmed by TEE ( Figure 5 ).…”

“…Myocardial infarction secondary to circumflex coronary artery (CX) distortion or occlusion during mitral valve (MV) surgery is associated with devastating postoperative morbidity and mortality outcomes [ 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 ]. Despite significant improvements in preoperative risk identification [ 50 , 51 , 52 , 53 , 54 ...…”