Department of Anesthesiology and Intensive Care Medicine II, Heart Center Leipzig, University of Leipzig, Leipzig, Germany.
Ann Thorac Surg. 2010 Jun;89(6):1866-72. doi: 10.1016/j.athoracsur.2010.02.059.
Injury to the circumflex artery after mitral valve (MV) repair or replacement is a recognized complication of this procedure. We designed an echocardiographic method to visualize the course and flow of the circumflex artery, to detect iatrogenic injury to this structure intraoperatively, as well as to predict the coronary dominance pattern in MV surgery patients.
After Ethics Committee approval, a prospective study was undertaken in 110 patients undergoing minimal invasive MV repair. Intraoperative transesophageal echocardiography was used to visualize the circumflex artery using a combination of B-mode imaging and color Doppler with different Nyquist limits. The course of the circumflex artery and the coronary sinus and their corresponding diameters were documented at the proximal and distal ends of both vessels. Preoperative angiographic data were used to determine the coronary dominance type.
The course of the circumflex artery could be detected proximally in 109 patients (99%), to the point of intersection with the coronary sinus in 99 patients (90%), and distal to this intersection in 95 patients (86%) using our technique. Three patients had evidence of iatrogenic aliasing (circumflex stenosis) or "no flow" (circumflex occlusion) on transesophageal echocardiography examination after repair and therefore underwent surgical or percutaneous correction. All 3 of these patients had an uncomplicated postoperative course thereafter with no evidence of perioperative myocardial infarction. All remaining patients with normal circumflex examinations after repair did not show any clinical evidence of myocardial infarction or unstable hemodynamics postoperatively. The 95% confidence interval for the diameter of the proximal circumflex artery was 4.5 mm to 5.6 mm for the left dominant type patients and 3.8 mm to 4.2 mm for the right dominant and balanced type patients (p = 0.01).
The early recognition of iatrogenic injury of the circumflex artery is feasible with intraoperative transesophageal echocardiography examination, and may lead to treatment before extensive myocardial infarction occurs. We suggest that visualization of the circumflex artery with our technique should be performed more frequently in patients undergoing MV surgery.
二尖瓣（MV）修复或置换术后回旋支动脉损伤是该手术的一种公认并发症。我们设计了一种超声心动图方法来可视化回旋支动脉的走行和血流，以在术中检测到该结构的医源性损伤，并预测 MV 手术患者的冠状动脉优势模式。
经伦理委员会批准，对 110 例接受微创 MV 修复的患者进行了前瞻性研究。术中经食管超声心动图使用 B 型成像和彩色多普勒相结合的方法，结合不同的奈奎斯特限制来可视化回旋支动脉。记录回旋支动脉和冠状窦的近端和远端的走行及其相应的直径。术前血管造影数据用于确定冠状动脉优势类型。
我们的技术可在 109 例患者（99%）中检测到回旋支动脉的近端，在 99 例患者（90%）中检测到与冠状窦的交叉点，在 95 例患者（86%）中检测到交叉点的远端。3 例患者在修复后经食管超声心动图检查发现回旋支动脉有医源性伪像（回旋支狭窄）或“无血流”（回旋支闭塞），因此进行了手术或经皮矫正。此后，这 3 例患者均顺利康复，无围手术期心肌梗死的证据。所有其余回旋支检查正常的患者在修复后均无心肌梗死或不稳定血液动力学的临床证据。左优势型患者近端回旋支动脉直径的 95%置信区间为 4.5 毫米至 5.6 毫米，右优势型和平衡型患者为 3.8 毫米至 4.2 毫米（p = 0.01）。
术中经食管超声心动图检查可早期识别回旋支动脉的医源性损伤，并可能在广泛心肌梗死发生之前进行治疗。我们建议在接受 MV 手术的患者中更频繁地进行我们技术的回旋支动脉可视化。
