1

Situation Awareness for Circumflex Artery Injury During Mitral Valve

Surgery – Report of Five Cases and Presentation of a Diagnostic

and Treatment Algorithm

Germán A. Fortunato1*, Martin Misfeld2*, Roberto Battellini1, Alberto

Domenech1, Jens Garbade2, Michael A. Borger2, and Vadim Kotowicz 1

* GAF, MM and RB contributed equally

1
Department of Cardiovascular Surgery, Hospital Italiano de Buenos Aires, Ar-

gentina.
2
University Clinic of Cardiac Surgery, Heart Center, University of Leipzig,

Leipzig, Germany

Word count: 2088

Key words: mitral valve surgery, circumflex artery, complications

Corresponding author:

Germán A. Fortunato

Cirugía Cardiovascular

Hospital Italiano de Buenos Aires

Juan D. Perón 4190 (C1199ABD) Buenos Aires, Argentina

Tel.: (05411) 4959-0200 / Fax: (05411) 4959-5804

Email: [email protected]
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Abstract

Injury of the circumflex artery (Cx) during mitral valve surgery is a rare, maybe

under-recognized, but a potential life threatening complication. Immediate diag-

nosis and treatment will decrease morbidity and mortality in cases in which the

Cx artery is compromised. Here, we report a series of five cases in which this

complication occurred and describe the individual clinical courses. An algorithm

was developed for immediate diagnosis and treatment options.

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Introduction

Injury to the circumflex artery (Cx) during mitral valve annuloplasty or mitral

valve replacement (MVR) has been described to occur in up to 1,8% (1). Mainly

only case reports of this complication can be found in the literature (2-7). The

close anatomical relation of the Cx to the mitral annulus has the potential risk

that the artery could be narrowed, closed or distorted by sutures. In patients

with left dominance of the coronary system the distance between the Cx and

the mitral valve annulus has been reported to be 4.1mm (range 3 to 6.5mm),

whereas in patient with co-dominance of the coronary system the distance is

5.5mm (range 4.5 to 7mm) (3). However, not only the coronary dominance is a

potential factor that increases the risk of Cx injury (4), also the surgical

technique and plays an important role.

In previous reports a variety of treatment options have been proposed (2-7).

Our objective was to classify various situations of Cx injury and develop a

diagnostic and therapeutic algorithm.

Case 1

68-year old female was scheduled for surgery due to mitral regurgitation (MR)

grade II-III and aortic stenosis (AS) grade III. Her co-morbidities included arterial

hypertension, chronic obstructive lung disease and previous heart failure. Pre-

operative diagnostics revealed a calcified mitral annulus. Intra-operatively, the

annulus was first decalcified and a mitral valve reconstruction was done. Initial

saline test showed residual relevant mitral regurgitation, so the decision to re-

place the valve with a bioprosthesis was done. Additional aortic valve replace-

ment was performed with pericardial prosthesis. After 150 minutes of X-clamp
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time with myocardial protection using Bretschneider’s cardioplegia (Custodiol®

HTK. Alsbach-Hahnlein, Germany) the patient was weaned from cardiopul-

monary bypass (CPB) without any problems. During transfer to the stretcher,

ventricular fibrillation (VF) occurred. Electrical defibrillation was performed suc-

cessfully. Transesophageal echocardiography (TEE) showed good left ventricu-

lar function without any dis- or akinesis. VF was interpreted as a result of poten-

tial delayed air mobilization and/or prolonged ischemic time. Under hemody-

namically stable conditions with inotropic support, the patient was transferred to

the intensive care unit (ICU). Postoperatively creatinine kinase level increased

(max. CK-MB: 29 UI/L, normal range <4 UI/L) and was interpreted as periopera-

tive myocardial infarction. Coronary angiography (CA) was not performed due

to her hemodynamic stable conditions and her inconspicuous TEE. Atrial fibrilla-

tion was detected on post-op day four. Another TEE showed preserved ejection

fraction. The patient was transferred to the normal ward with still elevated CK-

MB levels but normal lactate. Atrioventricular block grade III occurred on day

four after surgery and epicardial pacemaker leads were connected. On the 7th

postoperative day, the patient developed respiratory failure. Presuming pul-

monary embolism, she was immediately returned to ICU and eventually died

one hour later.

On autopsy a pulmonary embolism was excluded. However, about 4.5 cm after

the origin of the left coronary artery, a stitch compromising the CX was ob-

served. This suture was related to the reconstruction of the decalcified MV an-

nulus (fig. 1).

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Case 2

A 69-year old male with previous mechanical aortic valve replacement (size

19) and aortic root patch enlargement developed severe mitral valve stenosis.

Preoperative TEE confirmed preserved left ventricular ejection fraction, severe

mitral valve stenosis (mean gradient 12 mmHg), calcification of the posterior an-

nulus and pulmonary hypertension with right ventricular dilatation. CA showed

left dominance, without any coronary artery lesions. The surgical approach was

performed via redo mid-sternotomy. Ante- and retrograde cold blood cardiople-

gia was given every 30 minutes. The posterior MV annulus was partially decal-

cified and a mechanical valve 29 mm (St. Jude Medical Inc Minnesota, USA)

was implanted. After aortic declamping, TEE showed preserved left ventricular

function. However, during reperfusion, bradycardia and impairment of left ven-

tricular contraction appeared. An intra-aortic ballon pump was inserted. The pa-

tient was pacemaker dependent at this time. Hemodynamic parameters im-

proved and then, she was transferred to the ICU. Due to pathological ECG

changes with ST-segment elevation (lateral-inferior) an emergency coronary an-

giography was performed. Proximal occlusion of the Cx was observed (fig. 2,

Second Case A). A stent (BMS 3,5x18 mm, B. Braun Melsungen, Germany)

was implanted with good angiographic results (Fig. 2 Second Case B). How-

ever, the patient eventually died 48 hours after the operation due to persisting

low cardiac output with biventricular failure.

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Case 3

64-year old male was diagnosed with asymptomatic, severe MR. Preoperative

TEE showed severe MR with a flail P2 segment. CA showed normal coronaries

with right dominance. Surgery was performed through right mini-thoracotomy.

CPB was established via the right arterial and venous femoral vessels.

Bretschneider´s cardioplegia was used in a single dose of 2000 ml for myocar-

dial protection. Neochords of 16 mm length were attached to the flail segment

and an ring annuloplasty (Taylor™ St. Jude Medical Inc. Minnesota, USA) was

performed. Intra-operative water testing was satisfactory. During weaning from

CBP, systolic anterior motion was observed, causing severe MR. The heart was

arrested again and a bioprosthesis nº 31 (Hancock, Medtronic Inc. Minneapolis,

USA) was implanted. During decannulation of the groin vessels, left bundle

branch block appeared. On TEE, a mild to moderate ventricular impairment was

observed. The mitral valve prosthesis function was unremarkable and the cir-

cumflex artery was detected without any irregularities and with preserved flow

(fig. 2 C).

During chest closure, sudden ventricular fibrillation occurred and the patient

was successfully defibrillated. Urgent transfer to the catheter lab was arranged

and coronary angiogram revealed obstruction of the mid segment of the Cx. A

stent (BMS 3,5x18 mm, B. Braun Melsungen, Germany) was inserted (fig. 2

Third Case A and B). An additional intravascular ultrasound of the Cx showed

remaining, extrinsic retraction at the level of the mid stent segment. Therefore, a

second stent (BMS 4.0 x12 mm, B. Braun Melsungen, Germany) was implanted

(stent-in-stent). After 48 hours sudden ventricular fibrillation occurred again and

defibrillation was successfully performed. Immediate re-angiography showed

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patent stents. Eventually, the patient was discharged on the 7th postoperative

day in stable conditions. At one-year follow-up the patient was in stable clinical

conditions without any symptoms.

Case 4

A 68-year old female presented with severe MR due to P2 prolapse, dyspnea

(NYHA II) and mild to moderate pulmonary hypertension. CA was normal with

left dominance of the coronary system. Surgery was performed via mid-ster-

notomy. Ante- and retrograde cold blood cardioplegia was administered for my-

ocardial protection. The mitral valve was repaired using artificial chordae and an

ring annuloplasty nº 32 was done (Surgiflex® FOCMEDICAL, City Bell, Ar-

gentina). During weaning from CPB, signs of ischemia were observed on ECG.

TEE showed moderate ventricular dysfunction and no MR. Air was excluded as

a cause of ischemia and immediate bypass grafting using a venous graft was

performed to the Cx. Further weaning from CBP was possible with normal ECG

and without left ventricular abnormalities on TEE. Coronary magnetic resonance

(MRI) showed proximal occlusion of the Cx and a patent saphenous bypass

graft to the Cx (Fig 3).

Case 5

A 26-year-old female suffering from severe MR and NYHA II symptoms was

referred to our institution. The diagnostic echocardiography confirmed severe

MR due to bileaflet prolapse. The patient was also noted to have billowing and

excessive leaflet tissue in the posterior and anterior leaflets – consistent with a

Barlow´s valve – along with a normal left ventricular ejection fraction. Because
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of the young age and the absence of any risk factors, coronary angiography

was not performed. The patient underwent a minimally invasive approach. All

segments of the posterior leaflet and the A2 segment of the anterior leaflet

showed a prolapse intra-operatively. Repair of the valve by an annuloplasty

(Carpentier-Edwards Physio II Ring, size 38mm) an a direct approximation of

the A2 segment to the P2 segment creating a double orifice valve by using a 4.0

monofilament suture (Alferi-plasty was done). Intra-operatively TEE showed a

competent MV without any relevant regurgitation or elevated transvalvular

gradients. No echocardiographic abnormalities of the LV contractility or

coronary perfusion were observed and the patient was transferred to the

recovery room in stable condition. After arrival ECG showed signs of typical ST

elevation related to the Cx territory, indicating myocardial ischemia. Additionally,

a ventricular tachycardia was noticeable. An immediate coronary angiography

was performed and revealed total occlusion of the mid portion of the Cx in

projection of the P1 segment without any interventional options. Subsequently

the patient underwent urgent re-operation. Using the same surgical approach

the MV was exposed and the ring sutures in the region of P1 and P2 were

gently removed. The same annuloplasty ring was repositioned and fixed with

three additional sutures with pledgets originating from the basis of the posterior

leaflet. The further course was uneventful. TEE confirmed a competent MV

again and a sufficient perfusion of the Cx. The patient was extubated within

hours after the operation under stable hemodynamic conditions. Blood test

showed a maximum of CK levels of 3800 U/L and CK-MB levels of 420.5U/L.

Cardiac enzymes started to decline on the second postoperative day. ECG was

normal. Echocardiography before discharge confirmed normal LV function

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without any regional dysfunction and a competent MV. An additional CT-scan

with a 3D reconstruction of the heart and coronary arteries was performed

excluding any obstruction of the Cx (fig. 4). The patient was discharged on the

12th postoperative day.

Discussion

We present a series of five cases of Cx injury following MV surgery. A variety of

clinical presentations, delayed diagnosis, immediate diagnosis, fatal outcome,

as well as different treatment options are described. An algorithm is given to re-

duce the risk of delayed diagnosis and treatment for improved patient outcome

following this complication

The exact number of Cx injury after annuloplasty or MV replacement is un-

known. Although rarely reported, it is a serious and potential lethal complication

(1-7). Diagnostic signs and symptoms may vary and can even be delayed (case

5). Often, hemodynamic impairment and signs of myocardial ischemia on TEE

and/or ECG are interpreted as a result of air embolism due to improper initial

de-airing maneuvers, especially during minimally invasive mitral valve surgery.

These unstable hemodynamic conditions are transient and disappear after a

short time of reperfusion. If they persist, potential Cx compromising should be

suspected. However, even in stable hemodynamic conditions, isolated ECG

changes may represent Cx injury (case 1). In the first two cases presented, de-

layed adequate diagnosis resulted in fatal outcome.

Even without any hemodynamic or diagnostic abnormalities, Cx injury should be

excluded routinely. This can be performed using intra-operatively TEE, which

has been described by Ender et al. (8). They underlined the importance of com-
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paring the detection and flow in the Cx after repair or replacement with the intra-

operative TEE findings before MV surgery was performed. The distance to the

MV annulus can be measured by TEE and should act as a precaution for the

surgeon, if the relation of the Cx to the posterior annulus is close. Pre-operative

angiography or reconstructive coronary CT- or MRI- scans can also give impor-

tant information with regard to the size of the Cx. Beside these anatomical fac-

tors, technical factors play an important role to avoid Cx injury (table 1).

If diagnosis is delayed, even if adequate treatment is performed, fatal outcome

can occur (case 2). Immediate revascularization of the Cx is mandatory to avoid

this. There are different options to accomplish this and the decision should be

made on an individual base. Beside interventional procedures (cases 2 and 3),

removal of the sutures, which cause Cx obstruction (case 5) can be performed.

In some cases, immediate coronary artery bypass grafting may be necessary

(case 4). However, the latter one may be difficult to achieve, when a mitral valve

prosthesis is in place, as lifting of the heart may cause further damage.

In most published case reports, immediate coronary angiography was per-

formed demonstrating occlusion of the Cx near the anterolateral commissure

(2,3). We also could document by CA closure of the Cx (fig 2 and 3). Often, the

Cx is not completely blocked by a suture, but traction of the circumferential tis-

sue by an annular stitch causes kinking of the coronary artery and, therefore,

partial obstruction or even total blockage.

To avoid this complication, surgeons should be aware of it and should suspect

it, when diagnostic abnormalities occur immediately after MV surgery. Adequate

reaction is mandatory and therapeutic options as removal of stitches, which po-

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tentially are causing the obstruction, PCI or even coronary artery bypass graft-

ing should be considered early.

The algorithm depicted in figure 5 could lead as a guide during mitral valve

surgery to avoid, early detect and adequately deal with Cx injury. Close collabo-

ration between surgeon, echographist and anesthetist is of the utmost impor-

tance to sufficiently judge the situation and initiate adequate actions immedi-

ately.
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Tables
Table 1. Factors responsible for potential circumflex injury

Anatomical factors - Left dominance of coronary artery

system
- Close relation of circumflex artery to
mitral valve annulus
Technical factors - Reconstruction of posterior mitral
valve annulus (decalcification, repair
of annular abscess)
- Improper placement of annuloplasty
or valve sutures
- Inadequate size of annuloplasty ring
or valve
- Improper visualization of posterior
mitral valve annulus
- malposition of annuloplasty ring or
valve
- Inadequate size and form of suture
needle

Figures
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Fig. 1

Fig. 1. Case 1: Autopsy showing a polypropylene stitch (yellow arrow)

compromising the circumflex artery (Cx).
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Fig. 2

Fig. 2. Second Case. Coronary angiography. A: Total CX occlusion (yellow

arrow). B: Angiography after stent implantation.
Third Case. Coronary angiography. A: Injury of middle third of the CX (yellow
arrow). B: Results after stent implantation.
C. Flow in CX during transesophageal echocardiography (yellow arrow)

Fig. 2

Fig. 3. Case 4. Cardiac MRI showing CX occlusion and a patent saphenous

bypass graft (yellow arrow).
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Fig. 4

Fig.4 CT-scan and 3D reconstruction of the circumflex artery and the mitral
annuloplasty. The close anatomical relation between the circumflex artery and
the posterior mitral annulus in the region of P1 can be seen.
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References. Cx-Circumflex artery, CR-Coronary Angiography, CT-Computed Tomography,

MRI-Magnetic Resonance Imaging, ECG-Electrocardiogram, LV-Left Ventricle, CPB-Cardiopul-
monary Bypass, CABG-Coronary Artery Bypass Grafting, MV-Mitral Valve, PCI-Percutaneous
Coronary Intervention.

Fig. 5 Diagnostic and treatment algorithm for potential circumflex artery injury in
patients undergoing mitral valve surgery
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