Document Detail

Echocardiographic identification of iatrogenic injury of the circumflex artery during minimally invasive mitral valve repair.
MedLine Citation:
PMID:  20494041     Owner:  NLM     Status:  MEDLINE    
BACKGROUND: Injury to the circumflex artery after mitral valve (MV) repair or replacement is a recognized complication of this procedure. We designed an echocardiographic method to visualize the course and flow of the circumflex artery, to detect iatrogenic injury to this structure intraoperatively, as well as to predict the coronary dominance pattern in MV surgery patients. METHODS: After Ethics Committee approval, a prospective study was undertaken in 110 patients undergoing minimal invasive MV repair. Intraoperative transesophageal echocardiography was used to visualize the circumflex artery using a combination of B-mode imaging and color Doppler with different Nyquist limits. The course of the circumflex artery and the coronary sinus and their corresponding diameters were documented at the proximal and distal ends of both vessels. Preoperative angiographic data were used to determine the coronary dominance type. RESULTS: The course of the circumflex artery could be detected proximally in 109 patients (99%), to the point of intersection with the coronary sinus in 99 patients (90%), and distal to this intersection in 95 patients (86%) using our technique. Three patients had evidence of iatrogenic aliasing (circumflex stenosis) or "no flow" (circumflex occlusion) on transesophageal echocardiography examination after repair and therefore underwent surgical or percutaneous correction. All 3 of these patients had an uncomplicated postoperative course thereafter with no evidence of perioperative myocardial infarction. All remaining patients with normal circumflex examinations after repair did not show any clinical evidence of myocardial infarction or unstable hemodynamics postoperatively. The 95% confidence interval for the diameter of the proximal circumflex artery was 4.5 mm to 5.6 mm for the left dominant type patients and 3.8 mm to 4.2 mm for the right dominant and balanced type patients (p = 0.01). CONCLUSIONS: The early recognition of iatrogenic injury of the circumflex artery is feasible with intraoperative transesophageal echocardiography examination, and may lead to treatment before extensive myocardial infarction occurs. We suggest that visualization of the circumflex artery with our technique should be performed more frequently in patients undergoing MV surgery.
Joerg Ender; Michael Selbach; Michael A Borger; Eugen Krohmer; Volkmar Falk; Udo X Kaisers; Friedrich W Mohr; Chirojit Mukherjee
Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  The Annals of thoracic surgery     Volume:  89     ISSN:  1552-6259     ISO Abbreviation:  Ann. Thorac. Surg.     Publication Date:  2010 Jun 
Date Detail:
Created Date:  2010-05-24     Completed Date:  2010-06-16     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  15030100R     Medline TA:  Ann Thorac Surg     Country:  Netherlands    
Other Details:
Languages:  eng     Pagination:  1866-72     Citation Subset:  AIM; IM    
Copyright Information:
2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
Department of Anesthesiology and Intensive Care Medicine II, Heart Center Leipzig, University of Leipzig, Leipzig, Germany.
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MeSH Terms
Coronary Vessels / anatomy & histology,  injuries*,  ultrasonography*
Echocardiography, Transesophageal*
Iatrogenic Disease
Intraoperative Complications / ultrasonography*
Middle Aged
Mitral Valve / surgery*
Prospective Studies
Surgical Procedures, Minimally Invasive
Ultrasonography, Doppler, Color

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