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Letters to the Editor |
Pirajussara General Hospital, Cardiovascular Surgery, Federal University of São Paulo, São Paulo, Brazil
Received 27 December 2007; accepted 1 February 2008.
* Corresponding author. Address: Rua Borges Lagoa 1080 cj 608, São Paulo SP 04038-002, Brazil. Tel.: +55 11 5572 6309; fax: +55 11 5572 6309. (Email: wjgomes.dcir{at}epm.br).
Key Words: Mitral valve repair • Annuloplasty • Circumflex coronary artery • Myocardial ischemia
The letter from Acar [1] on the management of circumflex artery injury after mitral valve repair, as well as the original report from Zegdi et al. [2], were both very instructive and definitely life-saving.
On the other hand, we would like to present our experience in the management of such complication, which was rather the opposite.
In two cases where reconstructive surgery of the mitral valve was attempted with implant of a flexible annuloplasty ring, persistent ST segment elevation in posterolateral leads was noticed shortly after aortic cross-clamp release, along with poor left ventricular contraction. Without delay, the patients were placed back on bypass and cross-clamp reapplied, the left atrium was reopened and the sutures and ring removed. In the first case (the one with moderate calcified annulus and leaflets), the valve was replaced by a xenograft bioprosthesis using buttressed sutures. In the second case, the annular sutures were relocated further away from the annulus, toward the leaflets and the ring replaced. In either case, following cross-clamp release, the ST segment returned to baseline, weaning off bypass was uneventful and both patients did well postoperatively.
This finding suggests that rather than direct injury to the coronary artery, the mechanism involved was coronary artery kinking, likely related to suture knot tying and annulus plication.
We extensively studied the relationship between the posterior mitral valve annulus and the surrounding coronary arteries, in a series of 85 explanted human hearts [3]. Right dominance was observed in 81.17% of the cases, balanced dominance in 16.47% and left dominance in 2.35%. Right dominant hearts showed that the shortest distance between the annulus and the coronary arteries occurred at the level of the anterior commissure, where the circumflex artery was distant to the annulus 3.99 ± 1.86 mm (varying from 1.01 to 11.80 mm) while the longest distance was at the posterior commissure, measuring 7.78 ± 2.61 mm.
After this study, we altered the operative technique by placing the annular sutures slightly away from the annulus inwards the leaflets, particularly at the region nearby the anterior commissure.
Therefore, a strategy of relocating the annular sutures in this setting proved to be feasible and effective. We commend again both authors for their fine contribution and reinforce that our procedure needs to be kept in mind should the need arise.
Footnotes
The authors of the original papers [1,2] were invited to comment on this Letter to the Editor but declined the offer.
References
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