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Coronary artery obstruction during mitral valve surgery and concomitant left atrial appendage exclusion; choosing a culprit.
  • Marc W. Gerdisch
Marc W. Gerdisch
Franciscan Heart Center

Corresponding Author:[email protected]

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This letter is in response to the case report by Kuzmin et al. entitled “Left atrial appendage occlusion device causing coronary obstruction: A word of caution” , published in November 2020 issue of Journal of Cardiac Surgery. The report describes a circumflex lesion occurring following mitral valve (MV) repair, tricuspid valve repair, and left atrial appendage closure (LAAO) using AtriClip device. The authors concluded that LAAO is a safe procedure, but in the setting of a concomitant MV surgery LAAO may be a contributor to the reported event. Circumflex coronary artery occlusion or impingement during MV repair is well described in the literature. On the reported two-dimensional cine, the position of the stenosis is typical of mitral repair induced injury. A ring suture can gather and compress tissue adjacent to the coronary creating stenosis without a discrete ligation. It is also true that vigorous traction on the LAA without due attention to distortion of the adjacent circumflex might be capable of creating compression or accordioning of the vessel. To mitigate this, the clip should be placed at the true base of the appendage. A residual pouch carries as much or more risk as not attempting to close the appendage at all. The authors’ recommendation to place the clip more distally will inevitably lead to incomplete closures. In conclusion, the reported event was more likely due to a mitral stitch, the path of which is not directly visualized after it breaches the endocardium.
10 Feb 2021Submitted to Journal of Cardiac Surgery
26 Apr 2022Assigned to Editor
26 Apr 2022Submission Checks Completed
26 Apr 2022Editorial Decision: Accept
Aug 2022Published in Journal of Cardiac Surgery volume 37 issue 8 on pages 2506-2506. 10.1111/jocs.16586