The Heart Valve Society

Back to 2017 Program


Which Mitral Annuloplasty Device Allows Greater Respect for Circumflex Artery? A Case Report of Flow Disturbance.
Vincenzo D. Caruso, Inderpaul Birdi.
Basildon and Thurrock University Hospital, Basildon, United Kingdom.

Which Mitral Annuloplasty Device Allows Greater Respect for Circumflex Artery? A Case Report of Flow Disturbance.
Patient Demographics
A 72 year-old man with severe symptomatic mitral regurgitation was admitted for elective minimally invasive mitral valve surgery.
Relevant History
Preoperative echocardiography showed severe mitral regurgitation due to the prolapse of both leaflets, while the coronary angiography showed left coronary dominance and a large circumflex artery. A multi-slice coronary computed tomography angiography showed that the circumflex artery was close to the mitral annulus at level of the antero-lateral commissure and P1 scallops (2.5 mm).
Pre-Operative Plan
A minimally invasive approach was chosen, Because of the degenerative disease of the mitral valve, it was initially planned the use of semi-rigid ring to perform the mitral repair.
Discussion
Mitral valve repair was performed with two neochordae to P2 scallop and the implant of a 30 mm semi-rigid ring. Intraoperative transesophageal echocardiogram showed an excellent repair. However, subtle ST elevation in the infero-posterior leads was noted and echocardiography showed mild lateral wall hypokinesia. A clinical diagnosis of circumflex distortion was made and a long saphenous vein was anastomosed to the posterior descending artery; prior to this, using a 2 mm probe, the artery was found free from any obstruction. Subsequent weaning from CPB was smooth. An immediate post-operative angiogram confirmed the intra-operative diagnosis of circumflex distortion. The patient was returned to theatre, the semi-rigid ring was removed and a flexible band was implanted. The result of the post-operative angiogram was dramatically improved, with a complete restitution ad integrum of the circumflex flow.
Mitral valve surgery is associated with a potential risk of iatrogenic myocardial ischemia. In those patients with a short distance circumflex and mitral annulus, a flexible device may provide better protection of circumflex flow integrity, as in this case, where evidentially, circumflex flow disturbance was the result of stretch/external compression of the circumflex artery.
Figure 1. Angiography pre- and post-implant of a flexible device.


Back to 2017 Program