Echocardiographic Identification of Iatrogenic Injury of the Circumflex Artery During Minimally Invasive Mitral Valve Repair Joerg Ender, MD, Michael.

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Presentation transcript:

Echocardiographic Identification of Iatrogenic Injury of the Circumflex Artery During Minimally Invasive Mitral Valve Repair Joerg Ender, MD, Michael Selbach, MBBS, Michael A. Borger, MD, PhD, Eugen Krohmer, MD, Volkmar Falk, MD, PhD, Udo X. Kaisers, MD, PhD, Friedrich W. Mohr, MD, PhD, Chirojit Mukherjee, MD The Annals of Thoracic Surgery Volume 89, Issue 6, Pages 1866-1872 (June 2010) DOI: 10.1016/j.athoracsur.2010.02.059 Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Schematic drawing of the modified midesophageal long-axis (LAX) view. (AML = anterior mitral leaflet; CS = coronary sinus; CX = circumflex artery; LAD = left anterior descending artery; Left mainstem = left main coronary artery; PML = posterior mitral leaflet; Pulm = pulmonary; TC = tricuspid.) The Annals of Thoracic Surgery 2010 89, 1866-1872DOI: (10.1016/j.athoracsur.2010.02.059) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Three-dimensional transesophageal echocardiogram showing the cross-section views by rotating the probe counterclockwise from the modified midesophageal aortic valve (AV) long-axis view. (a, b, and c) Planes of cross-section required for acquisition of the course of the circumflex artery. (ALC = anterolateral commissure; AML = anterior mitral leaflet; PMC = posteromedial commissure; PML = posterior mitral leaflet.) The Annals of Thoracic Surgery 2010 89, 1866-1872DOI: (10.1016/j.athoracsur.2010.02.059) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Color Doppler of the circumflex artery. (LA = left atrium; LAD = left anterior descending artery; Left main = left main coronary artery.) (Large asterisk = strong echodense wall of the circumflex artery; small asterisk = weak echodense wall of the coronary sinus.) The Annals of Thoracic Surgery 2010 89, 1866-1872DOI: (10.1016/j.athoracsur.2010.02.059) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Preoperative color Doppler examinations of the circumflex artery in patient 3, showing (A) obtuse marginal artery (OM) and (B) left anterior descending artery (LAD). (CX = circumflex artery; LA = left atrium; PA = pulmonary artery.) The Annals of Thoracic Surgery 2010 89, 1866-1872DOI: (10.1016/j.athoracsur.2010.02.059) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Preoperative angiogram of patient 3. The circumflex artery is bifurcating into a large obtuse marginal artery and a small ongoing circumflex artery. The Annals of Thoracic Surgery 2010 89, 1866-1872DOI: (10.1016/j.athoracsur.2010.02.059) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 Color Doppler examination of the circumflex artery (CX) after mitral valve repair in patient 3, showing (A) interrupted flow in the CX and (B) aliasing flow in the left anterior descending artery (LAD) as well as in the obtuse marginal artery (MA). (LA = left atrium; PA = pulmonary artery.) The Annals of Thoracic Surgery 2010 89, 1866-1872DOI: (10.1016/j.athoracsur.2010.02.059) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 7 Color Doppler flow in the circumflex artery (CX) after implantation of a smaller annuloplasty ring. Note the absence of aliasing as compared with Figure 6. (A): Flow in CX; (B): Flow in LAD and in CX; (C): Flow in left main coronary artery. (LA = left atrium; LAD = left anterior descending artery; PA = pulmonary artery.) The Annals of Thoracic Surgery 2010 89, 1866-1872DOI: (10.1016/j.athoracsur.2010.02.059) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions