Next Article in Journal
Impact of SARS-CoV-2-Related Hygiene Measures on Community-Acquired Respiratory Virus Infections in Lung Transplant Recipients in Switzerland
Next Article in Special Issue
Learning Curve Analysis of Robotic-Assisted Mitral Valve Repair with COVID-19 Exogenous Factor: A Single Center Experience
Previous Article in Journal
The Prognostic Utility of the Metastatic Lymph Node Ratio and the Number of Regional Lymph Nodes Removed from Patients with Small Bowel Adenocarcinomas
Previous Article in Special Issue
Minimally Invasive Surgery: Standard of Care for Mitral Valve Endocarditis
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
Medicina
Volume 59
Issue 8
10.3390/medicina59081470
medicina-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles thumb_up
...
Endorse textsms
...
Comment
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Review

Circumflex Coronary Artery Injury during Modern Mitral Valve Surgery—A Review of Current Concepts and Perspectives

by
Johan van der Merwe
1 and
Filip Casselman
2,*
1
The Keyhole Heart Centre, Netcare Blaauwberg Hospital, Cape Town 7441, South Africa
2
Cardiovascular Surgery, Cardiovascular Centre, OLV Clinic, 9300 Aalst, Belgium
*
Author to whom correspondence should be addressed.
Medicina 2023, 59(8), 1470; https://doi.org/10.3390/medicina59081470
Submission received: 25 May 2023 / Revised: 30 July 2023 / Accepted: 3 August 2023 / Published: 16 August 2023
(This article belongs to the Special Issue New Advances in Mitral Valve Diseases Management)
Browse Figures
Versions Notes

Abstract

:
The devastating impact of a circumflex coronary artery (CX) injury during mitral valve (MV) surgery is well reported. Despite significant improvements in preoperative risk assessment, intraoperative diagnosis and perioperative treatment strategies of CX injury during MV surgery, recent reports re-emphasize the variability in presentation, the unpredictable mechanisms of injury and the conflicting evidence regarding perioperative management. The progressive transition from conventional sternotomy access to minimally invasive surgical and transcatheter (TC) interventions for MV disease are associated with significant learning curves and require additional single-shaft and robotic console suture manipulation skills with special attentiveness to the potential risk of CX injury. The introduction of hybrid theatres that facilitate single stage surgical and TC interventions also provides new intraoperative diagnostic and therapeutic options without transporting unstable patients for percutaneous coronary intervention (PCI) assessment. By utilizing a MeSH terms-based PubMed search, a total of 89 patients with CX injury that occurred during MV surgery was identified from 49 reports between 1967 and 2022. MV surgery was performed by conventional sternotomy (n = 76, 85.4%), endoscopic (n = 12, 13.4%) and robotic access (n = 1, 1.1%), with 35 injuries (39.3%) resulting in total CX occlusion. Rescue PCI was utilized in 40 patients (44.9%). This manuscript provides a systematic overview of all available historic and contemporary reports on CX injury during MV surgery, outlines recent refinements in CX injury mechanisms, describes current MV surgery associated CX injury prevention and diagnosis and treatment strategies and highlights important MV procedural aspects that may minimize the risk and consequences of CX injury.

1. Introduction

Myocardial infarction secondary to circumflex coronary artery (CX) distortion or occlusion during mitral valve (MV) surgery is associated with devastating postoperative morbidity and mortality outcomes [1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49]. Despite significant improvements in preoperative risk identification [50,51,52,53,54,55,56,57,58,59,60], surgical techniques [61,62,63,64,65] and surgical awareness, CX injury during MV surgery remains a dreaded complication with no current consensus on preventative and therapeutic strategies. This manuscript provides a systematic review of all available reports on CX injury during isolated MV surgery and describes current CX injury prevention and diagnosis and treatment strategies. Less invasive MV surgical approaches that utilize special single shafted instruments under direct, endoscopic or robotic vision [66] require additional instrument manipulation skills [67,68,69] and a thorough understanding of the CX, coronary sinus (CS) and MV surgical anatomy to avoid CX injury during the initial learning curves. Furthermore, reports on the potential incidence and risk of CX injury related to advances in innovative transcatheter MV repair [70,71] and replacement [72,73] technology are also emerging. By utilizing the MeSH terms “mitral valve surgery”, “mitral valve repair”, “mitral valve annuloplasty”, “mitral valve replacement”, “circumflex coronary artery injury”, “complications”, “myocardial infarction” in various combinations, a total of 89 patients who sustained CX injury secondary to MV surgery was identified from 49 PubMed reports between 1967 and 2022 (Table 1). Between 2011 and 2022, a total of 29 reports described 60 CX injury events during MV surgery. A flowchart that outlines the PubMed and PRISMA search methodology is presented in Figure 1.

2. Current Circumflex Coronary Artery Injury Prevention, Diagnosis and Treatment Strategies

The documented incidence of CX injury secondary to MV surgery varies between 0.15% and 4.0% [1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49], but various authors suggest that the true incidence is probably significantly higher due to underreporting. Danielson and colleagues [1] were the first to document 3 patients with CX injury in their series of 178 MV procedures in 1967, followed by Roberts [2], Morin [3], Virmani [4] and various other authors describing their experiences. The recent advances in minimally invasive and TC mitral valve technology and techniques are paralleled by renewed interest and awareness of CX injury during MV procedures, with contemporary reports outlining innovative strategies to prevent, timeously diagnose and optimally treat CX injury [31,48].
A.
Current strategies to identify circumflex coronary arteries at risk during mitral valve surgery
Bennani and colleagues [60] recently described the surgical anatomy of the CX–CS–MV complex after dissecting and measuring the course and distances of the CX, CS and MV in 25 explanted hearts. The CX usually courses between the base of the left atrial appendage and the anterior MV commissure, 3–4 mm from the MV leaflet–annular attachment and progressively courses further away from the posterior MV annulus (Figure 2). Table 2 summarizes clinical and contemporary imaging criteria considered to be high risk for CX injury within the context of MV procedures.
  • Coronary angiography;
Preoperative coronary angiography is regarded as the gold standard for coronary artery evaluation within the context of valvular heart disease [74,75]. The identification of anomalous [2,5,76], large left dominant (Figure 3A) or codominant CX systems predispose to a higher risk for CX injury [48,59].
  • Computerized tomography coronary angiography;
Numerous reports describe the expanding role of computerized tomographic coronary angiography (CTA) in the evaluation of the CX–CS–MV complex. Mlynarski and colleagues [58] reported 52 anatomical variations in 320 CTA evaluations of the CX–CS–MV complex and reported that only 1.6% of CX could not be visualized in their series. The authors concluded that the significant anatomical variation of the CX strengthens the role of CTA in preoperative surgical and transcatheter MV planning. Caruso and colleagues [59] recently concluded from their series of 95 examinations that the addition of 3D reconstruction to preoperative CTA facilitates improved and operator-independent distance measurement accuracy between the CX and MV annulus (Figure 3B) and regard CTA with 3D reconstruction superior to other imaging modalities in identifying CX potentially at risk during MV surgery. The measured distance between the CX and MV annulus was significantly smaller in left (mean distances of 3.0 ± 2.1 mm) and codominant CX systems (4.6 ± 2.3 mm) compared to right dominant CX systems (mean distances of 5.9 ± 3.2 mm). However, the authors also describe that more than 20% of right dominant CX systems presented with CX to MV annular distances of less than 3 mm, which concur with earlier reports from Virmani [4], Cornu [76] and Kaklikkaya [77]. Only reports from Mulpur [7], Grande [18] and Varela [21] describe CX injury during MV surgery in a dominant right coronary artery system. CTA is now well established in the diagnosis of coronary artery disease [55], and its role in evaluating coronary artery anatomy and disease as a primary imaging modality in valvular heart disease will continue to expand.
  • Transthoracic and transesophageal echocardiography;
Transthoracic echocardiography (TTE) can identify posterior MV leaflet pathology that requires extensive reconstructions in close relation to the CX anatomical course. Severe MV annular calcification and destructive posterior MV or annular infective endocarditis are amongst the TTE-identifiable diseases that present increased CX injury risk during MV surgery. The CX course in relation to the MV can also be appreciated by TTE. Krzanowski and colleagues [56] described their TTE technique to visualize the proximal and middle CX course by parasternal short axis and modified five-chamber TTE views. The authors suggest that CX evaluation by TTE can be of value in evaluating the CX–CS–MV complex, but acknowledge that advanced TTE skills are required and conclude that additional, non-operator-dependent imaging modalities should be used to guide CX anatomy in preparation for MV surgery. Bevilacque [51] and Mak [53] independently reported on the excellent CX and CX–CS–MV complex visualization by transesophageal echocardiography (TEE) and 3D imaging software, which facilitates accurate distance measurement capabilities that correlate well with current CTA technology. Ender and colleagues [57] routinely visualize the proximal and distal CX course with its associated diameter in relation to the CX–MV complex during MV surgery by using a combination of B-mode imaging and color Doppler. The authors reported successful proximal, CX coronary sinus intersection and distal CX visualization in 99%, 90% and 86% of patients, respectively. A modified mid-esophageal long-axis view of the aortic valve at a 110 ± 20 degrees transducer angle is regarded as the optimal TEE view for accurate CX diameter measurements along its course. The important role of TEE skilled anesthetists in ensuring optimal MV surgery outcomes were recently re-emphasized by Landa and colleagues [46]. Man and colleagues [54] described the application of CTA and TEE merger software to further refine the CX–CS–MV complex relationships in cases where CTA-derived measurements identify anatomy at risk. Experts currently suggest that the combination of TTE, TEE and CTA provides exciting multi-modality imaging to determine CX injury risk in preparation for less invasive and TC mitral valve interventional planning [48,54,57,59]. Further studies are required to define the role of each individual imaging modality in isolation and in combination to evaluate CX anatomy and to redefine the traditional role of routine coronary angiography at the expense of additional radiation exposure in preparation for contemporary MV surgery.
B.
Modern mitral valve surgical techniques and technology to minimize circumflex coronary artery injury risk
The rapid development, favorable outcomes and simplification of durable MV repair techniques as described by Carpentier [62,63,64] redefined the modern role of MV replacement [61]. The reported decrease in MV replacement procedures performed in developed countries [78] parallels modern international guidelines [74,75] that strongly advocate MV repair whenever possible. Various reports describe CX injury during MV repair [6,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,26,27,29,30,31,32,33,34,35,38,39,41,42,44,46,48,49] and emphasize the importance of accurate and meticulous annuloplasty needle entry angle, direction, depth, instrument manipulation and exteriorization in areas where the CX–CS–MV complex is at risk. Wide posterior leaflet quadrangular resection, extensive posterior sliding plasty and the use of excessively small or large annuloplasty rings should be avoided to minimize the risk of tissue traction, distortion or external compression of the CX in high-risk areas [79,80,81,82,83]. Caruso and colleagues [59] utilized flexible annuloplasty rings in high-risk CX–CS–MV-complex patients, which accounted for 50% of their series. Annular sutures between the anterolateral commissure and P1 were omitted in 58% of these patients. Chauvette and colleagues [83] strongly advocate anterolateral trigone stabilization to prevent partial annuloplasty as a fundamental principle of safe and durable MV repair, emphasized that the fear of CX injury should not result in inadequate MV repair and reiterated the importance of rigid rings within the context of ischemic MV disease. In addition to mechanical CX injury, Obarski and colleagues [84] suggested that water-testing of valve competence following MV repair may potentially result in air embolism and transient CX ischemia, which may resolve or evolve to infarction. Minimally invasive and robotic approaches are becoming increasingly established as excellent surgical alternatives to conventional MV surgery by sternotomy access [66]. However, the learning curves associated with establishing less invasive surgical programs are well reported [67,68,69] and require additional skills in single-shaft and robotic console instrument manipulation. CX injury during less invasive MV procedures is described [13,18,20,26,28,31,41,42,44,46]. The technical aspects of endoscopic posterior annular suture placement are outlined in Figure 4 and can be mastered in innovative simulation environments [85]. Everting and non-everting annular sutures should not be placed more than 3 mm from the posterior annulus in MV replacement. Extensive posterior annular resections and reconstructions required in severe MV annular calcification [86] and destructive infective endocarditis [87] should be performed with CX injury awareness. Innovative TC–MV technology currently includes various annuloplasty devices that use anchors or sutures for annular implantation through the left atrium or CS [70,71] and replacement technology [72,73] that are implanted through peripheral or trans-apical access. A meta-analysis by Kargoli and colleagues [72] recently reported that no CX injury secondary to TC mitral valve devices was described or observed to be up to date. Effectiveness and durability are the main concerns of TC approaches, and outcome reports are progressively emerging with exciting prospects for future treatment of MV disease.
C.
Intraoperative circumflex coronary artery injury diagnosis and treatment pathways
Pessa and colleagues [50] emphasized that the clinical presentation of CX injury correlates with the impact on CX flow and the underlying myocardial reserve. The inability to wean from cardiopulmonary bypass, acute hemodynamic compromise, ST-segment elevation on electrocardiography, refractory ventricular arrhythmias, lateral left ventricular regional wall motion abnormalities and disproportionate cardiac enzyme leak can present during or after the separation from cardiopulmonary bypass or later in the postoperative period [31,48]. The reported physiological classification and anatomical mechanisms that result in iatrogenic CX injury are outlined in Table 3.
The intraoperative diagnosis of CX injury is currently documented in 20 reports of 34 patients [6,10,11,13,14,16,17,18,19,20,22,28,31,35,39,40,41,42,45,46] and suggests that only 48.3% of all documented CX injuries during MV surgery are diagnosed intraoperatively. Once suspected, urgent confirmation of CX injury and the rapid identification of the responsible mechanism by TEE and/or coronary angiography are crucial to expedite the appropriate treatment strategy [10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49]. Flow-limiting CX injuries diagnosed intraoperatively require emergency revascularization and restoration of distal perfusion by either emergency empiric coronary artery bypass grafting (CABG) of the obtuse marginal branches utilizing saphenous vein [6,10,14,15,19,27,31,37,38,48], by revising the prosthesis sutures [6,7,17,20,22,30,32,36,38,42,48] or by PCI [8,9,11,12,13,16,18,20,21,22,23,24,26,28,29,31,32,33,34,35,37,38,39,40,41,42,43,44,45,46,47,48,49]. CABG should strongly be considered in an unstable intraoperative setting, where transfer to the catheterization laboratory is prohibited or delayed and where TEE or angiography confirm total CX occlusion [48], especially if sternotomy access is utilized. Revision of annuloplasty sutures in isolation or in combination with either CABG or PCI is documented in 14 reports and can be considered in minimally invasive MV surgery where conversion to sternotomy is not possible or desirable, or where emergency CABG may be challenging [13,18,20,26,28,31,41,44]. Various authors elected to transfer confirmed CX injuries directly from the operating room (n = 21) or from a postoperative intensive care setting (n = 18) for coronary angiography and PCI after Mantilla and colleagues [8] reported the first PCI for a partially occluded CX injury in 2004. Revascularization by PCI is feasible and preferred in a stable intraoperative setting where CX injury is confirmed to be the result of a partial CX occlusion and where transfer and ischemic reperfusion times are minimal. The inability to cross totally occluded CX injuries with guidewires, stent under-expansion and potential CX rupture are amongst the immediate risks reported with PCI [43,48,49]. The recent advances in hybrid theatre technology, which facilitate combined single-stage surgical MV and TC interventions [65], may decrease CX ischemic reperfusion time by providing the option of rapid on-table coronary angiography and attempts at PCI as an alternative to CABG once the clinical suspicion and mechanism of CX injury is confirmed by TEE (Figure 5).
D.
Postoperative and delayed circumflex coronary artery injury diagnosis and treatment strategies
Available reports suggest that the majority of CX injuries secondary to MV surgery manifest during the postoperative period, with 47 of 89 currently documented patients (52.8%) reported to be diagnosed and treated postoperatively. The postoperative clinical presentation of CX injury includes acute or progressive hemodynamic compromise, increased exogenous inotropic support requirement, ST segment elevation or new refractory ventricular arrhythmias on electrocardiography, new lateral left ventricular regional wall motion abnormalities and cardiac enzyme levels suggestive of myocardial ischemia [31,48]. Zegdi and colleagues [15] reported the only postoperative diagnosis of CX injury treated by emergency CABG in 2007, while revision of MV sutures was utilized in four patients with CX injury diagnosed in the postoperative period (8.5%). PCI was the preferred strategy in 46.8% (n = 22) of postoperative CX injury patients. Grande [18] and Pettinari [29] independently emphasized the technical difficulty of postoperative PCI in anomalous vessels and advocate careful preoperative MV planning in the event of postoperative CX injury. Reports of delayed complications following rescue PCI are emerging and include in-stent restenosis and a need for future repeat revascularization reinterventions [26,48]. Somekh and colleagues [26] described an iatrogenic CX to left atrial fistula following a PCI for CX injury secondary to MV surgery on the 15th postoperative day. The patient presented with progressive cardiac failure, partial annuloplasty ring dehiscence, severe left atrial enlargement and a fistula. The patient underwent subsequent MV replacement and suture closure of the fistula with a favorable short-term outcome. Gentry and colleagues [36] reported a CX to left atrial fistula 1 year postoperatively, with successful subsequent redo-MV replacement and a favorable outcome. Ziadi and colleagues [27] described the presentation of a large left ventricle pseudoaneurysm and severe MV regurgitation recurrence 5 months after initial MV repair and unrecognized CX injury. The authors postulate that the occlusion may have developed gradually, suggesting that this complication resulted from a combination of fixed mechanical suture occlusion, sub-intimal hematoma, formation, CX spasm and deformation of the vessel. The surgical repair included patch closure of the pseudoaneurysm, mitral valve replacement and tricuspid annuloplasty with a favorable prognostic outcome. Mulpur and colleagues [7] presented a CX injury identified by coronary angiography 14 years after the initial MV surgery. The authors postulate that a suture laceration resulted in an external hematoma around the CX origin in a right dominant coronary artery system and resulted in partial occlusion.
E.
The impact of CX injury on contemporary in-hospital outcomes
Only seven reports on CX injury during MV surgery were present up to the year 2000 [1,2,3,4,5,6,7], which included nine MV replacements and two annuloplasty repairs. None of these patients survived the incident prior to 1982, with Tavilla and colleagues [6] being the first to recognize CX injury after annuloplasty intraoperatively and managing the event successfully by combining annuloplasty revision and CABG. Speziale [5] reported a successful 30-day survival without any intervention, but acknowledge poor quality life resulting from irreversible cardiac failure. The progressive awareness of CX injury related to MV surgery, paralleled by improved diagnostic imaging and therapeutic options, resulted in 42 subsequent groups sharing their cumulative experiences that include 89 patients up to date. In total, 30-day mortality occurred in 20.2% of documented patients who sustained CX injury during MV surgery from 1967, which improved to 16.7% from reports published between 2011 and 2022. The favorable in-hospital survival outcomes of conservative therapy in partial CX occlusions were recently independently reported by Yavari [43] and Nasseradine [49] after attempts at rescue PCI were unsuccessful. However, post-discharge reports on these patients were not available. Raza [13], Grande [18], Ender [20], Folkmann [28], Felekos [41], Caruso [42] and Landa [46] described CX injury after endoscopic MV surgery without any 30-day mortality after successful PCI or revision of the annuloplasty. Aravelo [44] described CX injury after robotic MV surgery, which was successfully managed by PCI. Bargagna and colleagues [48] reported 10 patients with CX injury in their series of 6501 MV procedures over a 13-year period. The diagnosis was confirmed intraoperatively and postoperatively in five patients respectively. PCI was performed in distorted or partially occluded CX injuries (n = 5) and in one patient with a totally occluded CX. Severe PCI complications occurred in three patients due to coronary artery rupture (n = 2) and balloon under-expansion (n = 1), which required emergency CABG in two patients. In contrast to PCI, no complications were observed in patients who were treated by immediate CABG (n = 3). One patient with CX distortion was treated by removing sutures from the anterolateral commissure to the middle of the posterior annulus with immediate restoration of flow. The authors demonstrated prolonged intensive care admission, blood transfusion requirements and risk of multi-organ dysfunction in all patients. Eight patients were eventually discharged to cardiac rehabilitation centers and two patients died of multi-organ failure and massive cerebral hemorrhage while awaiting heart transplantation, respectively. Severe MV regurgitation was diagnosed 1 year postoperatively and required MV replacement with subsequent mortality due to multi-organ failure.
F.
Proposal of a comprehensive algorithm to prevent, diagnose and treat circumflex artery injury during mitral valve surgery
The detrimental impact of CX injury during MV surgery on mortality and subsequent quality of life in survivors is well described [1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49]. Bargagna and colleagues [48] re-emphasized that the true incidence of CX injury is most likely underreported due to unawareness of CX injury in clinically stable patients, publication bias and unrecognized clinical features. Logistical and infrastructure challenges may also contribute to delays in establishing a swift diagnosis. The pathophysiology of acute coronary occlusion and the devastating sequelae of myocardial infarction is extensive studied [88] and reconfirms the importance and urgency in recognizing, diagnosing and treating suspected CX injury during MV surgery as soon as possible. It is imperative that the MV surgeons examine the CX–CS–MV complex in detail as part of their routine valvular heart disease protocols [74,75] with special attention to TTE, TEE, CTA and coronary angiographic-derived images. Anesthetic proficiency in perioperative TEE interpretations is strongly recommended and a thorough CX–CS–MV complex evaluation should be part of the routine. Surgical techniques should follow routine principles with special attention to needle manipulation angles and depth in higher risk zones, meticulous sizing of prosthesis and careful resection and reconstruction of posterior MV components. The operating team should be familiar with the clinical presentation of CX injury and be well prepared to implement a protocol of rapid decision making and treatment. Postoperative continuation of care should also be aware of signs and symptoms suggestive of CX injury and must be able to identify, diagnose and assist with rapid decision making and treatment. A comprehensive CX injury prevention, diagnosis and treatment algorithm is proposed in Figure 6.

3. Conclusions

MV interventions are associated with the infrequent risk of iatrogenic CX injury, which requires rapid recognition and appropriate therapy. The preoperative coronary angiography, CTA, TTE and TEE evaluation of coronary artery dominance, CX origin, CX course and the CX–CS–MV complex relationships should be routine. Potential intraoperative maneuvers that increase the risk of CX injury should be avoided where possible and intraoperative suspicions of CX injury should be rapidly confirmed by TEE and treated by either suture release, CABG or PCI. Postoperative CX injury identification must be confirmed by either TEE or coronary angiography with subsequent PCI suggested as being the preferred treatment strategy. Increasing awareness of CX injury during MV surgery is mandatory for the early detection and prompt treatment in an exciting era of increasing minimally invasive surgical and TC interventions.

Funding

This research received no external funding.

Institutional Review Board Statement

Ethical review and approval were not applicable for this study.

Informed Consent Statement

Patient consent was not applicable.

Data Availability Statement

The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Acknowledgments

The authors wish to thank Gavin Jackson, Renier Verbeek and Ernest Horsley for their image contributions.

Conflicts of Interest

The authors declare no conflict of interest.

References

  1. Danielson, G.K.; Cooper, E.; Tweedore, D.N. Circumflex coronary artery injury during mitral valve replacement. Ann. Thorac. Surg. 1967, 4, 53–59. [Google Scholar] [CrossRef]
  2. Roberts, W.C.; Morrow, A.G. Compression of anomalous left circumflex coronary arteries by prosthetic valve fixation rings. J. Thorac. Cardiovasc. Surg. 1969, 57, 834–838. [Google Scholar] [CrossRef] [PubMed]
  3. Morin, D.; Fischer, A.P.; Sohl, B.E.; Sadeghi, H. Iatrogenic myocardial infarction. A possible complication of mitral valve surgery related to anatomical variation of the circumflex coronary artery. Thorac. Cardiovasc. Surg. 1982, 30, 176–179. [Google Scholar] [CrossRef] [PubMed]
  4. Virmani, R.; Chun, P.K.; Parker, J.; McAlister, H.A. Suture obliteration of the circumflex coronary artery in three patients undergoing mitral valve operation. Role of left dominant or codominant coronary artery. J. Thorac. Cardiovasc. Surg. 1982, 84, 773–778. [Google Scholar] [CrossRef]
  5. Speziale, G.; Fattouch, K.; Ruvolo, G.; Fiorenza, G.; Papalia, U.; Marino, B. Myocardial infarction caused by compression of anomalous circumflex coronary artery after mitral valve replacement. Minerva Cardioangiol. 1998, 46, 455–456. [Google Scholar]
  6. Tavilla, G.; Pacini, D. Damage to the circumflex artery during MVR with sliding leaflet technique. Ann. Thorac. Surg. 1998, 66, 2091–2093. [Google Scholar] [CrossRef]
  7. Mulpur, A.K.; Kotidis, K.N.; Nair, U.R. Partial circumflex artery injury during mitral valve replacement: Late presentation. J. Cardiovasc. Surg. 2000, 41, 333–334. [Google Scholar]
  8. Mantilla, R.; Legarra, J.J.; Pradas, G.; Bravo, M.; Sanmartin, M.; Goicolea, J. Percutaneous coronary intervention for iatrogenic occlusion of the circumflex artery after mitral anuloplasty. Rev. Esp. Cardiol. 2004, 57, 702–704. (In Spanish) [Google Scholar] [CrossRef]
  9. Sangha, R.; Hui, P. Intravascular ultrasound imaging and percutaneous intervention in a patient with post-mitral valve replacement circumflex coronary artery occlusion. J. Invasive Cardiol. 2004, 16, 351–352. [Google Scholar]
  10. Nakajima, H.; Ikari, Y.; Kigawa, I.; Kitamura, T.; Hatori, M.; Tooda, E.; Tanabe, K.; Miyairi, T.; Hara, K. Rapid diagnosis and management of intraoperative myocardial infarction during valvular surgery: Using intraoperative transesophageal echocardiography followed by emergency coronary artery bypass grafting without coronary angiography. Echocardiography 2005, 22, 834–838. [Google Scholar] [CrossRef]
  11. Meursing, D.F.; Boonswang, N.A.; Dobrilovic, N.; Wait, M.A. Perioperative myocardial infarction secondary to dynamic circumflex coronary artery occlusion after mitral valve repair. Tex. Heart Inst. J. 2006, 33, 85–87. [Google Scholar] [PubMed]
  12. Wykrzykowska, J.; Cohen, D.; Zimetabum, P. Mitral annuloplasty causing left circumflex injury and infarction: Novel use of intravascular ultrasound to diagnose suture injury. J. Invasive Cardiol. 2006, 18, 505–508. [Google Scholar] [PubMed]
  13. Raza, J.A.; Rodriguez, E.; Miller, M.J. Successful percutaneous revascularization of circumflex artery injury after minimally invasive mitral valve repair and left atrial cryo-MAZE. J. Invasive Cardiol. 2006, 18, E285–E287. [Google Scholar] [PubMed]
  14. Acar, C. Re: Injury to the circumflex coronary artery following mitral valve repair. Eur. J. Cardiothorac. Surg. 2007, 32, 818. [Google Scholar] [CrossRef]
  15. Zegdi, R.; Jouan, J.; Fabiani, J.N.; Deloche, A. Injury to the circumflex coronary artery following mitral valve repair. Eur. J. Cardiothorac. Surg. 2007, 31, 740. [Google Scholar] [CrossRef]
  16. Aubert, S.; Barthelemy, O.; Landi, M.; Acar, C. Circumflex coronary artery injury following mitral annuloplasty treated by emergency angioplasty. Eur. J. Cardiothorac. Surg. 2008, 34, 922–924. [Google Scholar] [CrossRef]
  17. Gomes, W.J. Injury to the circumflex coronary artery following mitral valve repair: A rather opposite strategy. Eur. J. Cardiothorac. Surg. 2008, 33, 948–949. [Google Scholar] [CrossRef]
  18. Grande, A.M.; Fiore, A.; Massetti, M.; Vigano, M. Iatrogenic circumflex coronary lesion in mitral valve surgery: Case report and review of the literature. Tex. Heart Inst. J. 2008, 35, 179–183. [Google Scholar]
  19. Calafiore, A.M.; Iaco, A.L.; Varone, E.; Bosco, P.; Di Mauro, M. Distortion of the proximal circumflex artery during mitral valve repair. J. Card. Surg. 2010, 25, 163–165. [Google Scholar] [CrossRef]
  20. Ender, J.; Gummert, J.; Fassl, J.; Krohmer, E.; Bossert, T.; Mohr, F.W. Ligation or distortion of the right circumflex artery during minimal invasive mitral valve repair detected by transesophageal echocardiography. J. Am. Soc. Echocardiogr. 2008, 21, 408.e4–408.e5. [Google Scholar] [CrossRef]
  21. Varela, N.L.; Pulido, J.N.; Lynch, J.J.; Mauermann, W.J.; Rehfeldt, K.H. Acute coronary syndrome after mitral valve surgery: A rare complication secondary to mechanical occlusion of the circumflex artery. Int. Anesthesiol. Clin. 2011, 49, 32–41. [Google Scholar] [CrossRef]
  22. Murugesan, C.; Raghu, B.; Rao, P.V. Transesophageal Echocardiographic Diagnosis and Management of Circumflex Artery Injury Following Mitral Valve Repair. Cardiol. Res. 2011, 2, 90–92. [Google Scholar] [CrossRef] [PubMed]
  23. Postorino, S.; Buja, P.; Grassi, G.; Millosevich, P.; Barbierato, M.; Venturini, A.; Zanchettin, C.; Polesel, E.; Di Pede, F.; Raviele, A. Mitral valve repair complicated by iatrogenic coronary artery lesion treated with percutaneous coronary intervention. J. Cardiovasc. Med. 2011, 12, 180–181. [Google Scholar] [CrossRef] [PubMed]
  24. Sheth, H.; Swamy, R.S.; Shah, A.P. Acute myocardial infarction and cardiac arrest due to coronary artery perforation after mitral valve surgery: Successful treatment with a covered stent. Cardiovasc. Revasc. Med. 2012, 13, 62–65. [Google Scholar] [CrossRef] [PubMed]
  25. Schyma, C.; Kernbach-Wighton, G.; Madea, B. Kinking of a coronary artery as a rare complication in mitral valve replacement. Forensic Sci. Int. 2012, 221, e30–e33. [Google Scholar] [CrossRef]
  26. Somekh, N.N.; Haider, A.; Makaryus, A.N.; Katz, S.; Bello, S.; Hartman, A. Left circumflex coronary artery occlusion after mitral valve annuloplasty: “A stitch in time”. Tex. Heart Inst. J. 2012, 39, 104–107. [Google Scholar]
  27. Ziadi, J.; Mleyhi, S.; Denguir, R.; Khayati, A. Iatrogenic occlusion of the circumflex artery and left ventricle pseudoaneurysm after mitral annuloplasty. J. Cardiol. Cases 2013, 9, 104–105. [Google Scholar] [CrossRef]
  28. Folkmann, S.; Mohr, F.W.; Garbade, J. Emergency PCI after occlusion of the circumflex artery due to minimally invasive mitral valve replacement in redo operation. Acta Cardiol. 2014, 64, 451–453. [Google Scholar] [CrossRef]
  29. Pettinari, M.; Gutermann, H.; Van Kerrebroeck, C.; Dion, R. Anomalous Origin of the Circumflex Artery: An Underestimated Threat During Mitral Valve Operation. Ann. Thorac. Surg. 2015, 100, 1437–1439. [Google Scholar] [CrossRef]
  30. Monteiro, J.P.; Rijo, D.; Simões Costa, S.; Martins, D.; Pereira, R.; Ribeiro, J.; Melica, B.; Vouga, L.; Guerra, M. Circumflex Coronary Artery Lesion and Consequent Papillary Muscle Rupture after Chordal Sparing Mitral Valve Replacement. Rev. Port. Cir. Cardiotorac. Vasc. 2016, 23, 165–168. [Google Scholar]
  31. Hiltrop, N.; Bennett, J.; Desmet, W. Circumflex coronary artery injury after mitral valve surgery: A report of four cases and comprehensive review of the literature. Catheter. Cardiovasc. Interv. 2017, 89, 78–92. [Google Scholar] [CrossRef] [PubMed]
  32. Coutinho, G.F.; Leite, F.; Antunes, M.J. Circumflex artery injury during mitral valve repair: Not well known, perhaps not so infrequent-lessons learned from a 6-case experience. J. Thorac. Cardiovasc. Surg. 2017, 154, 1613–1620. [Google Scholar] [CrossRef] [PubMed]
  33. Busu, T.; Alqahtani, F.; Kawsara, A.; Hijazi, M.; Alkhouli, M. Iatrogenic Circumflex Artery Stenosis Following Mitral Valve Repair. Cureus 2017, 9, e1680. [Google Scholar] [CrossRef]
  34. Sunagawa, O.; Nakamura, M.; Hokama, R.; Miyara, T.; Taba, Y.; Touma, T. A case of percutaneous coronary intervention for treatment of iatrogenic chronic total occlusion of the left circumflex artery after mitral valve repair. Cardiovasc. Interv. Ther. 2017, 32, 146–150. [Google Scholar] [CrossRef] [PubMed]
  35. Ahmad, T.A.; Nudy, M.; Pabst, D.; Kozak, M. Mitral valve repair complicated by left circumflex coronary artery occlusion: An under-recognized but potentially deadly complication. Cardiovasc. Revasc. Med. 2018, 19, 77–81. [Google Scholar] [CrossRef]
  36. Gentry, J.L., 3rd; Summers, M.R.; Harb, S.; Jaber, W.; Pettersson, G.; Griffin, B. Iatrogenic Left Circumflex Coronary Artery Fistula after Mitral Valve Replacement. CASE 2018, 2, 218–221. [Google Scholar] [CrossRef]
  37. Husain, A.; Alsanei, A.; Tahir, M.; Dahdouh, Z.; AlHalees, Z.; AlMasood, A. Left circumflex artery injury postmitral valve surgery, single center experience. J. Saudi Heart Assoc. 2019, 31, 94–99. [Google Scholar] [CrossRef]
  38. Fortunato, G.A.; Misfeld, M.; Battellini, R.; Domenech, A.; Garbade, J.; Borger, M.A.; Kotowicz, V. Situation Awareness for Circumflex Artery Injury During Mitral Valve Surgery. Ann. Thorac. Surg. 2019, 108, e329–e332. [Google Scholar] [CrossRef]
  39. Scarsini, R.; De Maria, G.L.; Ciofani, J.; Jin, X.Y.; Sayeed, R.; Petrou, M.; Banning, A. Coronary Injury in Mitral and Aortic Valve Surgery: A Case Series Using Optical Coherence Tomography. Ann. Thorac. Surg. 2020, 109, e171–e174. [Google Scholar] [CrossRef]
  40. Dello, S.A.; Leus, S.J.; Tan, M.E.S.; Otterspoor, L.C.; Botman, C.J. Percutaneous coronary intervention of an iatrogenic occlusion of the circumflex coronary artery after mitral valve replacement. Eur. Heart J. Acute Cardiovasc. Care 2020, 9, NP1–NP2. [Google Scholar] [CrossRef]
  41. Felekos, I.; Theodoropoulos, K.C.; Mullen, L. Acute Circumflex Occlusion After a Successful Mitral Valve Repair. Cardiovasc. Revasc. Med. 2020, 21, 60–62. [Google Scholar] [CrossRef] [PubMed]
  42. Caruso, V.; Sabry, H.; Birdi, I. Dramatic resolution of an immediate postoperative distortion of the circumflex artery during mitral valve surgery. J. Card. Surg. 2020, 35, 1135–1137. [Google Scholar] [CrossRef] [PubMed]
  43. Yavari, N.; Ghorbanpour Landy, M.; Motevali, Y.; Tavousi Tabatabaei, E.; Mansourian, S.; Mohseni Badalabadi, R.; Javad Mehrabanian, M.; Hossein Ahmadi Tafti, S. Iatrogenic left circumflex coronary occlusion following mitral valve replacement surgery: A case report. Clin. Case Rep. 2021, 9, 1534–1538. [Google Scholar] [CrossRef]
  44. Arevalos, V.; Ortega-Paz, L.; Pereda, D.; Sandoval, E.; Brugaletta, S. Percutaneous treatment of a circumflex artery occlusion after minimally invasive barlow disease mitral valve repair. JACC Case Rep. 2021, 3, 173–176. [Google Scholar] [CrossRef] [PubMed]
  45. Gaba, P.; Kaneko, T.; Kochar, A.; Sung, J.; O’Gara, P.T.; Bhatt, D.L. Left circumflex artery injury following surgical mitral valve replacement: A case report. Eur. Heart J. Case Rep. 2021, 5, ytab464. [Google Scholar] [CrossRef]
  46. Landa, A.B.; Hoyos, J.; D’Mello, J. Mitral valve repair complicated by left circumflex coronary artery occlusion: The vital role of the anesthesiologist. Ann. Card. Anaesth. 2021, 24, 405–407. [Google Scholar] [CrossRef]
  47. Bulak, L.; Brzozowski, P.; Reczuch, K.W.; Kuliczkowski, W. Iatrogenic circumflex coronary artery injury after mitral valve replacement. Postepy Kardiol. Interwencyjnej 2021, 17, 315–316. [Google Scholar] [CrossRef]
  48. Bargagna, M.; Trumello, C.; Sala, A.; Blasio, A.; Castiglioni, A.; Alfieri, O.; De Bonis, M. Left circumflex artery injury after mitral valve surgery: An algorithm management proposal. Ann. Thorac. Surg. 2020, 111, 899–904. [Google Scholar] [CrossRef]
  49. Nassereddine, Z.; Kazem, H.; Moussa, M.; Saab, M. Left circumflex coronary artery injury following mitral valve replacement with late presentation: A case report and literature review. J. Cardiovasc. Thorac. Res. 2022, 14, 268–271. [Google Scholar] [CrossRef]
  50. Pessa, C.J.N.; Gomes, W.J.; Catani, R.; Prates, J.C.; Buffolo, E. Anatomical relashionship [sic] between the posterior mitral valve annulus and the coronary arteries. Implication to operative treatment. Braz. J. Cardiovasc. Surg. 2004, 19, 372–377. [Google Scholar] [CrossRef]
  51. Bevilacqua, C.; Eibel, S.; Foldyna, B.; Knoefler, T.; Lehmkuhl, L.; Gutberlet, M.; Mukherjee, C.; Seeburger, J.; Davierwala, P.; Ender, J. Analysis of circumflex artery anatomy by real time 3D transesophageal echocardiography compared to cardiac computed tomography. Int. J. Cardiovasc. Imaging 2017, 33, 1703–1710. [Google Scholar] [CrossRef] [PubMed]
  52. Kishimoto, N.; Takahashi, Y.; Fujii, H.; Sakon, Y.; Izuta, S.; Kitada, R.; Morisaki, A.; Yoshida, H.; Ehara, S.; Shibata, T. Computed tomography to identify risk factors for left circumflex artery injury during mitral surgery. Eur. J. Cardiothorac. Surg. 2022, 61, 675–683. [Google Scholar] [CrossRef] [PubMed]
  53. Mak, G.J.; Blanke, P.; Ong, K.; Naoum, C.; Thompson, C.R.; Webb, J.G.; Moss, R.; Boone, R.; Ye, J.; Cheung, A.; et al. Three-Dimensional Echocardiography Compared With Computed Tomography to Determine Mitral Annulus Size Before Transcatheter Mitral Valve Implantation. Circ. Cardiovasc. Imaging 2016, 9, e004176. [Google Scholar] [CrossRef] [PubMed]
  54. Man, J.P.; Bouma, B.J.; Schuuring, M.J. Fusion imaging in preoperative planning of mitral valve surgery to prevent injury of the left circumflex artery. Eur. Heart J. 2022, 43, 4762. [Google Scholar] [CrossRef]
  55. Nakanishi, R.; Osawa, K.; Kurata, A.; Miyoshi, T. Role of coronary computed tomography angiography (CTA) post the ISCHEMIA trial: Precision prevention based on coronary CTA-derived coronary atherosclerosis. J. Cardiol. 2022, 79, 572–580. [Google Scholar] [CrossRef]
  56. Krzanowski, M.; Bodzoń, W.; Dimitrow, P.P. Imaging of all three coronary arteries by transthoracic echocardiography. An illustrated guide. Cardiovasc. Ultrasound 2003, 1, 16. [Google Scholar] [CrossRef]
  57. Ender, J.; Selbach, M.; Borger, M.A.; Krohmer, E.; Falk, V.; Kaisers, U.X.; Mohr, F.W.; Mukherjee, C. Echocardiographic identification of iatrogenic injury of the circumflex artery during minimally invasive mitral valve repair. Ann. Thorac. Surg. 2010, 89, 1866–1872. [Google Scholar] [CrossRef]
  58. Młynarski, R.; Młynarska, A.; Sosnowski, M. Anatomical variants of left circumflex artery, coronary sinus and mitral valve can determine safety of percutaneous mitral annuloplasty. Cardiol. J. 2013, 20, 235–240. [Google Scholar] [CrossRef]
  59. Caruso, V.; Shah, U.; Sabry, H.; Gedela, S.; Birdi, I. Mitral valve annulus and circumflex artery: In vivo study of anatomical zones. J. Thorac. Cardiovasc. Surg. Tech. 2020, 4, 122–129. [Google Scholar] [CrossRef]
  60. Bennani, F.; Sebestyen, A.; Grimont, P.; Ghaffar, N.; Cavallo, D.; Nocenti, M.; Tardy, N.; Chessel, E.; Chaffanjon, P.; Chavanon, O. Relationships between coronary arteries and atrioventricular annuli: Surgical and percutaneous implications. Gen. Thorac. Cardiovasc. Surg. 2022, 70, 132–138. [Google Scholar] [CrossRef]
  61. Van der Merwe, J.; Casselman, F. Mitral Valve Replacement-Current and Future Perspectives. Open J. Cardiovasc. Surg. 2017, 9, 1179065217719023. [Google Scholar] [CrossRef] [PubMed]
  62. Carpentier, A.F.; Lessana, A.; Relland, J.Y.; Belli, E.; Mihaileanu, S.; Berrebi, A.J.; Palsky, E.; Loulmet, D.F. The “Physio-Ring”: An advanced concept in mitral valve annuloplasty. Ann. Thorac. Surg. 1995, 60, 1177–1185. [Google Scholar] [PubMed]
  63. Carpentier, A.; Adams, D.H.; Filsoufi, F. Carpentier’s Reconstructive Valve Surgery: From Valve Analysis to Valve Reconstruction; Saunders-Elsevier: Philadelphia, PA, USA, 2010. [Google Scholar]
  64. Filsoufi, F.; Carpentier, A. Principles of reconstructive surgery in degenerative mitral valve disease. Semin. Thorac. Cardiovasc. Surg. 2007, 19, 103–110. [Google Scholar] [CrossRef]
  65. Van der Merwe, J.; Casselman, F.; Van Praet, F. The principles of minimally invasive atrioventricular valve repair surgery utilizing endoaortic balloon occlusion technology: How to start and sustain a safe and effective program. J. Vis. Surg. 2019, 5, 72. [Google Scholar] [CrossRef]
  66. Van der Merwe, J.; Casselman, F.; Van Praet, F. Minimally invasive atrioventricular surgery—Current status and future perspectives. SA Heart 2019, 16, 310–316. [Google Scholar] [CrossRef]
  67. Van der Merwe, J.; Van Praet, F.; Stockman, B.; Degrieck, I.; Vermeulen, Y.; Casselman, F. Reasons for conversion and adverse intraoperative events in Endoscopic Port Access™ atrioventricular valve surgery and minimally invasive aortic valve surgery. Eur. J. Cardiothorac. Surg. 2018, 54, 288–293. [Google Scholar]
  68. Van der Merwe, J.; Van Praet, F.; Vermeulen, Y.; Casselman, F. Complications and pitfalls in minimally invasive atrioventricular valve surgery utilizing endo-aortic balloon occlusion technology. J. Vis. Surg. 2018, 4, 248. [Google Scholar] [CrossRef]
  69. Czesla, M.; Götte, J.; Weimar, T.; Ruttkay, T.; Doll, N. Safeguards and pitfalls in minimally invasive mitral valve surgery. Ann. Cardiothorac. Surg. 2013, 2, 849–852. [Google Scholar]
  70. De Backer, O.; Wong, I.; Taramasso, M.; Maisano, F.; Franzen, O.; Søndergaard, L. Transcatheter mitral valve repair: An overview of current and future devices. Open Heart 2021, 8, e001564. [Google Scholar] [CrossRef]
  71. Noack, T.; Kiefer, P.; Besler, C.; Lurz, P.; Leontyev, S.; Abdel-Wahab, M.; Holzhey, D.M.; Seeburger, J. Transcatheter mitral valve repair: Review of current techniques. Indian. J. Thorac. Cardiovasc. Surg. 2020, 36 (Suppl. S1), 53–63. [Google Scholar] [CrossRef]
  72. Kargoli, F.; Pagnesi, M.; Rahgozar, K.; Goldberg, Y.; Ho, E.; Chau, M.; Colombo, A.; Latib, A. Current Devices and Complications Related to Transcatheter Mitral Valve Replacement: The Bumpy Road to the Top. Front. Cardiovasc. Med. 2021, 8, 639058. [Google Scholar] [CrossRef] [PubMed]
  73. Fiorilli, P.N.; Herrmann, H.C.; Szeto, W.Y. Transcatheter mitral valve replacement: Latest advances and future directions. Ann. Cardiothorac. Surg. 2021, 10, 85–95. [Google Scholar] [CrossRef] [PubMed]
  74. Otto, C.M.; Nishimura, R.A.; Bonow, R.O.; Carabello, B.A.; Erwin, J.P., 3rd; Gentile, F.; Jneid, H.; Krieger, E.V.; Mack, M.; McLeod, C.; et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021, 143, e35–e71. [Google Scholar] [CrossRef] [PubMed]
  75. Vahanian, A.; Beyersdorf, F.; Praz, F.; Milojevic, M.; Baldus, S.; Bauersachs, J.; Capodanno, D.; Conradi, L.; De Bonis, M.; De Paulis, R.; et al. ESC/EACTS Scientific Document Group. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur. Heart J. 2022, 43, 561–632. [Google Scholar] [CrossRef]
  76. Cornu, E.; Lacroix, P.H.; Christides, C.; Laskar, M. Coronary artery damage during mitral valve replacement. J. Cardiovasc. Surg. 1995, 36, 261–264. [Google Scholar]
  77. Kaklikkaya, I.; Yeginoglu, G. Damage to coronary arteries during mitral valve surgery. Heart Surg. Forum 2003, 6, E138–E142. [Google Scholar]
  78. Iung, B.; Baron, G.; Tornos, P.; Gohlke-Bärwolf, C.; Butchart, E.G.; Vahanian, A. Valvular heart disease in the community: A European experience. Curr. Probl. Cardiol. 2007, 32, 609–661. [Google Scholar] [CrossRef]
  79. Hu, X.; Zhao, Q. Systematic evaluation of the flexible and rigid annuloplasty ring after mitral valve repair for mitral regurgitation. Eur. J. Cardiothorac. Surg. 2011, 40, 480–487. [Google Scholar] [CrossRef]
  80. Cetinkaya, A.; Waheed, M.; Bramlage, K.; Liakopoulos, O.J.; Zeriouh, M.; Hein, S.; Bramlage, P.; Schönburg, M.; Choi, Y.H.; Richter, M. Comparison of flexible, open with semi-rigid, closed annuloplasty-rings for mitral valve repair. J. Cardiothorac. Surg. 2021, 16, 35. [Google Scholar] [CrossRef]
  81. Chang, B.C.; Youn, Y.N.; Ha, J.W.; Lim, S.H.; Hong, Y.S.; Chung, N. Long-term clinical results of mitral valvuloplasty using flexible and rigid rings: A prospective and randomized study. J. Thorac. Cardiovasc. Surg. 2007, 133, 995–1003. [Google Scholar] [CrossRef]
  82. Silberman, S.; Klutstein, M.W.; Sabag, T.; Oren, A.; Fink, D.; Merin, O.; Bitran, D. Repair of ischemic mitral regurgitation: Comparison between flexible and rigid annuloplasty rings. Ann. Thorac. Surg. 2009, 87, 1721–1726. [Google Scholar] [CrossRef] [PubMed]
  83. Chauvette, V.; Bouchard, D.; Pellerin, M.; Perrault, L.P. Commentary: Mitral valve annuloplasty and circumflex artery injury: Are fewer stitches better? JTCVS Tech. 2020, 5, 31–33. [Google Scholar] [CrossRef] [PubMed]
  84. Obarski, T.P.; Loop, F.D.; Cosgrove, D.M.; Lytle, B.W.; Stewart, W.J. Frequency of acute myocardial infarction in valve repairs versus valve replacement for pure mitral regurgitation. Am. J. Cardiol. 1990, 65, 887–890. [Google Scholar] [CrossRef] [PubMed]
  85. Sardari Nia, P.; Daemen, J.H.T.; Maessen, J.G. Development of a high-fidelity minimally invasive mitral valve surgery simulator. J. Thorac. Cardiovasc. Surg. 2019, 157, 1567–1574. [Google Scholar] [CrossRef]
  86. Ascione, G.; Denti, P. Mitral annular calcification in patients with significant mitral valve disease: An old problem with new solutions. Front. Cardiovasc. Med. 2022, 9, 1033565. [Google Scholar] [CrossRef] [PubMed]
  87. van der Merwe, J.; Casselman, F.; Stockman, B.; Roubelakis, A.; Vermeulen, Y.; Degrieck, I.; Van Praet, F. Endoscopic port access surgery for isolated atrioventricular valve endocarditis. Interact. Cardiovasc. Thorac. Surg. 2018, 27, 487–493. [Google Scholar] [CrossRef]
  88. Tibaut, M.; Mekis, D.; Petrovic, D. Pathophysiology of Myocardial Infarction and Acute Management Strategies. Cardiovasc. Hematol. Agents Med. Chem. 2017, 14, 150–159. [Google Scholar] [CrossRef]
Medicina 59 01470 g001
Figure 1. Flowchart outlining the PubMed search methodology.
Figure 1. Flowchart outlining the PubMed search methodology.
Medicina 59 01470 g001
Medicina 59 01470 g002
Figure 2. Expected circumflex artery course in relation to the posterior mitral valve annulus during endoscopic mitral valve repair.
Figure 2. Expected circumflex artery course in relation to the posterior mitral valve annulus during endoscopic mitral valve repair.
Medicina 59 01470 g002
Medicina 59 01470 g003
Figure 3. A coronary angiogram (A) and computerized tomographic coronary angiographic 3D reconstruction (B) of a large left dominant circumflex system at risk during mitral valve surgery.
Figure 3. A coronary angiogram (A) and computerized tomographic coronary angiographic 3D reconstruction (B) of a large left dominant circumflex system at risk during mitral valve surgery.
Medicina 59 01470 g003
Medicina 59 01470 g004
Figure 4. The principles of posterior mitral valve annuloplasty suture placement include (A) a 90 degree annular angle entrance (B) in parallel with the mitral valve annulus. (C) Careful driving of the needle through the appropriate depth and (D) careful needle extraction along its curve.
Figure 4. The principles of posterior mitral valve annuloplasty suture placement include (A) a 90 degree annular angle entrance (B) in parallel with the mitral valve annulus. (C) Careful driving of the needle through the appropriate depth and (D) careful needle extraction along its curve.
Medicina 59 01470 g004
Medicina 59 01470 g005
Figure 5. Simultaneous minimally invasive valve surgery and percutaneous coronary interventions in a modern hybrid cardiovascular theatre.
Figure 5. Simultaneous minimally invasive valve surgery and percutaneous coronary interventions in a modern hybrid cardiovascular theatre.
Medicina 59 01470 g005
Medicina 59 01470 g006
Figure 6. Comprehensive CX injury prevention, diagnosis and treatment algorithm. Abbreviations: CX: circumflex coronary artery; MV: mitral valve; CPB: cardiopulmonary bypass; TEE: transesophageal echocardiography; CL: catheterization laboratory; CABG: coronary artery bypass grafting; PCI: percutaneous coronary intervention. MI-MVS: minimally invasive mitral valve surgery.
Figure 6. Comprehensive CX injury prevention, diagnosis and treatment algorithm. Abbreviations: CX: circumflex coronary artery; MV: mitral valve; CPB: cardiopulmonary bypass; TEE: transesophageal echocardiography; CL: catheterization laboratory; CABG: coronary artery bypass grafting; PCI: percutaneous coronary intervention. MI-MVS: minimally invasive mitral valve surgery.
Medicina 59 01470 g006
Table 1. Current reports that describe circumflex coronary artery injury during mitral valve surgery.
Table 1. Current reports that describe circumflex coronary artery injury during mitral valve surgery.
AuthorYearProcedureAccessMechanismTime of Diagnosis30-Day MortalityTreatment Strategy
Danielson [1]1967MVR (n = 3)SternoTotalPOYesNone
Roberts [2]1969MVRSternoTotalPOYesNone
Morin [3]1982MVRSternoTotalPOYesNone
Virmani [4]1982MVR (n = 2)
MVr (n = 1)		SternoTotalPO YesNone
Speziale [5]1998MVRSternoTotalPO Nonenone
Tavilla [6]1998MVrSternoTotalIntraONoneRevision and CABG
Mulpur [7]2000MVRSternoPartialDelNoneMVR
Mantilla [8]2004MVrSternoPartialPONonePCI
Sangha [9]2004MVrSternoPartialPONonePCI
Nakajima [10]2005MVrSternoTotalIntraONoneCABG
Meursing [11]2006MVrSternoPartialIntraONonePCI
Wykrzykowska [12]2006MVrSternoPartialPONonePCI
Raza [13]2006MVrMI-MVSPartialIntraONonePCI
Acar [14]2007MVr (n = 3)SternoTotal (n = 3)IntraO (n = 3)NoneCABG (n = 3)
Zegdi [15]2007MVrSternoPartialPONoneCABG
Aubert [16]2008MVrSternoPartialIntraONonePCI
Gomes [17]2008MVr (n = 2)SternoPartialIntraONoneRevision
Grande [18]2008MVrMI-MVSPartialIntraONonePCI
Calafiore [19]2010MVrSternoTotalIntraONoneCABG
Ender [20]2010MVr (n = 3)MI-MVSPartial (n = 3)IntraO (n = 3)NoneRevision (n = 2)
PCI (n = 1)
Varela [21]2011MVr (n = 2)SternoPartialPONonePCI (n = 2)
Murugesan [22]2011MVrSternoPartialIntraONoneRevision
Postorino [23]2011MVrSternoPartialPONonePCI
Sheth [24]2012MVRSternoLacerationPONonePCI
Schyma [25]2012MVRSternoPartialPOyesNone
Somekh [26]2012MVrMI-MVSTotalPONonePCI
Ziadi [27]2014MVrSternoPartialDel(5 months)NoneCABG and aneurysmectomy
Folkmann [28]2014MVRMI-MVSPartialIntraONonePCI
Pettinari [29]2015MVrSternoPartialPONonePCI
Monteiro [30]2016MVrSternoPartialDelNoneRevision
Hiltrop [31]2016MVr (n = 2)
MVR (n = 2)		MI-MVS (n = 2) Sterno (n = 2)Total (n = 1)
Partial (n = 2)		IntraO (n = 1)
PO (n = 2)
Del (n = 1)		Yes (n = 1)PCI (n = 2)
CABG (n = 2)
Coutinho [32]2017MVr (n = 6)SternoPartial (n = 3)
Total (n = 3)		PO (n = 6)NoneNone (n = 1)
Transplant (n = 1)
Revision (n = 3)
PCI (n = 1)
Busu [33]2017MVrSternoPartialDel (2 years)NonePCI
Sunagawa [34] 2017MVrSternoTotalDel (3 years)NonePCI
Ahmad [35]2018MVrSternoTotalIntraOYesPCI
Gentry [36]2018MVRSternoFistulaDel (1 year)NoneRedo-MVR
Husain [37]2018MVR (n = 9)SternoPartial (n = 3)
Total (n = 6)		N/AYes (n = 3)PCI (n = 3)
CABG (n = 6)
Fortunato [38]2019MVr (n = 4)
MVR (n = 1)		SternoTotal (n = 4)
Partial (n = 1)		PO (n = 2)
IntraO (n =3)		Yes (n = 2)None (n = 1)
PCI (n = 2)
CABG (n = 1)
Revision (n = 1)
Scarsini [39]2020MVr (n = 2)SternoPartial (n = 2)IntraO (n = 2)NonePCI (n = 2)
Dello [40]2020MVRSternoPartialIntraONonePCI
Felekos [41]2020MVrMI-MVSPartialIntraONonePCI
Caruso [42]2020MVrMI-MVSPartialIntraONoneRevision
Yavari [43]2020MVRSternoPartialPONonePCI (unsuccessful)
Arevalos [44]2021MVrMI-MVSTotalPONonePCI
Gaba [45]2021Redo-MVRSternoTotalIntraONonePCI
Landa [46]2021MVrMI-MVSPartialIntraONonePCI
Bulak [47]2021MVR SternoTotalPONonePCI
Bargagna [48]2021MVr (n = 5)
MVR (n = 5)		SternoTotal (n = 4)
Partial (n = 6)		PO (n = 5)
IntraO = 5		Yes (n = 2)PCI (n = 4)
CABG (n = 5)
Revision (n = 1)
Nassereddine [49]2022MVrSternoTotalDel (4 weeks)NonePCI (unsuccessful)
Abbreviations: MVR = Mitral valve replacement; MVr = Mitral valve repair; Sterno = Sternotomy access; MI-MVS = Minimally invasive mitral valve surgery; PO = Postoperative diagnosis; IntraO = Intraoperative diagnosis; Del = Delayed diagnosis; PCI = Percutaneous coronary intervention; CABG = Coronary artery bypass grafting.
Table 2. Potential imaging criteria considered to be high risk for CX injury within the context of mitral valve procedures.
Table 2. Potential imaging criteria considered to be high risk for CX injury within the context of mitral valve procedures.
Echocardiographic/clinical criteria
   Repeat mitral valve surgery
   Severe posterior mitral annular calcification
   Destructive posterior leaflet infection
   Anomalous circumflex coronary artery course
   Circumflex artery distance to mitral valve annulus less than 3 mm
Coronary angiographic criteria
   Anomalous circumflex coronary artery course
   Left dominant coronary system
   Codominant coronary system
   Computerised tomographic coronary angiographic criteria
Circumflex artery distance to mitral valve annulus less than 3 mm
Table 3. Potential mechanisms of circumflex coronary artery injury during mitral valve surgery.
Table 3. Potential mechanisms of circumflex coronary artery injury during mitral valve surgery.
External compression
   Oversized prosthesis
   Hematoma
Suture injury
   Vessel laceration with bleeding
   Vessel distortion with partial occlusion
   Vessel occlusion
Thermal injury of endothelium
   Cryoablation injury
   Radiofrequency ablation injury
Embolism
   Air
   Bone marrow
   Fat fragments
   Suture material
   Prosthetic material
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

van der Merwe, J.; Casselman, F. Circumflex Coronary Artery Injury during Modern Mitral Valve Surgery—A Review of Current Concepts and Perspectives. Medicina 2023, 59, 1470. https://doi.org/10.3390/medicina59081470

AMA Style

van der Merwe J, Casselman F. Circumflex Coronary Artery Injury during Modern Mitral Valve Surgery—A Review of Current Concepts and Perspectives. Medicina. 2023; 59(8):1470. https://doi.org/10.3390/medicina59081470

Chicago/Turabian Style

van der Merwe, Johan, and Filip Casselman. 2023. "Circumflex Coronary Artery Injury during Modern Mitral Valve Surgery—A Review of Current Concepts and Perspectives" Medicina 59, no. 8: 1470. https://doi.org/10.3390/medicina59081470

Article Metrics

Back to TopTop