This document discusses potential intraoperative issues that can occur during or after mitral valve repair surgery. It notes that the circumflex coronary artery is often very close to the mitral valve annulus and can be inadvertently injured by sutures or ring annuloplasty. A prospective echocardiography study identified 3 patients who experienced circumflex injury during minimally invasive mitral valve repair, including 1 with ECG changes and 2 requiring coronary intervention. The document emphasizes that surgeons must be aware of the variable position of the circumflex artery and should check for signs of injury before closing the chest. It also discusses how systolic anterior motion (SAM) of the mitral valve can occasionally occur after repair due to an unders

1. INTRAOP ISSUES POST
MITRAL VALVE REPAIR

3. CORONARY INJURY
• Proximity of Circumflex
coronary artery to Mitral
valve annulus
• Very variable in position.
• Any suture during
annuloplasty can go through
Circumflex artery.
• Plication of the annulus can
distort it

4. CIRCUMFLEX CAN BE VERY CLOSE TO
ANNULUS
• Coronary artery can be
much closer to the
annulus then we realise.
• Almost bulging in the
left atrium and very
close to the annulus.
• If surgeon not aware –it
would be very easy to
go through the suture

5. CIRCUMFLEX IS CLOSER THAN YOU THINK
• When the ring is in
place –it is just
adjacent to the
circumflex coronary
artery.
• That artery was
clearly at risk.

6. PROSPECTIVE STUDY- ECHO BASED
• This problem occur
more commonly
then we appreciate.
• Most people will claim it
doesn’t exist-that’s because
they haven’t looked for it.
• Paper from Mohrs group –
prospective study to look at
the frequency of this
problem.

7. ECHOCARDIOGRAPHIC
IDENTIFIATION
IATROGENICV INJURY OF
THE CIRCUMFLEX ARTERY
DURING MINIMALLY
INVASIVE MITRAL CVALVE
REPAIR

9. PATIENT 1
1. Inferior ST elevation and
posterior RWMA noted but no
hemodynamic consequence
and no need for ionotropes.
2. Coronary angiography done
post surgery showed coronary
stenosis.
3. Returned to OR, sutures in P1
removed , Ring replaced.Flow
resumed , ECG normalised

10. PATIENT 2
• Echo picked coronary flow
changes.
• No associated findings so
returned to ICU .
• SIX HOUR post op –
hemodynamic instability .
• Cath showed occluded distal
circumflex.
• Coronary stent placed

11. PATIENT 3
• Unable to wean off bypass.
Posterior dyskinesia
• Reperfused for half hour,
still could not wean
• Ring replaced with one two
sizes smaller
• Weaned off by pass with
ease
• Good flow now observed
on circumflex artery
• All 3 patients did well with
no echocardiogenic
evidence of MI

12. INFORMATION TO
SURGEONS
• 1.Distance from the annulus to the
circumflex..
• 2. If at P1 level close to 3 mm- need to
be careful and superficial while taking
stitches.
• 3. Check for the Left dominant system-
may kink coronary even at P2 & P3 level.
( left dominant artery can be very close
to entire posterior annulus).
• 4. Close the atrium ,take the clamp off
and look for persistence of corornary
flow- small ring pulls the tissue and

13. DON’T FORGET THE
CORONARY ARTERY

14. B E A W A R E O F T H E A B E R R A N T C O R O N A R Y
A R T E R Y

15. CIRCUMFLEX
COURSES ALONG
AORTO MITRAL
CURTAIN

16. B E A W A R E O F
T H E A B E R R A N T
C O R O N A R Y
A R T E R Y

19. ATRIAL DISRUPTION
• Atrium is less
pressurized.
• Sometimes –Can be
managed
conservatively- if no
gradient/inflow
obstruction or
compromise to mitral
valve or pulmonary
veins.

24. MANAGEMENT OF SAM

25. ALGORITHM
• Not rare as you think -
As we progress from
resection to
preservation.
• Key is to optimize the
fluid, optimize your
preload, slow down the
heart rate and
contraction.

26. INTRAOPERATIVE POST
REPAIR SAM
• Mismatch between
leaflet tissue and
orifice.
• Residual posterior
leaflet tissue height
and undersized ring.

27. INTRAOPERATIVE POST REPAIR SAM

28. INTRA OPERATIVE
POST REPAIR SAM
• Rather then replace the ring-
Create a curtain effect-closing
the cleft that was left behind .
• Tie lower in the ventricle to
restrict posterior leaflet
mobility.
• Develop a coaptation surface
more posteriorly.

29. EARLY POST – REPAIR SAM ( DAY 5)

30. E A R L Y P O S T R E P A I R S A M ( D A Y 5 )
P E A K G R A D I E N T 7 1 M M H G

31. EARLY POST
REPAIR
SAMDAY (8)
P E A K G R A D I E N T 9
M M H G

32. E A R L Y P O S T R E P A I R S A M ( D A Y 4 )
PEAK GRADIENT 110 MM HG

33. EARLY POST – REPAIR SAM
(DAY 30)
P E A K G R A D I E N T 7 M M O F M E R C U R Y