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Ann Thorac Surg 1998;66:2091-2093
© 1998 The Society of Thoracic Surgeons

Case Reports

Damage to the circumflex coronary artery during mitral valve repair with sliding leaflet technique

Giuseppe Tavilla, MDa, Davide Pacini, MDa

a Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands

Accepted for publication May 21, 1998.

Address reprint requests to Dr Tavilla, Department of Cardiothoracic Surgery, University Hospital Leiden, K6-S, Postbus 9600, 2300 RC Leiden, the Netherlands


   Abstract
Top
 Abstract
Introduction
 Comment
 Acknowledgments
 References
 
We report a case of damage to the circumflex coronary artery during mitral valve repair using sliding leaflet technique in a patient with a posterior mitral leaflet prolapse and coronary artery disease who underwent mitral valve reconstruction using Carpentier’s technique and coronary artery bypass grafting. This case underscores the risk of circumflex coronary artery injury during mitral valve reconstruction, especially in patients with left coronary dominance or codominance, and therefore emphasizes the importance of knowing the coronary artery anatomy preoperatively. The use of intraoperative transesophageal echocardiography is mandatory for the evaluation of mitral valvuloplasty.


   Introduction
Top
 Abstract
 Introduction
Comment
 Acknowledgments
 References
 
Mitral valve repair has become the procedure of choice for patients with mitral insufficiency, and the long-term results have been promising [1]. However, left ventricular outflow tract obstruction has been reported to occur in 4% to 6% of mitral repair [2]. To avoid this complication, the sliding technique was developed by Carpentier [3]. The results of the sliding leaflet technique to prevent left ventricular outflow tract obstruction seem to be excellent [4]. In mitral valve reconstruction, damage of the circumflex coronary artery (CCA) can occur, especially in patients with left coronary dominance or codominance in which the CCA is very close to the mitral anulus running the atrioventricular groove.

We report a case of obstruction of CCA during mitral valve repair using the sliding leaflet technique in a patient with left-dominant coronary system.

A 60-year-old man with chronic, symptomatic mitral regurgitation and single-vessel disease was referred to our hospital for elective mitral valve and coronary artery bypass grafting. A preoperative transesophageal echocardiogram (TEE) demonstrated severe mitral regurgitation from prolapse of a redundant posterior leaflet and anterior billowing of excess leaflet tissue (Barlow syndrome), with probable rupture of a small chorda in the middle portion of the posterior leaflet. The diameter of the mitral annulus measured by echocardiography was 54 mm. The left ventricle presented a normal ventricular septum, and moderate left atrial enlargement was observed. A preoperative coronary angiography showed a normal left main left and left descending anterior artery, a big CCA that provided the descending posterior artery (Fig 1), and a hypoplastic right coronary artery. The first diagonal branch had a proximal critical stenosis.



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  		Fig 1. Preoperative coronary angiography showing a big circumflex coronary artery running in the atrioventricular groove.

 
Operation was performed in February 1997. The patient was put on extracorporeal circulation, and saphenous vein grafting was performed on the first diagonal branch. The mitral valve, as seen on the preoperative TEE, presented a primary chorda rupture on the midportion of the posterior leaflet. The posterior leaflet was abundant and prolapsing, and the anterior leaflet prolapsed minimally. To repair the valve, a large quadrilateral resection of the posterior leaflet and the posterior leaflet sliding advancement technique was performed. A Carpentier–Edwards ring with a diameter of 34 mm was used for the annuloplasty. The intraoperative evaluation of the repaired valve by saline injection yielded acceptable results. After weaning from cardiopulmonary bypass and before decannulation and normalization of loading conditions, the hemodynamic status was stable but the intraoperative electrocardiogram demonstrated transmural posterior and inferior ischemia. An intraoperative TEE showed hypokinesia of the corresponding regions and a moderate mitral regurgitation. Because of the findings, we suspected damage of the CCA caused by the plication of the posterior portion of the mitral annulus. Cardiopulmonary bypass was reestablished and cardioplegia was administrated. The Carpentier-Edwards ring was excised, and all plication sutures on the posterior annulus were removed. The mitral leaflets were excised, and a mechanical mitral prosthesis was implanted. An additional saphenous vein bypass graft to the posterolateral branch of the CCA was performed. The patient was weaned from cardiopulmonary bypass without incident. The postoperative course was characterized by a slight increase of cardiac enzyme levels and electrocardiographic signs of limited myocardial infarction on the posterior wall (negative T-waves in leads V4 to V6 and slight ST-segment elevation in leads II, III, and aVF). On the eighth postoperative day, coronary angiography showed total occlusion of the CCA in the atrioventricular groove (Fig 2), with patent venous bypass grafts on the diagonal branch and on the posterolateral branch of the circumflex artery.



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  		Fig 2. Postoperative coronary angiography showing total occlusion of the circumflex coronary artery in the atrioventricular groove.

 

   Comment
Top
 Abstract
 Introduction
 Comment
Acknowledgments
 References
 
Injury of the CCA is a rare but serious complication of mitral valve operation. In the era before the intraoperative use of TEE this complication was always fatal [5, 6]. The coronary artery anatomy is extremely variable, and a simple classification is based on the origin of the descending posterior artery: right dominance when the right coronary artery gives rise to the descending posterior artery (77%), left dominance when the CCA gives rise the DP (8%), codominance when both or neither gives rise to the DP (15%) [6].

Virmani and colleagues [6] observed that the distance of the CCA from the mitral anulus is closer in hearts with left dominance or codominance in 15 postmortem human hearts. They measured a mean distance between CCA and mitral annulus of 4.1 mm (range, 3 mm to 6.5 mm) in left dominance, 5.5 mm (range, 4.5 mm to 7.5 mm) in codominance, and 8.4 mm (range, 6 mm to 11.5 mm) in right dominance. Cornu and colleagues [7], in a recent anatomic study in 15 hearts, found 5 patients with right dominance with a mean distance of 8 mm. In the other 10 patients with codominant systems (they did not find left dominance), the mean distance was 5 mm. Therefore, the risk of CCA injury is more important in patients with left dominance or codominance; in fact no case of coronary artery injury in right dominance has been reported in the literature. No cases of CCA injury have been reported after mitral valve repair using the sliding leaflet technique. With the latter procedure, a large portion of the posterior leaflet must be removed with additional triangular resection of the remnant leaflet portions. Before approximation and reconstruction of the posterior leaflet, a considerable plication of the posterior annulus is needed. If a big CCA is present, running the atrioventricular groove (as in our patient), damage of the artery consequent to the annulus plication (not necessarily an injury by the sutures), can easily occur. Therefore, it is mandatory that preoperative coronary angiography is performed in every patient undergoing mitral valve repair to assess the dominance of coronary system and the course of the circumflex artery.

This report underlines the importance of the intraoperative TEE to assess not only the results of the mitral valve repair, but also the functionality of the left ventricle to recognize early the eventual ischemic segments due to circumflex coronary artery damage.


   Acknowledgments
Top
 Abstract
 Introduction
 Comment
 Acknowledgments
References
 
The authors thank Carl Ascoop, MD, for the echocardiographic examinations.


   References
Top
 Abstract
 Introduction
 Comment
 Acknowledgments
 References
 

  1. Deloche A., Jebara V.A., Relland J.Y., et al. Valve repair with Carpentier technique: the second decade. J Thorac Cardiovasc Surg 1990;99:990-1002.[Abstract]
  2. Schiavone W., Cosgrove D.M., Lever H.M., et al. Long-term follow-up of patients with left ventricular outflow tract obstruction after Carpentier ring valvuloplasty. Circulation 1988;78(suppl 1):60-65.[Abstract/Free Full Text]
  3. Carpentier A. The sliding leaflet technique. Le Club Mitrale Newsletter 1988;1:2-3.
  4. Jebara V.A., Mihaileanu S., Acar C., et al. Left ventricular outflow tract obstruction after mitral valve repair: results after the sliding leaflet technique. Circulation 1993;88(part 2):30-34.
  5. Danielson G.K., Cooper E., Tweeddale D.N. Circumflex coronary artery injury during mitral valve replacement. Ann Thorac Surg 1967;4:53-59.
  6. Virmani R., Major M.C., Patrick K.C., et al. Suture obliteration of circumflex coronary artery in three patients undergoing mitral valve operation: role of left dominant or codominant coronary artery. J Thorac Cardiovasc Surg 1982;84:773-778.[Abstract]
  7. Cornu E., Lacroix P.H., Christides C., Laskar M. Coronary artery damage during mitral valve replacement. J Cardiovasc Surg 1995;36:261-264.[Medline]



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