Direct Injury to Right Coronary Artery in Patients
Undergoing Tricuspid Annuloplasty
ADULT CARDIAC
Pablo Díez-Villanueva, MD, Enrique Guti
errez-Iba~
nes, MD,
Gregorio P. Cuerpo-Caballero, MD, Ricardo Sanz-Ruiz, MD, Manuel Abeytua, MD,
Javier Soriano, MD, Fernando Sarnago, MD, Jaime Elízaga, MD, PhD,
Angel Gonz
alez-Pinto, MD, PhD, and Francisco Fern
andez-Avil
es, MD, PhD
n, Instituto de Investigación Sanitaria Gregorio Mara~
n,
Department of Cardiology, Hospital General Universitario Gregorio Mara~
no
no
Universidad Complutense de Madrid; Departments of Cardiovascular Surgery and Anesthesiology, Hospital General Universitario
n, Madrid, Spain
Gregorio Mara~
no
Background. Direct injury to the right coronary artery as
a result of reparative operation on the tricuspid valve is a
rare, probably underdiagnosed, but serious complication,
which often involves dramatic clinical consequences. So
far, only five cases have been described in the literature.
Methods. We describe our single-center experience of
this complication, and review and analyze relevant clinical
and anatomic considerations related to this entity. Cases
previously reported in the literature were also reviewed.
Results. We describe four cases of direct injury to the
right coronary artery in patients undergoing tricuspid
annuloplasty (DeVega annuloplasty, 3; ring annuloplasty, 1) in our institution since 2005. All patients had
right ventricular dilatation and severely dilated tricuspid
annulus. Right coronary artery occlusion always occurred
between the right marginal artery and the crux of the
heart. Patients presented with hemodynamic or electrical
instability. Coronary flow could be restored in 2 patients
(percutaneously 1; surgically 1), both of whom finally
survived, while it was not technically possible in the
other 2 (1 died).
Conclusions. Occlusion of the right coronary artery in
patients undergoing tricuspid annuloplasty is a rare
complication that may occur if great annulus dilatation is
present, thus altering both normal annular geometry and
the relationship between the right coronary artery and the
tricuspid annulus, particularly when DeVega annuloplasty is performed. Such an entity should be considered
in the immediate postoperative period in an unstable
patient, especially when complementary tests support
this diagnosis. Prompt recognition and treatment can
positively affect the patient’s outcome, most often by
means of an emergency revascularization strategy.
S
Both cardiogenic shock and electrical instability may
complicate the course of patients undergoing reparative
surgery of the tricuspid valve (TV). Direct injury to the
right coronary artery (RCA) is a rare but serious complication, probably underdiagnosed, which often entails dramatic clinical consequences. We describe our single-center
experience of this complication, and review the literature to
analyze relevant clinical and anatomic considerations.
econdary or functional tricuspid regurgitation (TR) is
the most common type of TR, most often related to leftsided myocardial or valve heart disease, principally
advanced mitral valve disease [1]. The TR is secondary to
right ventricular (RV) enlargement and tricuspid annulus
dilatation, causing impaired proper leaflet coaptation,
which results in valve insufficiency [2, 3]. In case of moderate
or severe TR or dilated annulus, tricuspid valve annuloplasty (TA) performed at the time of mitral valve surgery
improves both TR and RV function and remodeling [4–6],
and consequently prognosis in the short and long term [7–9].
The number of tricuspid interventions has greatly
increased during the last several years, usually being
performed in the context of other cardiac operations [10].
Surgical technique has greatly evolved during the last
decades, with great acceptance of valve repair, which is
the technique of choice [9, 11]. The two most widely used
repair techniques are the DeVega pursestring repair
(suture technique) and ring or band annuloplasty.
(Ann Thorac Surg 2014;97:1300–5)
Ó 2014 by The Society of Thoracic Surgeons
Material and Methods
We reviewed our experience in recent years (2005
through 2012) regarding direct injury to the RCA related
to TV repair in patients with functional TR. Cases previously reported in the literature were also reviewed.
Moreover, anatomic and pathophysiologic features that
may be involved in this entity, as well as surgical considerations, are also considered and explained.
Accepted for publication Dec 18, 2013.
Results
Address correspondence to Dr Díez-Villanueva, Department of Cardioln, C/ Doctor
ogy, Hospital General Universitario Gregorio Mara~
no
Esquerdo 46, 28007, Madrid, Spain; e-mail: pablo_diez_villanueva@
hotmail.com.
Between 2005 and 2012, 499 patients underwent TV surgery in our institution; repair techniques were performed
in 450 of them (320 ring annuloplasty, and 130 De Vega
Ó 2014 by The Society of Thoracic Surgeons
Published by Elsevier Inc
0003-4975/$36.00
http://dx.doi.org/10.1016/j.athoracsur.2013.12.021
Ann Thorac Surg
2014;97:1300–5
DíEZ-VILLANUEVA ET AL
CORONARY ARTERY INJURY IN TRICUSPID SURGERY
Case 1
A 78-year-old woman with rheumatic valve disease was
referred for poor functional class (New York Heart Association III/IV). Her electrocardiogram showed atrial
fibrillation. An echocardiogram demonstrated that she
had a preserved left ventricular (LV) function, but a
dilated RV with mild systolic dysfunction. Severe mitral
and aortic stenoses were present, and she had severe TR
and annulus dilatation (44 mm). Preoperative coronary
arteriography showed calcified arteries, without significant lesions.
She underwent mitral and aortic valve replacement
with prosthetic mechanical valves (Carbomedics, CM;
Sorin Group USA, Inc, Arvada, CO), 25-mm and 21-mm,
respectively, and De Vega annuloplasty.
Postoperatively, she was initially dependent on low
doses of inotropic agents. A transesophageal echocardiogram described hypokinesia in the inferoposterior LV
wall (LV ejection fraction, 0.50), poorer RV function than
preoperatively assessed, and normal mitral and aortic
valve prosthesis function. Significant hemodynamic
impairment appeared a few hours later; thus intensive
vasoactive drug support and counterpulsation balloon
were needed. An electrocardiogram showed inferoposterior infarction, and urgent echocardiography
showed severe biventricular dysfunction, with akinetic
interventricular septum and inferior and inferoposterior
ventricular walls. The patient was then transferred to
the catheterization laboratory. Emergent coronary angiography showed the RCA had a subocclusive stenosis
at the crux. It was not possible to cross the lesion
with a percutaneous coronary intervention wire, thus
percutaneous revascularization was not achieved. The
patient finally died as a result of cardiogenic shock.
Case 2
A 76-year-old woman with a history of rheumatic valve
disease, LV dilatation, and poor functional class (New
York Heart Association III/IV) was referred for surgery.
Electrocardiogram showed atrial fibrillation. An echocardiogram demonstrated that she had mild LV dilatation, with normal function, a slightly dilated RV, and mild
systolic dysfunction. Severe mitral and tricuspid regurgitation and a dilated tricuspid annulus (44 mm) were
present. Preoperative coronary arteriography showed
calcified arteries, without significant lesions.
Surgical treatment consisted of mitral valve repair
(annuloplasty and neochordae implantation) and De
Vega annuloplasty.
After unclamping the aorta, the electrocardiogram
showed signs of inferior ST-segment elevation, which
initially normalized with nitroglycerin. One hour after
leaving the operating room, the patient exhibited severe
hypotension and new electrocardiographic abnormalities,
as well as several episodes of nonsustained ventricular
tachycardia. Echocardiogram showed RV dysfunction and
dilatation. Emergent coronary arteriography showed
multiple obstructive lesions along the middle and distal
segments of the RCA. A wire was placed in the artery, and
a balloon was used to dilate the obstruction, but the
procedure was unsuccessful as the artery became
occluded time and time again, probably because of the
plication caused by the suture. Hemodynamic stability
could finally be achieved with a low dose of inotropic
agents and a counterpulsation balloon, so the tricuspid
annuloplasty was not undone. Posterior evolution was
good. Follow-up echocardiograms showed recovery of RV
function.
Case 3
A 68-year-old woman was admitted for decompensated
heart failure. She had a history of rheumatic valve disease. An electrocardiogram demonstrated that she was in
atrial fibrillation. An echocardiogram showed normal LV
function, a dilated RV with preserved function, severe
Table 1. Cases From Our Seriesa
Case
Age (y),
Sex (M/F)
Tricuspid
Annulus (mm)
Surgery
Diagnosis
RCA Segment
Injured
1
2
78, F
76, F
44
44
DeVega
DeVega
ECG þ TTE þ shock
ECG þ shock
Crux
Mid
3
4
68, F
69, F
40
41
DeVega
Ring
ECG þ TEE þ arrhythmia
ECG þ TEE þ shock
Mid
Distal
Treatment
Result
Failed PCI
Failed PCI, shock
treatment
CABG
PCI
Died
Good
Good
Good
a
Right ventricular and right atrial enlargement is present in all cases, as is pulmonary hypertension. They are all women between 68 and 78 years old, with
a history of rheumatic valve disease.
CABG ¼ coronary artery bypass grafting (coronary angiography was performed before patient discharge);
ECG ¼ electrocardiogram;
percutaneous coronary intervention;
TEE ¼ transesophageal echocardiography;
TTE ¼ transthoracic echocardiography.
PCI ¼
ADULT CARDIAC
pursestring repair), and 49 underwent TV replacement.
Direct injury to the RCA complicated 4 of those 450 repair
operations, as described in the case reports. Severe
tricuspid annulus dilatation and right atrial and RV
enlargement were present in all patients of our series, as
well as severe pulmonary hypertension. Furthermore,
RCA occlusion occurred between the right marginal artery and the crux of the heart in all cases. Patient characteristics are summarized in Table 1 (postoperative
coronary arteriograms are shown in Fig 1).
1301
1302
DíEZ-VILLANUEVA ET AL
CORONARY ARTERY INJURY IN TRICUSPID SURGERY
Ann Thorac Surg
2014;97:1300–5
Fig 1. Coronary angiograms of our 4 patients (cases 1 to 4), showing right coronary
artery occlusion occurring between the right
marginal artery and the crux of the heart in
all cases.
ADULT CARDIAC
mitral valve stenosis and regurgitation, and severe TR,
with a dilated annulus (40 mm). Preoperative coronary
arteriography showed calcified arteries, without significant lesions.
We performed mitral valve replacement with a 27-mm
St. Jude mechanical prosthesis valve (St. Jude Medical,
Inc, St. Paul, MN) and De Vega annuloplasty.
During the postoperative course, while still in the
operating room the patient experienced electrical instability (several episodes of ventricular fibrillation). An urgent echocardiogram showed biventricular dysfunction,
and the electrocardiogram was compatible with inferior
infarction. Because the diagnosis was established in the
operating room, coronary artery bypass graft surgery
(saphenous vein to RCA) was immediately performed.
No complications occurred, although the patient had
persisting mild RV dysfunction at discharge. Coronary
angiography before discharge showed permeability of the
graft; a significant RCA stenosis was observed in the mid
segment, which was not present at baseline angiogram.
Case 4
A 69-year-old woman with a history of rheumatic valve
disease was admitted for worsening functional class. Her
electrocardiogram indicated she was in sinus rhythm. An
echocardiogram indicated preserved LV function, but she
had a severely dilated RV with moderately depressed
function, severe mitral valve stenosis and regurgitation,
and a severe TR with a dilated annulus (41 mm). Preoperative coronary arteriography showed calcified arteries,
without significant lesions.
She underwent mitral valve replacement with a biologic prosthesis, the St. Jude Medical Epic heart valve (St.
Jude Medical), 29-mm, and implantation of a 30-mm
Physio annuloplasty tricuspid ring (Edwards Lifesciences,
Irvine, CA).
Severe biventricular dysfunction was evident after
unclamping the aorta, but the hemodynamic situation
improved with high doses of inotropic agents and initial
stabilization was achieved. Later on, 2 hours after leaving
the operating room, an electrocardiogram showed STsegment elevation in the inferior leads. Emergency coronary angiography showed critical stenosis in the distal
RCA. Implantation of a bare metal stent achieved
percutaneous revascularization. No further complications
occurred after that. The patient exhibited mildly
depressed LV function at discharge, with no other echocardiographic remarkable changes.
Literature Review
To date we found only five case reports in the literature
describing direct injury to the RCA related to TR surgery
[12–16]; one of them [15] is case 2 of our series, included in
Table 1. The other four cases are summarized in Table 2
Ann Thorac Surg
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DíEZ-VILLANUEVA ET AL
CORONARY ARTERY INJURY IN TRICUSPID SURGERY
1303
Patient
1
2
3
4
a
Age (y),
Sex (M/F)
Surgery
Diagnosis
–
64, F
38, M
83, M
Ring
DeVega
Band
Band
ECG
ECG þ TEE
ECG þ TEE þ arrhythmia
ECG þ TEE þ arrhythmia
RCA Segment
Injured
Treatment
Result
Non specified
Distal
Distal
Beyond right
marginal artery
None
PCI
CABG
Failed PCI, shock
treatment
Died
Good
Good
Good
Right ventricular and annular dilatation is present in all cases.
No more data were available from patient 1 [12]. Patient 2 was a 64-year-old woman referred for mitral insufficiency and recent onset of dyspnea. She had
undergone mechanical aortic valve replacement because of acute endocarditis 14 years before [13]. Patient 3 was a 38-year-old man referred for symptomatic severe mitral regurgitation caused by bacterial endocarditis in a myxomatous mitral valve with significant tricuspid regurgitation and dilated
annulus [14]. Patient 4 was an 83-year-old man with mitral valve prolapse in poor functional class [16].
CABG ¼ coronary artery bypass grafting (coronary angiography was performed before patient discharge);
ECG ¼ electrocardiogram;
percutaneous coronary intervention;
TEE ¼ transesophageal echocardiography;
TTE ¼ transthoracic echocardiography.
(including a brief description of them in the footnote).
Three of them underwent annuloplasty ring or band, and
one underwent De Vega annuloplasty. Again, RV dilatation and tricuspid annulus dilatation were present in all
cases, and RCA occlusion always occurred between the
right marginal artery and the crux of the heart.
Comment
Circumflex artery injury related to mitral annuloplasty
has been repeatedly reported [17], but injury to the RCA
appears to be a rare complication of TA, often presenting
as cardiogenic shock and electrical instability. So far, only
five cases had been reported, one of them in our center
[15]. From this standpoint, and considering this complication may be underdiagnosed, we reviewed the cases in
which this entity complicated TA (cases reported to date
in the literature and those discussed in this article).
The relationship between the valve complex and surrounding structures is of great importance to optimize
surgery outcomes, as detailed elsewhere [18, 19].
Regarding the relationship between the RCA and the TV,
it is perceptive to remark on some anatomic considerations. First, the tricuspid annulus is not a consistent
collagen structure, so the atrioventricular groove is said to
directly fold into the TV leaflets at the vestibule, and the
entire parietal attachment of the TV is usually encircled
by the RCA running within the atrioventricular groove
[20]. Second, the RCA has three well-defined portions
(proximal RCA, before the origin of the marginal branch;
mid RCA, the segment just beyond the marginal branch;
and distal RCA, the segment halfway between the right
marginal branch and the origin of the posterior
descending artery); the segment delimited by the right
marginal artery and the crux is the most closely related to
the tricuspid annulus (Figs 2, 3). The distance between the
RCA and the endocardium is particularly small in those
areas closest to the tricuspid annulus, especially in the
cavotricuspid isthmus in the lower right atrium, with a
distance of less than 5 mm in over 80% of patients [21].
Deep suture placement for TA is not indicated given
the low wall stress in the right atrium. Therefore,
PCI ¼
placement of more superficial stitches, particularly in the
“danger zone” (anteroposterior commissure) should
greatly decrease the likelihood of injury.
In our opinion, there are two likely mechanisms that
can explain RCA injury: direct obstruction with the suture, which seems to be more plausible, and kinking of
the artery as a result of changes in annular shape.
Annulus dilatation may distort the normal RCA course,
and severely atherosclerotic arteries (more calcified and
rigid) could be more prone to kinking, thus leading to
plaque fracture and subsequent obstruction. Dilated
annuli, which in turn require more plication, probably
have an increased risk of direct RCA injury during TA,
especially when performing suture techniques (this
complication has not been reported with tricuspid prosthesis because there is no need to purse string the tissue)
taking into account the close relationship between the
artery and the annulus, as explained before. Risk of RCA
occlusion may be minimized by using semirigid rings,
applying fewer sutures along the posterior annulus, and
avoiding applying the stitches to the atrial wall.
Fig 2. Relationship between the right coronary artery and tricuspid
valve. The segment delimited by the right marginal artery and the
crux is the most closely related to the tricuspid annulus (between the
anteroposterior commissure and posterior leaflet).
ADULT CARDIAC
Table 2. Cases Previously Reported in Literaturea
1304
DíEZ-VILLANUEVA ET AL
CORONARY ARTERY INJURY IN TRICUSPID SURGERY
ADULT CARDIAC
Fig 3. Relationship between the right coronary artery and tricuspid
valve. The segment delimited by the right marginal artery and the
crux is the most closely related to the tricuspid annulus (between the
anteroposterior commissure and posterior leaflet).
Patients may present hemodynamic or electrical instability (ventricular arrhythmias) as well as RV or biventricular dysfunction. Nevertheless, this entity is often
diagnosed some hours after the patient leaves the operating room. This may be because RCA obstruction is
usually incomplete, thus allowing for better hemodynamic tolerance and delayed diagnosis. In case of complete occlusion, diagnosis may be achieved earlier
(greater hemodynamic or electrical instability, or earlier
and more evident electrocardiogram alterations), even in
the operating room itself, as in case 3.
Differential diagnosis with RCA occlusion in TA should
include other causes of RV dysfunction, such as LV
dysfunction, volume overload, pulmonary hypertension,
or myocardial stunning caused by extracorporeal circulation, each requiring specific treatment [22]. Also, air
emboli [23], considering the origin of the RCA (anterior
and cranial), may be present after releasing the aortic
crossclamp. Onset of ventricular dysfunction in this case
is very early and usually transient, as are electrocardiographic findings. In case of direct RCA injury by the suture, RV dysfunction, characteristically persistent, may
sometimes be evident only hours after the surgery, and
no apparent ST-segment changes are often noted initially,
which may delay the diagnosis. Electrical instability
(ventricular arrhythmia) is not uncommon in the early
postoperative period, and is usually attributed to electrolyte disturbances, ischemia, or ventricular dysfunction.
Ischemia may be related to anemia, bleeding, poor blood
oxygenation, or heart failure, but also can occur with
preexisting coronary artery disease. Interestingly,
obstructive coronary disease is not present in any of the
patients of our series, nor in any of the cases previously
reported. This is why RCA occlusion should be considered in the early postoperative period of patients undergoing TA, with or without preexisting coronary disease.
Significantly, ventricular pacing may also complicate the
diagnosis of any coronary occlusion as ST-segment
changes may not be evident.
Ann Thorac Surg
2014;97:1300–5
Urgent revascularization of an occluded coronary artery through percutaneous coronary intervention or coronary artery bypass graft surgery is crucial in cardiogenic
shock occurring in the context of a myocardial infarction,
as restoring normal blood flow greatly improves the
prognosis of these patients [24, 25]. Considering all the
cases, those from our series and those previously reported, revascularization was not achieved in 4 patients
(50%), 2 of whom died (50%). On the other hand, all those
patients who underwent revascularization survived.
Nonetheless, revascularization in this subset of patients
has proved challenging, with a relatively high rate of
failure owing to the impossibility of inserting a wire into
the artery beyond the surgical stenosis, or failure of the
balloon to achieve a lasting and sufficient dilatation of the
stenosis. However, in other cases it was possible to stent
or bypass the artery, with excellent clinical results.
The first cases in our institution increased awareness of
this problem, and we established a diagnostic and therapeutic algorithm, shown in Figure 4. Thus, in case of
hemodynamic or electrical instability with RV or biventricular dysfunction in the postoperative period owing to
persistent ischemia, and after excluding other possible
etiologies (previously described), RCA injury should be
suspected. If complementary tests (ST-segment changes
in electrocardiogram, and abnormal wall motion in
echocardiography) support this diagnosis, flow should be
restored. Consequently, if such diagnosis is achieved in
the operating room (in major obstructions, diagnosis is
often achieved earlier), the surgeon can remove the sutures or the ring, thus resolving the occlusion, or perform
empiric RCA bypass. In this case, coronary angiography
should be performed before discharge to evaluate coronary flow. On the other hand, if diagnosis is done in the
postoperative period after leaving the operating room, the
Fig 4. Proposed diagnostic and therapeutic algorithm in case of right
coronary artery (RCA) injury in tricuspid annuloplasty (TA). * Other
causes of instability: prior RV or LV dysfunction, volume overload,
pulmonary hypertension, myocardial stunning caused by extracorporeal circulation, air emboli and electrolyte disturbances.
DíEZ-VILLANUEVA ET AL
CORONARY ARTERY INJURY IN TRICUSPID SURGERY
patient should be immediately transferred to the catheterization laboratory to assess and reestablish coronary
flow percutaneously. If the percutaneous approach fails,
coronary artery bypass graft must be performed.
In conclusion, direct injury or occlusion of the RCA
by a suture in patients undergoing TA is an infrequent complication, although probably underdiagnosed.
Therefore, a high index of suspicion is essential in
the postoperative period, and urgent assessment of the
coronary circulation is mandatory in every patient with
hemodynamic or electrical instability in whom complementary tests (mainly electrocardiogram and echocardiogram) support this possibility. This entity should be
especially considered in case of great annulus dilatation
and calcified arteries.
Revascularization is the treatment of choice, particularly in patients in cardiogenic shock. In some cases it can
be performed percutaneously at the time of diagnosis; a
surgical approach appears as a valid alternative if a
percutaneous approach fails or the diagnosis is made
while still in the operating room.
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