© 2014 Wiley Periodicals, Inc.
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Mitral Valve Repair in a Patient with an Anomalous Left Coronary Artery Robbert C. Bakker, M.D., Wobbe Bouma, M.D., Inez J. Wijdh-den Hamer, M.D., Ehsan Natour, M.D., Ph.D., and Massimo A. Mariani, M.D., Ph.D. Department of Cardiothoracic Surgery, University Medical Center Groningen, Groningen, The Netherlands ABSTRACT Anomalous coronary arteries may course in close proximity to the mitral annulus, which increases the risk of iatrogenic occlusion due to annular suture placement. We report a mitral valve repair in a 55-yearold male with severe mitral regurgitation and an anomalous retro-aortic left coronary artery, originating from the right coronary sinus, coursing in close proximity to the anterior mitral annulus. To minimize iatrogenic occlusion risk an open annuloplasty ring was used with good long-term results. doi: 10.1111/jocs.12374
(J Card Surg 2014;29:782–784)
A rare, but serious complication of mitral valve surgery is iatrogenic occlusion of the circumflex coronary artery (Cx) due to annular suture placement, which may occur in as many as 1.8% of patients.1 Anomalous coronary arteries may course in close proximity to the mitral valve annulus, which increases the risk of iatrogenic occlusion due to annular suture placement. Therefore, awareness and prompt diagnosis of anomalous coronary arteries are important in mitral valve surgery, since coronary artery anomalies are relatively common with a reported incidence of 5.64%.2 We report a mitral valve repair in a 55-year-old male with severe mitral reurgitation (MR) (Grade 4þ) and an anomalous retro-aortic course of the left coronary artery (LCA), originating from the right coronary sinus, and close to the mitral annulus. This report emphasizes the potential risks related to the placement of mitral annular sutures in patients with anomalous coronary arteries, which course closely to the mitral annulus, and discusses strategies to reduce these risks. SURGICAL TECHNIQUE A 55-year-old male presented with progressive shortness of breath (NYHA Class II) and a blowing systolic murmur at the apex radiating to the left axilla. Conflict of interest: The authors acknowledge no conflict of interest in the submission. Address for correspondence: Robbert C. Bakker, M.D., Department of Cardiothoracic Surgery, University Medical Center Groningen, P.O. Box 30001, 9700 RB Groningen, The Netherlands. Fax: þþ31 50 3611 347; e-mail: [email protected]
Transthoracic (TTE) and transesophageal echocardiography (TEE) showed severe MR (Grade 4þ) (Fig. 1A and B), and a normal left ventricular (LV) function. Coronary angiography did not show significant coronary artery disease. However, it did show that both the right coronary artery (RCA) and the LCA originated from two separate ostia in the right coronary sinus (Fig. 1C). The LCA coursed behind the aorta and in close proximity to the anterior mitral annulus until it reached its normal course. Computer tomography with 3D reconstruction showed the LCA originating from the right coronary sinus (Fig. 1D). The patient underwent an elective mitral valve repair. After a median sternotomy, the mitral valve was exposed with a left atrial approach through Waterston’s groove. Inspection of the mitral valve revealed a myxomatous thickened valve with a complete cleft of the posterior mitral valve leaflet between P2 and P3. The cleft was closed with interrupted prolene 5-0 sutures. Mitral annuloplasty was performed with an open 33 mm St. Jude Medical Tailor flexible ring (St. Jude Medical, Inc., St. Paul, MN, USA). By using this open annuloplasty ring annular sutures were avoided at the anterior side of the mitral annulus (i.e., part of the course of the anomalous LCA). Intraoperative TEE showed good function of the repaired mitral valve without residual MR (Grade 0) or mitral stenosis (MS). The patient was discharged on the fifth postoperative day. After two years of follow-up, the patient remained asymptomatic and TTE still showed Grade 0 MR and a normal LV function. Written informed consent was obtained from the patient for publication of this report and any accompanying images.
J CARD SURG 2014;29:782–784
BAKKER, ET AL. MITRAL REPAIR-ANOMALOUS CORONARY ARTERY
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Figure 1. Preoperative imaging. Preoperative TEE (A) and Doppler TEE (B); mitral valve prolapse and Grade 4+ MR. Preoperative coronary angiogram (right anterior oblique view) (C) and preoperative 3D computer tomographic reconstruction (D): left coronary artery originating from the right coronary sinus. Ao, aorta; Cx, circumflex coronary artery; LA, left atrium; LAD, left anterior descending coronary artery; LCA, left coronary artery; LCS, left coronary sinus; LV, left ventricle; MR, mitral regurgitation; RCA, right coronary artery; RCS, right coronary sinus; TEE, transesophageal echocardiography.
DISCUSSION Anomalous coronary arteries may course in close proximity to the mitral annulus, which increases the risk of iatrogenic occlusion due to placement of annular sutures for mitral valve surgery. Awareness and prompt diagnosis of an anomalous coronary artery are important in the preoperative work-up of mitral valve surgery. This raises the question whether all patients should undergo coronary angiography or other diagnostic imaging prior to mitral valve surgery, irrespective of age or other risk factors. Although there is some evidence that suggests that intraoperative TEE may be sufficient to identify coronary anomalies and iatrogenic occlusion due to annular suture placement, TEE is highly operator-dependent and does not guarantee the clinical accuracy that coronary angiography can provide in this setting.3 Regardless of the timing (preoperatively or intraoperatively) and the diagnostic modality, awareness and diagnosis of coronary anomalies remain important to prevent occlusion due to annular suture placement. Coronary artery anomalies are in fact relatively common with an incidence of 5.64% in angiographic studies.2 However, an LCA that originates from the right coronary sinus is more unusual with an incidence of 0.15%.2 This type of anomalous LCA may have a variable course, for example, retro-aortic (this case), pre-aortic (between aorta and pulmonary artery, most commonly encountered), or intraseptal.2
The anomalous course of the LCA, close to the anterior mitral annulus, increased the risk of iatrogenic occlusion due to annular suture placement. To minimize this risk we used an open (flexible) annuloplasty ring as a preventive measure. An open, flexible ring may not be the most obvious choice, since some evidence suggests that complete semirigid or rigid rings remodel the entire annulus, provide a better coaptation depth, and provide better long-term durability.4 However, open, more flexible rings allow for a more physiologic movement of the annulus during the cardiac cycle.4 Fortunately, several types of rings have shown good and comparable longterm durability in degenerative MR.5 The risk of iatrogenic coronary artery occlusion due to mitral annular suture placement may be reduced by awareness and prompt diagnosis of anomalous coronary arteries that course in close proximity to the annulus combined with preventive measures such as the use of a (flexible) open annuloplasty ring. Acknowledgment: We would like to thank Dr. G. Michielon for his expert advice on coronary artery anomalies and his assistance in writing this paper.
REFERENCES 1. Aybek T, Risteski P, Miskovic A, et al: Seven years’ experience with suture annuloplasty for mitral valve repair. J Thorac Cardiovasc Surg 2006;131:99–106.
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2. Angelini P, Villason S, Chan AV, et al: Normal and anomalous coronary arteries in humans. In Angelini P, (ed): Coronary Artery Anomalies: A Comprehensive Approach. Lippincott Williams & Wilkins, Philadelphia, 1999, pp. 27–150. 3. Ender J, Selbach M, Borger MA, et al: Echocardiographic identification of iatrogenic injury of the circumflex artery during minimally invasive mitral valve repair. Ann Thorac Surg 2010;89:1866–1872.
J CARD SURG 2014;29:782–784
4. Modi P, Hassan A, Chitwood WR Jr: Minimally invasive mitral valve surgery: A systematic review and meta-analysis. Eur J Cardiothorac Surg 2008;34:943– 952. 5. Gillinov AM, Cosgrove DM, Blackstone EH, et al: Durability of mitral valve repair for degenerative disease. J Thorac Cardiovasc Surg 1998;116:734–743.
Copyright of Journal of Cardiac Surgery is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
782
SURGICAL TECHNIQUE ___________________________________________________________
Mitral Valve Repair in a Patient with an Anomalous Left Coronary Artery Robbert C. Bakker, M.D., Wobbe Bouma, M.D., Inez J. Wijdh-den Hamer, M.D., Ehsan Natour, M.D., Ph.D., and Massimo A. Mariani, M.D., Ph.D. Department of Cardiothoracic Surgery, University Medical Center Groningen, Groningen, The Netherlands ABSTRACT Anomalous coronary arteries may course in close proximity to the mitral annulus, which increases the risk of iatrogenic occlusion due to annular suture placement. We report a mitral valve repair in a 55-yearold male with severe mitral regurgitation and an anomalous retro-aortic left coronary artery, originating from the right coronary sinus, coursing in close proximity to the anterior mitral annulus. To minimize iatrogenic occlusion risk an open annuloplasty ring was used with good long-term results. doi: 10.1111/jocs.12374
(J Card Surg 2014;29:782–784)
A rare, but serious complication of mitral valve surgery is iatrogenic occlusion of the circumflex coronary artery (Cx) due to annular suture placement, which may occur in as many as 1.8% of patients.1 Anomalous coronary arteries may course in close proximity to the mitral valve annulus, which increases the risk of iatrogenic occlusion due to annular suture placement. Therefore, awareness and prompt diagnosis of anomalous coronary arteries are important in mitral valve surgery, since coronary artery anomalies are relatively common with a reported incidence of 5.64%.2 We report a mitral valve repair in a 55-year-old male with severe mitral reurgitation (MR) (Grade 4þ) and an anomalous retro-aortic course of the left coronary artery (LCA), originating from the right coronary sinus, and close to the mitral annulus. This report emphasizes the potential risks related to the placement of mitral annular sutures in patients with anomalous coronary arteries, which course closely to the mitral annulus, and discusses strategies to reduce these risks. SURGICAL TECHNIQUE A 55-year-old male presented with progressive shortness of breath (NYHA Class II) and a blowing systolic murmur at the apex radiating to the left axilla. Conflict of interest: The authors acknowledge no conflict of interest in the submission. Address for correspondence: Robbert C. Bakker, M.D., Department of Cardiothoracic Surgery, University Medical Center Groningen, P.O. Box 30001, 9700 RB Groningen, The Netherlands. Fax: þþ31 50 3611 347; e-mail: [email protected]
Transthoracic (TTE) and transesophageal echocardiography (TEE) showed severe MR (Grade 4þ) (Fig. 1A and B), and a normal left ventricular (LV) function. Coronary angiography did not show significant coronary artery disease. However, it did show that both the right coronary artery (RCA) and the LCA originated from two separate ostia in the right coronary sinus (Fig. 1C). The LCA coursed behind the aorta and in close proximity to the anterior mitral annulus until it reached its normal course. Computer tomography with 3D reconstruction showed the LCA originating from the right coronary sinus (Fig. 1D). The patient underwent an elective mitral valve repair. After a median sternotomy, the mitral valve was exposed with a left atrial approach through Waterston’s groove. Inspection of the mitral valve revealed a myxomatous thickened valve with a complete cleft of the posterior mitral valve leaflet between P2 and P3. The cleft was closed with interrupted prolene 5-0 sutures. Mitral annuloplasty was performed with an open 33 mm St. Jude Medical Tailor flexible ring (St. Jude Medical, Inc., St. Paul, MN, USA). By using this open annuloplasty ring annular sutures were avoided at the anterior side of the mitral annulus (i.e., part of the course of the anomalous LCA). Intraoperative TEE showed good function of the repaired mitral valve without residual MR (Grade 0) or mitral stenosis (MS). The patient was discharged on the fifth postoperative day. After two years of follow-up, the patient remained asymptomatic and TTE still showed Grade 0 MR and a normal LV function. Written informed consent was obtained from the patient for publication of this report and any accompanying images.
J CARD SURG 2014;29:782–784
BAKKER, ET AL. MITRAL REPAIR-ANOMALOUS CORONARY ARTERY
783
Figure 1. Preoperative imaging. Preoperative TEE (A) and Doppler TEE (B); mitral valve prolapse and Grade 4+ MR. Preoperative coronary angiogram (right anterior oblique view) (C) and preoperative 3D computer tomographic reconstruction (D): left coronary artery originating from the right coronary sinus. Ao, aorta; Cx, circumflex coronary artery; LA, left atrium; LAD, left anterior descending coronary artery; LCA, left coronary artery; LCS, left coronary sinus; LV, left ventricle; MR, mitral regurgitation; RCA, right coronary artery; RCS, right coronary sinus; TEE, transesophageal echocardiography.
DISCUSSION Anomalous coronary arteries may course in close proximity to the mitral annulus, which increases the risk of iatrogenic occlusion due to placement of annular sutures for mitral valve surgery. Awareness and prompt diagnosis of an anomalous coronary artery are important in the preoperative work-up of mitral valve surgery. This raises the question whether all patients should undergo coronary angiography or other diagnostic imaging prior to mitral valve surgery, irrespective of age or other risk factors. Although there is some evidence that suggests that intraoperative TEE may be sufficient to identify coronary anomalies and iatrogenic occlusion due to annular suture placement, TEE is highly operator-dependent and does not guarantee the clinical accuracy that coronary angiography can provide in this setting.3 Regardless of the timing (preoperatively or intraoperatively) and the diagnostic modality, awareness and diagnosis of coronary anomalies remain important to prevent occlusion due to annular suture placement. Coronary artery anomalies are in fact relatively common with an incidence of 5.64% in angiographic studies.2 However, an LCA that originates from the right coronary sinus is more unusual with an incidence of 0.15%.2 This type of anomalous LCA may have a variable course, for example, retro-aortic (this case), pre-aortic (between aorta and pulmonary artery, most commonly encountered), or intraseptal.2
The anomalous course of the LCA, close to the anterior mitral annulus, increased the risk of iatrogenic occlusion due to annular suture placement. To minimize this risk we used an open (flexible) annuloplasty ring as a preventive measure. An open, flexible ring may not be the most obvious choice, since some evidence suggests that complete semirigid or rigid rings remodel the entire annulus, provide a better coaptation depth, and provide better long-term durability.4 However, open, more flexible rings allow for a more physiologic movement of the annulus during the cardiac cycle.4 Fortunately, several types of rings have shown good and comparable longterm durability in degenerative MR.5 The risk of iatrogenic coronary artery occlusion due to mitral annular suture placement may be reduced by awareness and prompt diagnosis of anomalous coronary arteries that course in close proximity to the annulus combined with preventive measures such as the use of a (flexible) open annuloplasty ring. Acknowledgment: We would like to thank Dr. G. Michielon for his expert advice on coronary artery anomalies and his assistance in writing this paper.
REFERENCES 1. Aybek T, Risteski P, Miskovic A, et al: Seven years’ experience with suture annuloplasty for mitral valve repair. J Thorac Cardiovasc Surg 2006;131:99–106.
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BAKKER, ET AL. MITRAL REPAIR-ANOMALOUS CORONARY ARTERY
2. Angelini P, Villason S, Chan AV, et al: Normal and anomalous coronary arteries in humans. In Angelini P, (ed): Coronary Artery Anomalies: A Comprehensive Approach. Lippincott Williams & Wilkins, Philadelphia, 1999, pp. 27–150. 3. Ender J, Selbach M, Borger MA, et al: Echocardiographic identification of iatrogenic injury of the circumflex artery during minimally invasive mitral valve repair. Ann Thorac Surg 2010;89:1866–1872.
J CARD SURG 2014;29:782–784
4. Modi P, Hassan A, Chitwood WR Jr: Minimally invasive mitral valve surgery: A systematic review and meta-analysis. Eur J Cardiothorac Surg 2008;34:943– 952. 5. Gillinov AM, Cosgrove DM, Blackstone EH, et al: Durability of mitral valve repair for degenerative disease. J Thorac Cardiovasc Surg 1998;116:734–743.
Copyright of Journal of Cardiac Surgery is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
