Management of Anomalous Left Circumflex Artery Encircling the Aortic Annulus in a Patient Undergoing Multivalvular Surgery

When too much closeness harms: circumflex artery injury during mitral valve surgery

Occlusion of the left coronary circumflex artery (LCX) during surgical procedures of the mitral valve is an infrequent but potentially life-threatening complication (1-3). Due to its close anatomical relationship to the posterior mitral valve annulus, there is a relevant risk of causing a stenosis or an occlusion of the left circumflex artery, especially by surgical annular sutures. The perioperative clinical course is heterogeneous, ranging from-initially-asymptomatic or solely electrocardiographic abnormalities to cardiogenic shock. Both severely impaired ventricular contractility or malignant arrhythmia may potentially lead to a weaning failure from cardiopulmonary bypass (CPB) and eventually result in chronic heart failure with persistently reduced ejection fraction. Possible therapeutic strategies include the immediate reopening of causal sutures, aortocoronary bypass grafting or percutaneous coronary intervention (PCI), yet PCI seems to be the preferred method at present.

Anomalous circumflex artery: a benign variant generating a malignant potential after valve surgery

Coronary artery anomalies are a diverse group of congenital disorders presenting with highly variable clinical manifestations. The anomalous origin of left circumflex artery from the right coronary sinus following a retro-aortic trajectory is a well-recognized anatomic variation. Despite its benign course, it can prove lethal in association with valvular surgery. When single aortic valve replacement or combined with mitral valve replacement is performed, the aberrant coronary vessel may be compressed by or between the prosthetic rings triggering postoperative lateral myocardial ischemia. If left untreated, the patient is at risk of sudden death or myocardial infarction with its detrimental complications. Skeletonization and mobilization of the aberrant coronary artery is the most widely accepted intervention, but valve downsizing or concomitant surgical or transcatheter revascularization have also been described. However, large series are lacking from the literature. Therefore, no guidelines exist. This study is a thorough review of the literature concerning the aforementioned anomaly in association with valvular surgery.

AVR in patients with anomalous course of the circumflex artery without prosthetic downsizing

An anomalous origin of the left circumflex coronary artery that arises as a side branch of the right coronary artery and encircles the aortic annulus is usually an incidental finding. However, in patients undergoing aortic valve/root procedures, its existence can significantly complicate the surgical treatment. We report our operative strategy with three different prostheses without valve downsizing.

Aortic Valve Replacement in 8 Adults with Anomalous Aortic Origin of Coronary Artery

Patients with anomalous origin of a coronary artery during aortic valve replacement (AVR) are at risk of coronary compromise. Large case series are lacking. In this retrospective study, we review our experience with this condition. From August 2014 through June 2016, 8 adult patients (mean age, 74 ± 17.5 yr; age range, 33-86 yr; 5 men) with anomalous aortic origin of a coronary artery underwent surgical or transcatheter AVR at our institution. Six patients had aortic stenosis; 2 had aortic insufficiency, one of whom had an associated aortic root aneurysm. In 7 patients, the left anomalous coronary artery originated from the right aortic sinus, and in one, the right coronary artery arose from the left cusp. The anatomic course was revealed by means of 3-dimensional computed tomographic angiography. No patient underwent primary aortic reimplantation of the anomalous artery. Two had the artery mobilized from encircling the annulus too closely and then underwent coronary artery bypass grafting. Two high-risk patients underwent transcatheter AVR. After surgical AVR, 2 patients had perioperative myocardial infarction caused by coronary compression, so percutaneous coronary intervention was performed. One patient died of sepsis 3 months after discharge from the hospital. In our patients, AVR sometimes led to severe perioperative complications. Successful AVR depended on 3-dimensional computed tomographic angiographic findings, individual anatomic variations, and appropriate treatment choices.

Left circumflex artery injury postmitral valve surgery, single center experience

The left circumflex (LCX) artery is located close to the mitral valve (MV), making it susceptible to injury during MV surgery. We are reporting our experience in the diagnosis and management of this complication. We retrospectively reviewed our surgical and coronary angiography databases for patients with documented LCX artery injury during MV surgery between January 2000 and December 2016. The complication was associated with MV replacement (9/1313, 0.7%) but not MV repair (0/393, 0.0%). Eight patients (88.9%) were female and the mean age was 40.4 ± 14.2 years. There was roughly similar distribution of left and right dominant coronary circulations (5 and 4 patients, respectively). Eight patients (88.9%) had ischemic changes on electrocardiogram and ventricular arrhythmias were documented on six patients (66.7%). Three patients (33.3%) were treated with percutaneous coronary intervention while six patients (66.7%) required redo surgery to graft the LCX artery. The 30-day mortality was high (33.3%). A high index of suspicion is required to diagnose this injury. At the moment, no consensus is available on the optimal treatment strategy. We propose percutaneous approach as the first option to spare the patients from undergoing open-heart surgery for the second time.

Circumflex coronary artery injury after mitral valve surgery: A report of four cases and comprehensive review of the literature

As the LCx is closely related to the mitral valve annulus, it is susceptible to perioperative injury. Various underlying mechanisms, predisposing factors, and therapeutic strategies have been suggested but disagreement exists. Using a MeSH terms-based PubMed search, 44 cases of mitral valve surgery-related LCx injury were detected, including our 4 cases. We provide a comprehensive review of current knowledge regarding mitral valve surgery-related left circumflex coronary artery (LCx) injury. Preoperative coronary angiography was performed in 55% (n = 24). Coronary abnormalities were present in 11% (n = 5). Coronary dominance was reported in 73% (n = 32), predominantly showing left (69%, n = 22) or balanced (19%, n = 6) circulations. Right coronary dominance was present in 12% (n = 4). Ischemia was detected in the perioperative or early postoperative phase in 86% (n = 30). Delayed symptoms were present in 14% (n = 5). Echocardiography demonstrated new regional wall motion abnormalities in 80% (n = 24), but was negative in 20% (n = 6) despite coronary compromise. Electrocardiography showed myocardial ischemia in 97% (n = 34), including regional ST-segment elevations in 68% (n = 23). Primary treatment was surgical in 42% (n = 15) and percutaneous in 58% (n = 21), reporting success ratios of 87% (n = 13) and 81% (n = 17), respectively. We confirm an augmented risk of mitral valve surgery-related LCx injury in balanced or left-dominant coronary circulations. Preoperative knowledge of coronary anatomy does not preclude LCx injury. An anomalous LCx arising from the right coronary cusp was identified as a possible specific high-risk entity. Electrocardiographic monitoring and intraoperative echocardiography remain paramount to ensure a timely diagnosis and treatment. © 2016 Wiley Periodicals, Inc.

Anomalous Origin of the Circumflex Artery: An Underestimated Threat During Mitral Valve Operation

Ischemic iatrogenic lesions can complicate surgical procedures on the mitral valve. One of the causative mechanisms is direct injury to or distortion of the circumflex coronary artery. The risk of damaging the circumflex coronary artery depends mainly on the proximity of that vessel to the posterior segment of the mitral annulus, and this varies from patient to patient. Herein, we report the case of an iatrogenic circumflex coronary artery lesion after mitral annuloplasty in a patient with an anomalous origin of the circumflex artery.

Intraoperative transeophageal echocardiography to diagnose an anomalous circumflex artery

We describe a 43-year-old male presenting for hemiarch replacement and possible aortic valve replacement. Intraoperative transesophageal echocardiography (TEE) demonstrated an atypical coronary vessel, enabling proper diagnosis of an anomalous circumflex artery and appropriate operative planning.

Identifying, characterizing, and classifying congenital anomalies of the coronary arteries

The clinical manifestations of coronary artery anomalies vary in severity, with some anomalies causing severe symptoms and cardiovascular sequelae and others being benign. Cardiovascular computed tomography (CT) has emerged as the standard of reference for identification and characterization of coronary artery anomalies. Therefore, it is important for the reader of cardiovascular CT images to be thoroughly familiar with the spectrum of coronary artery anomalies. Hemodynamically significant anomalies include atresia, origin from the pulmonary artery, interarterial course, and congenital fistula. Non-hemodynamically significant anomalies include duplication; high origin; a prepulmonic, transseptal, or retroaortic course; shepherd's crook right coronary artery; and systemic termination. In general, coronary arteries with an interarterial course are associated with an increased risk of sudden cardiac death. Coronary artery anomalies that result in shunting, including congenital fistula and origin from the pulmonary artery, are also commonly symptomatic and may cause steal of blood from the myocardium. Radiologists should be familiar with each specific variant and its specific constellation of potential implications.

Compression of an anomalous left circumflex artery after aortic and mitral valve replacement

A 52-year-old gentleman with a history of rheumatic fever presented with dyspnea. Transthoracic echocardiography revealed severe valvular aortic stenosis and severe mitral stenosis. A preoperative coronary angiogram revealed an anomalous left circumflex (LCX) artery arising from the right coronary sinus. The patient underwent aortic and mitral valve replacement. Postoperatively, a non-ST segment elevation myocardial infarction developed, and coronary angiography confirmed subtotal occlusion of the anomalous LCX. An emergent reoperation with surgical revascularization was performed. Intraoperatively, the mechanism of injury to the LCX was determined to be compression of the distal LCX by the sewing ring of the two prosthetic valves.