A Novel Hybrid Approach To Iatrogenic Circumflex Artery Injury After Mitral Repair
Fadi Hage, Ali Hage, Kumar Sridhar, Bob Kiaii, Michael W.A. Chu
Western University, London, ON, Canada
Iatrogenic coronary injury after mitral repair is related to blind annuloplasty suture ligation of the circumflex artery (CxA) and presents with electrocardiographic (ECG) ischemic changes and wall motion abnormalities. Corrective treatment is imperative and commonly includes coronary bypass for distal revascularization.
In the last 10 years, we have had 2 patients experience iatrogenic CxA injury out of 415 consecutive patients undergoing mitral repair. Both patients had large CxA, severe myxomatous mitral regurgitation and underwent endoscopic, minimally invasive mitral repair with leaflet and annular correction, performed in a hybrid operating theater with fixed fluoroscopy. Both patients presented with early persistent ischemic ECG changes (Figure 1A), and new segmental wall motion abnormalities in only one patient.
Given these findings, iatrogenic CxA injury was strongly suspected. Coronary angiography was performed immediately in the same hybrid operating room, identifying complete cut-off of the CxA. Using the same mini-thoracotomy incision and under hypothermic fibrillatory arrest, the left atrium was opened. Two radiographically distinct surgical instruments were clamped on the annuloplasty suture knots of the suspected injurious sutures (Figure 1B). A diagnostic catheter was left in the left coronary artery to inject the CxA simultaneously. Under fluoroscopic assistance, the offending suture was identified by its proximity to one of the surgical instruments (Figure 1C) and removed, which resulted in immediate reperfusion of the distal coronary (Figure 1D). The removed suture was not replaced. The ST changes became isoelectric and trans-esophageal echocardiography revealed no segmental wall motion abnormalities and no mitral insufficiency. Both patients were discharged home with no further complications and had normal left ventricular function at follow-up.
These cases illustrate the successful use of a novel hybrid approach to: 1) confirm the diagnosis of an injury to the CxA after mitral repair; 2) precisely identify the injurious annuloplasty suture; and 3) confirm the reperfusion of the CxA after removal of the culprit suture.
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