Real 3D Visualization of the Circumflex Artery Surrounding the Mitral AnnulusFunding None.
Background The circumflex coronary artery is located close to the mitral annulus. Consequently, it is not immune to iatrogenic damage during mitral valve procedures. Our objective was to visualize the circumflex artery from a surgeon's point of view, emphasizing its proximity. Furthermore, comparing it to coronary angiograms might support preoperative planning.
Methods Ten adult human hearts preserved in 4% formaldehyde solution were investigated (left coronary artery injected with contrast agent). After performing coronary angiographies from LAO (left anterior oblique) 40/cranial 20, RAO (right anterior oblique) 10/cranial 40, and true lateral projections, anatomical preparations were performed. Images were captured throughout the full course of the circumflex coronary artery from multiple angles. Finally, the mean distances were measured in every 5 mm between the investigated artery and the annulus of the mitral valve.
Results Three-dimensional model of the circumflex coronary artery and its surroundings was successfully achieved from a left atrial surgical viewpoint. The main branches were identified on the coronary angiograms. The closest distance was measured under the region of the left auricle (2.02 ± 0.69 mm; 1–3.1 mm). Afterward, the circumflex artery was observed to make a loop away from the annular region.
Conclusion Our observations show correlation with previous anatomical studies and case reports addressing iatrogenic lesions on the circumflex coronary artery. Based on all these, we could determine a “danger zone” on the vessel. The simultaneous evaluation of the anatomical preparations and the angiograms might improve the acknowledgment of this vulnerable region serving to avoid any damage to the coronary artery.
The authors declare outside interests were not involved in neither the collection, analysis, and interpretation of the data nor the design of the study. Furthermore, the authors had freedom to fully disclose all results. Finally, no grants were received from any funding agencies in the public, commercials, or not-for-profit sectors.
B.F.: project development, data collection, data analysis, manuscript writing; A.O.: data collection, data analysis; L.B.: data collection, project development; G.B.: project development; G.R.: data collection; T.R.: project development, data collection, data analysis, manuscript writing.
Received: 15 April 2020
Accepted: 29 May 2020
21 October 2020 (online)
Georg Thieme Verlag KG
Stuttgart · New York
- 1 Kron IL, LaPar DJ, Acker MA. , et al; American Association For Thoracic Surgery Ischemic Mitral Regurgitation Consensus Guidelines Writing Committee. 2016 update to The American Association for Thoracic Surgery consensus guidelines: ischemic mitral valve regurgitation. J Thorac Cardiovasc Surg 2017; 153 (05) 1076-1079
- 2 Chatterjee S, Rankin JS, Gammie JS. , et al. Isolated mitral valve surgery risk in 77,836 patients from the Society of Thoracic Surgeons database. Ann Thorac Surg 2013; 96 (05) 1587-1594 , discussion 1594–1595
- 3 Nappi F, Avatar Singh SS, Santana O, Mihos CG. Functional mitral regurgitation: an overview for surgical management framework. J Thorac Dis 2018; 10 (07) 4540-4555
- 4 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 (02) 94-99
- 5 Aybek T, Risteski P, Miskovic A. , et al. Seven years' experience with suture annuloplasty for mitral valve repair. J Thorac Cardiovasc Surg 2006; 131 (01) 99-106
- 6 Nickenig G, Hammerstingl C, Schueler R. , et al. Transcatheter mitral annuloplasty in chronic functional mitral regurgitation: 6-month results with the Cardioband percutaneous mitral repair system. JACC Cardiovasc Interv 2016; 9 (19) 2039-2047
- 7 Malakouti-Nejad B, Winkler E, Johnson M. , et al. Evaluation of two methods of left atrial appendage (LAA) closure and its proximity to the circumflex artery. FASEB J 2015; 29 (1 Suppl); 552.6
- 8 Banayan J, Dhawan R, Vernick WJ, McCarthy PM. CASE 3--2012. Iatrogenic circumflex artery injury during minimally invasive mitral valve surgery. J Cardiothorac Vasc Anesth 2012; 26 (03) 512-519
- 9 Coutinho GF, Leite F, Antunes MJ. 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 (05) 1613-1620
- 10 Danielson GK, Cooper E, Tweeddale DN. Circumflex coronary artery injury during mitral valve replacement. Ann Thorac Surg 1967; 4: 53-59
- 11 Grande AM, Fiore A, Massetti M, Viganò M. Iatrogenic circumflex coronary lesion in mitral valve surgery: case report and review of the literature. Tex Heart Inst J 2008; 35 (02) 179-183
- 12 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 (01) 78-92
- 13 Cornu E, Lacroix PH, Christides C, Laskar M. Coronary artery damage during mitral valve replacement. J Cardiovasc Surg (Torino) 1995; 36 (03) 261-264
- 14 Kaklikkaya I, Yeginoglu G. Damage to coronary arteries during mitral valve surgery. Heart Surg Forum 2003; 6 (06) E138-E142
- 15 Pessa CJN, Gomes WJ, Catani R. , et al. Anatomical relationship between the posterior mitral valve annulus and the coronary arteries. Implications to operative treatment. Rev Bras Cir Cardiovasc 2004; 19: 372-377
- 16 Bevilacqua C, Eibel S, Foldyna B. , et al. Analysis of circumflex artery anatomy by real time 3D transesophageal echocardiography compared to cardiac computed tomography. Int J Cardiovasc Imaging 2017; 33 (11) 1703-1710
- 17 Ghersin N, Abadi S, Sabbag A. , et al. The three-dimensional geometric relationship between the mitral valvar annulus and the coronary arteries as seen from the perspective of the cardiac surgeon using cardiac computed tomography. Eur J Cardiothorac Surg 2013; 44 (06) 1123-1130
- 18 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 (10) 505-508
- 19 Falk V, Baumgartner H, Bax JJ. , et al. Corrigendum to ‘2017 ESC/EACTS Guidelines for the management of valvular heart disease’ [Eur J Cardiothorac Surg 2017;52:616-664]. Eur J Cardiothorac Surg 2017; 52 (04) 832
- 20 Kreusser MM, Pleger ST, Abu Sharar H. , et al. Transient elevation of high-sensitive troponin T after Cardioband implantation. Herz 2019; 44 (06) 546-552
- 21 Miura M, Zuber M, Gavazzoni M. , et al. Possible left circumflex artery obstruction in a Cardioband transcatheter mitral annuloplasty caused by coronary kinking during cinching. JACC Cardiovasc Interv 2019; 12 (06) 600-601
- 22 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 (06) 1866-1872
- 23 Murugesan C, Raghu B, Rao PV. Transesophageal echocardiographic diagnosis and management of circumflex artery injury following mitral valve repair. Cardiol Res 2011; 2 (02) 90-92
- 24 Virmani R, Chun PK, Parker J, McAllister Jr HA. 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 (05) 773-778
- 25 Winkler E, Malakouti-Nejad B, Johnson M. , et al. Establishing anatomical proximity between the coronary circumflex artery and the mitral valve annulus: implications for mitral valve surgery. FASEB J 2015; 29 (1 Suppl); 552.7
- 26 Gentry III JL, Summers MR, Harb S, Jaber W, Pettersson G, Griffin B. Iatrogenic left circumflex coronary artery fistula after mitral valve replacement. CASE (Phila) 2018; 2 (05) 218-221
- 27 Mantilla R, Legarra JJ, Pradas G, Bravo M, Sanmartín M, Goicolea J. [Percutaneous coronary intervention for iatrogenic occlusion of the circumflex artery after mitral anuloplasty]. Rev Esp Cardiol 2004; 57 (07) 702-704
- 28 Aubert S, Barthélémy O, Landi M, Acar C. Circumflex coronary artery injury following mitral annuloplasty treated by emergency angioplasty. Eur J Cardiothorac Surg 2008; 34 (04) 922-924
- 29 Calafiore AM, Iacò AL, Varone E, Bosco P, Di Mauro M. Distortion of the proximal circumflex artery during mitral valve repair. J Card Surg 2010; 25 (02) 163-165
- 30 Scarsini R, De Maria GL, Ciofani J. , et al. Coronary injury in mitral and aortic valve surgery: a case series using optical coherence tomography. Ann Thorac Surg 2020; 109 (03) e171-e174