A stitch too far: The circumflex artery in jeopardy during mitral valve repair

Intraoperative indocyanine green imaging as an adjunctive technique to reduce any circumflex artery damage during mitral valve surgery: a feasibility study

Iatrogenic injuries to the circumflex coronary artery during mitral valve surgery are probably underestimated (reported rates of 0.3-1.8%). This complication arises from the artery's close proximity to the mitral annulus, particularly at the anterolateral commissure. The study aimed to assess this risk in a patient group prone to such injury. The surgical procedure utilized a minimally invasive approach and indocyanine green-based fluorescence imaging. This technique allows a real-time visualization of the circumflex artery, aiding precise placement of annular sutures and minimizing the risk of injury. The method, applied in 6 patients, integrates preoperative assessments with intraoperative fluorescence imaging, ensuring accurate arterial depiction and preventing iatrogenic damage. The study highlights the safety and efficacy of fluorescence imaging, especially in identifying vessel anomalies, indicating potential applications in various cardiac procedures.

Left circumflex artery injury following surgical mitral valve replacement: a case report

Background

Mitral valve (MV) repair or replacement surgery is indicated for a variety of conditions. Although uncommon, damage to the left circumflex (LCx) coronary artery, which courses in close proximity to the MV annulus, is a devastating complication.

Case summary

This report describes the case of a 63-year-old woman following re-operative MV replacement. Shortly after being transferred to the surgical intensive care unit after MV replacement, her EKG was notable for persistent inferolateral ST-segment elevations and reciprocal ST-segment depressions. Emergency transthoracic echocardiogram revealed a reduced left ventricular ejection fraction of 35–40% and mid to distal lateral wall motion hypokinesis. She was emergently taken to the cardiac catheterization laboratory where coronary angiography demonstrated complete occlusion of her mid LCx artery. She underwent urgent percutaneous coronary intervention of the lesion and was started on dual antiplatelet treatment, anticoagulation for comorbid atrial fibrillation, as well as guideline directed medical therapy with improvement in her EKG changes and cardiac function.

Conclusion

Prompt diagnosis and recognition of LCx injury is crucial. Management involves immediate percutaneous recanalization or surgical coronary bypass grafting.

Anomalous course of coronary artery challenging mitral valve surgery

Suture-related injuries of the left circumflex branch are a serious and well-known complication of mitral valve surgery. Avoiding this complication is challenging, especially in an unexpected course of coronary arteries. We present a case of minimally invasive mitral valve repair in a patient with a rare anatomical variant of the main stem in direct proximity to the whole anterior leaflet.