Eur J Cardiothorac Surg 2007;32:818-819. doi:10.1016/j.ejcts.2007.07.022
Copyright © 2007, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
Reply to Acar
Rachid Zegdia,b,*,
Ghassan Sleilatya,
Jean-Noël Fabiania,b,
Alain Delochea,b
a Assistance Publique-Hôpitaux de Paris, AP-HP, Service de Chirurgie Cardiovasculaire, Hôpital Européen Georges Pompidou, Paris, France
b Université René Descartes, Paris V, France
Received 19 July 2007;
accepted 20 July 2007.
* Corresponding author. Address: Hôpital Européen Georges Pompidou, Service de Chirurgie Cardiovasculaire, 20, rue Leblanc, 75908 Paris, France. Tel.: +33 1 56 09 37 48; fax: +33 1 56 09 22 19. (Email: rzegdi{at}hotmail.com).
Key Words: Mitral valve repair • Circumflex coronary artery
We would like to thank Professor Acar for his comments [1] regarding our case of circumflex coronary artery obstruction following mitral valve repair, published in a recent issue of the journal. From his experience and ours, several important points should be underscored:
- - First, it is a rare complication, occurring in less than 0.5% in our experience (but can be higher, up to 1.8% in a recent series [2]), and it still occurs in teams with significant experience in mitral valve repair.
- - This complication has been typically observed in patients with a dominant or codominant left coronary configuration. A close contact between the mitral annulus and the proximal circumflex coronary artery at the level of the anterior commissure or P1 – a distance as short as 1 mm [3,4] – is one reason for this occurrence. Large tissue bites, particularly in those cases of calcified or loose mitral annulus, have also been considered as predisposing factors.
- - The mechanism of vascular obstruction is a direct trauma by entrapment of the circumflex artery inside encircling or transfixing stitches [3]. This occlusion may be either complete or partial, as in our case report. Indirect occlusion via annular plication has been also suggested [5]. Although easily conceivable, this hypothesis has not been clearly demonstrated so far. Even in this case, formally excluding a direct trauma is impossible.
- - Circumflex coronary artery obstruction is a severe and often fatal complication if not promptly recognized. The diagnosis is usually suspected intraoperatively in the presence of hemodynamic instability with typically persistent ST segment elevation in posterolateral leads. Confirmatory transesophageal echocardiography analysis reveals left ventricular segmental wall motion abnormalities in the same territory. However, the diagnosis may be delayed in the postoperative course in cases of partial obstruction as in our case.
- - Treatment of symptomatic circumflex coronary artery obstruction relies on surgical revascularization by venous bypass grafting with usually unremarkable postoperative course. Redoing valve surgery without bypass grafting is not warranted and is even dangerous, since coronary obstruction may persist in cases of direct trauma injury [5]. Cases of complete extrinsic obstruction do not seem accessible to endovascular treatment, and dilation or stenting of a suboccluded circumflex coronary artery may lead to vascular rupture. We are unaware of any reports of endovascular treatment of such cases.
References
- Acar C. Re: Injury to the circumflex coronary artery following mitral valve repair. Eur J Cardiothorac Surg 2007;32:818.[Free Full Text]
- Aybeck T, Risteski P, Miskovic A, Simon A, Dogan S, Abdel-Rahman U, Moritz A. Seven years’ experience with suture annuloplasty for mitral valve repair. J Thorac Cardiovasc Surg 2006;131:99-106.[Abstract/Free Full Text]
- Virmani R, Chun PKC, Parker J, Mc Allister HA. Suture obliteration of the circumflex coronary artery in three patients undergoing mitral valve operation. J Thorac Cardiovasc Surg 1982;84:773-778.[Abstract]
- Cornu E, Lacroix PH, Christides C, Laskar M. Coronary artery damage during mitral valve replacement. J Cardiovasc Surg 1995;36:261-264.[Medline]
- Tavilla G, Pacini D. Damage to the circumflex coronary artery during mitral valve repair with sliding leaflet technique. Ann Thorac Surg 1998;66:2091-2093.[Abstract/Free Full Text]
