Mitral valve arcade with concomitant anomalous left coronary artery from the pulmonary artery

The presence of congenital mitral valve arcade with concomitant anomalous coronary artery arising from the pulmonary artery (ALCAPA) is exceedingly rare. We describe a case of a 5-month-old female patient with both ALCAPA and severe mitral regurgitation secondary to mitral valve arcade.     

Early recovery of left ventricle following coronary artery bypass grafting and mitral valve repair in a case of anomalous origin of left coronary artery from pulmonary artery

Anomalous origin of Left Coronary Artery from Pulmonary Artery (ALCAPA) is a rare congenital malformation, which can result in myocardial infarction, congestive heart failure and sudden death if left untreated. Reports of myocardial revascularization and Mitral Valve (MV) repair following ALCAPA repair in infants are uncommon. We report a critically ill infant with ALCAPA needing myocardial revascularization and MV repair after which there was early recovery of Left Ventricular (LV) function. At two years follow up, the child is clinically well; the postoperative cardiac catheterization shows good flow in the Left Internal Mammary Artery (LIMA) and Left Anterior Descending artery (LAD), good LV function and competent mitral valve.     

Mitral valve replacement through right thoracotomy after previous coronary artery bypass grafting

The Usefulness of Brachial Artery Cannulation, Perfused Ventricular Fibrillation with Moderate Hypothermia, and Minimal Dissection Techniques It has been reported by several authors that a right thoracotomy for mitral valve surgery can be useful after previous coronary aortery bypass grafting (CABG). A 76-year-old man with mitral valve regurgitation after previous CABG underwent mitral valve replacement with some modified techniques. Cardiopulmonary bypass was established with right brachial artery cannulation and right femoral venous cannulation with the aid of vacuum-assisted venous drainage. Ventricular fibrillation (VF) was induced by rapid pacing of the ventricle, and mitral valve replacement was performed under perfused VF with moderate hypothermia. The patient’s postoperative course was uneventful. This method appears to be a safe and easy alternative mitral valve surgery for complicated cases of this type.     

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) presenting with ventricular fibrillation in an adult: a case report

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital anomaly. The usual clinical course is severe left sided heart failure and mitral valve insufficiency presenting during the first months of life. However, in some cases collateral blood supply from the right coronary artery is sufficient and symptoms may be subtle or even absent. Arrhythmias or sudden cardiac death in adult life may be the first clinical presentation in patients with ALCAPA. We report a case, where a 39-year old woman presented with ventricular fibrillation during phycial exertion. Coronary angiography and CT-angiography revealed an anomalous origin of the left coronary artery, and an aortic reimplantation of the left coronary artery was performed followed by ICD implantation. A review of the literature on ALCAPA is presented along with CT images before and after surgery.     

Combining off pump coronary artery bypass with mitral valve replacement

Background Conventional approach to combined coronary artery bypass grafting (CABG) and mitral valve replacement (MVR) is associated with longer cardiopulmonary bypass (CPB) and aortic cross clamp (ACC) time leading to high operative risk. Methods We conducted a retrospective review of nine consecutive patients undergoing coronary artery bypass grafting/mitral valve replacement combining the off pump technique with cardioplegic arrest. Elective intra aortic balloon pump (IABP) support was instituted in all cases. CABG was first done in all cases without cardiopulmonary bypass support. Mitral valve replacement was then done using conventional cardiopulmonary bypass and cardioplegic arrest using the superior septal approach. Results Nine consecutive patients underwent coronary artery bypass grafting with mitral valve replacement including three patients with acute myocardial infarction. Preoperative echocardiogram revealed a mean ejection fraction (EF) of 38.4 ± 6.0%. Intra aortic balloon pump was inserted in all patients preoperatively. The average number of grafts were 3.0 ± 0.7. Eight patients received bioprosthetic valve while one patient received mechanical prosthesis. The average length of stay in intensive care unit was 3.3 ± 0.5 days. There was no mortality. One patient had superficial wound infection. Conclusion The data suggest that the combined technique (off pump coronary artery bypass grafting and conventional mitral valve replacement) is a safe method to perform coronary artery bypass grafting/mitral valve replacement with minimal morbidity and mortality.     

Atherosclerosis in type IV dual left anterior descending artery and anomalous aortic origin of the left circumflex artery in association with rheumatic valve disease: a case report

Double left anterior descending coronary artery arising from the left and right coronary arteries is a very rare congenital coronary artery anomaly. In this case, there was also a circumflex artery arising from the right sinus Valsalva and in association with severe rheumatic valve disease. Subsequently, the patient underwent mechanical aortic valve replacement with a 21-mm bileaflet mechanical aortic valve and coronary artery bypass grafting. We performed coronary artery bypass grafting of 3 vessels, including the left internal mammary artery to the large diagonal branch and the saphenous vein graft to the circumflex artery and the right coronary artery, under cardiopulmonary bypass. In this report, we describe an unusual case of this combination in association with both atherosclerosis and rheumatic aortic and mitral valve disease.     

Compression of an anomalous left circumflex coronary artery by a bioprosthetic valve ring

The most common anomaly of the coronary arteries is the origin of the left circumflex artery from the right sinus of Valsalva or the right coronary artery proper. This anomaly is rarely clinically significant. A patient is reported here who has such an anomaly which did become clinically significant after a bioprosthetic aortic valve replacement. The circumflex artery described here became compressed between the Hancock aortic valvular ring and the mitral valvular apparatus. This case is the first antemortem report of such a compression to be demonstrated angiographically and the first case to be the results of an aortic bioprosthetic ring alone. Special surgical considerations must be made when performing valvular replacements on patients with this coronary artery anomaly.     

Late outcome of mitral valve surgery for patients with coronary artery disease

BACKGROUND: We plan to determine whether the cause of mitral valve regurgitation, ischemic or degenerative, affects survival after combined mitral valve repair or replacement and coronary artery bypass grafting (CABG) surgery and to assess the influence of residual mitral regurgitation on late outcome. METHODS: A retrospective study was made of 302 patients having mitral valve repair or replacement and CABG from January 1987 through December 1996. Risk factors for death, for development of New York Heart Association class III or IV congestive heart failure (CHF), and recurrent mitral valve regurgitation were identified by proportional hazards analysis. RESULTS: The cause of mitral regurgitation was ischemic in 137 patients (45%) and degenerative in 165 patients (55%). Valve replacement was performed in 51 patients (17%) and valve repair in 251 patients (83%). Median follow-up was 64 months. Ten-year actuarial survival rates were 33% (95% confidence interval: 22% to 47%) in the ischemic group and 52% (95% confidence interval: 42% to 64%) in the degenerative group. Univariate predictors of death, were entered into a multivariate model. Older age, ejection fraction of 35% or less, three-vessel coronary artery disease, replacement of the mitral valve, and residual mitral regurgitation at dismissal were independent risk factors for death. The cause of mitral valve regurgitation (ischemic or degenerative) was not an independent predictor of long-term survival, class III or IV CHF, or recurrent regurgitation. CONCLUSIONS: Survival after mitral valve surgery and CABG is determined by the extent of coronary disease and ventricular dysfunction and by the success of the valve procedure; etiology of mitral valve regurgitation has relatively little impact on late outcome.     

Repair of anomalous left main coronary artery arising from the pulmonary artery in infants: long-term impact on the mitral valve

Background. Infants presenting with anomalous left coronary artery off the pulmonary artery (ALCAPA) are generally in heart failure and often have significant mitral valve regurgitation (MR). Although establishing a dual coronary circulation is the procedure of choice, there remains controversy as to how the mitral valve is handled.

Methods. We reviewed our experience with this lesion at St. Louis Children’s Hospital. Over the past 15 years, 17 infants under 18 months of age have undergone repair, with all but one being treated with reimplantation of the left coronary artery into the aorta; the other underwent the Takeuchi procedure (intrapulmonary artery baffle) and was excluded from this evaluation. The average age and weight at operation were 0.5 ± 0.3 years and 6.1 ± 1.9 kg, respectively. All presented with varying degrees of heart failure and 9 patients also had either moderate or severe MR.

Results. There was one early and no late deaths after reimplantation of the left coronary artery. The left ventricular function postrepair improved from a preoperative shortening fraction of 0.19 ± 0.09 to 0.34 ± 0.08 (p < 0.01). Moderate or severe MR was present in 2 patients postoperatively, and both developed significant obstruction in the left coronary artery postoperatively as well. Both underwent mitral valve repair and revascularization of the left coronary artery.

Conclusions. Excellent results can be obtained in the treatment of this very high-risk group of patients. Mitral valve repair is not generally necessary at the time of the initial operation. However, should MR recur or persist late, it may herald the presence of a coexistent, significant coronary stenosis. Cardiac catheterization should be performed to assess the patency of the left coronary artery before performing mitral valve surgery.     

Port-access mitral valve replacement after surgical correction for Bland-White-Garland syndrome

A 79-year-old woman with Bland-White-Garland syndrome was admitted to our institution for surgical treatment of severe mitral regurgitation (MR). She had previously undergone mitral valve repair and coronary artery bypass grafting for both mitral insufficiency and a coronary artery anomaly 14 years earlier. However, the degree of residual MR had gradually worsened, and redo mitral valve surgery was scheduled. Multidetector row computed tomography revealed that the right coronary artery (RCA) was dilated and located just behind the sternum, and saphenous vein graft bypassed to the left anterior descending artery was occluded. This meant that the RCA was the only vessel supplying coronary blood flow. We successfully performed port-access mitral valve replacement under mild hypothermia with fibrillatory arrest to prevent damage to the RCA. We propose that port-access surgery is a safe and effective treatment for redo cardiac surgery after initial surgical correction of a congenital heart anomaly.     

Right coronary artery fistula draining into the right atrium and associated with mitral valve stenosis: a case report

Coronary artery fistula (CAF) is a rare congenital anomaly of the coronary arteries in which abnormal connections are present between the coronary artery branch and the cardiac chambers or a major vessel. The incidence of CAF is estimated at 1 in 50,000 live births, and it is detected in approximately 0.2% of the adult population during coronary angiography. Reports of the coincidence of mitral stenosis and CAF are rare in the literature. We report a case of CAF and mitral valve stenosis in a patient with dyspnea and fatigue before valve replacement and surgical radiofrequency ablation. Coronary angiography showed a connection between the right coronary artery and right atrium. A fistula opening into the right atrium is rare in patients with coronary artery anomalies and mitral valve disease. Coronary angiography of the patient 1 month after surgical repair showed that the coronary anatomy was normal and the fistula was occluded. CAF can be diagnosed more frequently if coronary angiography is performed simultaneously with cardiac catheterization to evaluate valve functions or nonatherosclerotic myocardial ischemia in each valvular heart disease case. Surgical repair of CAF is the first-choice treatment to prevent complications and improve quality of life.     

Mitral valve replacement combined with coronary artery operation: determinants of early and late results

Mitral valve replacement combined with coronary artery bypass grafting has been reported as being associated with a higher mortality than either mitral valve replacement or coronary artery bypass grafting alone. Cause of mitral valve disease and severity of mitral regurgitation have been reported as related to mortality. To study the correlation of the cause of mitral valve disease and severity of mitral regurgitation to hospital mortality and long-term survival, we analyzed the results of 135 patients undergoing mitral valve replacement and coronary artery bypass grafting between June 1974 and August 1989. The hospital mortality was 11.8% (16/135). Fifteen preoperative and operative variables were tested for correlation with hospital or late mortality using univariate tests and multivariate regression. Advanced age (greater than 60 years), New York Heart Association functional class, and wall motion score were independently associated with hospital mortality (p less than 0.05). The cause of mitral valve disease and severity of mitral regurgitation were not related to hospital mortality or long-term survival (p greater than 0.05). The follow-up rate was 96.6% for the hospital survivors (115/119). Mean follow-up was 52.6 +/- 4.1 months. There were 35 late deaths. Survival was 91.9%, 89.9%, 78%, and 49.9% at 1, 2, 5, and 10 postoperative years, respectively. Preoperative New York Heart Association functional class and use of catecholamines during the postoperative intensive care period were independently related to late survival (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Combined mitral valve replacement and coronary artery bypass grafting through a left thoracotomy after retrosternal oesophageal reconstruction

A 74-year-old man with a history of retrosternal oesophageal reconstruction was referred for surgical treatment of mitral valve regurgitation and coronary artery disease. He underwent mitral valve replacement combined with coronary artery bypass grafting through a left thoracotomy. Combined mitral valve replacement and coronary artery bypass grafting through a left thoracotomy were feasible in this patient with a retrosternal neo-oesophageal conduit.     

Mitral regurgitation after myocardial infarction. Coronary artery bypass grafting and mitral valve replacement with chordae preservation.

A patient with acute ischemic mitral regurgitation after acute myocardial infarction required emergency coronary artery bypass grafting and mitral valve replacement with chordae preservation. For severe mitral regurgitation and heart failure due to myocardial infarction and ischemic papillary muscle dysfunction, mitral valve replacement with chordae preservation was effective. Here, we discuss the etiology of ischemic mitral regurgitation and the operative method for valve repair or replacement.     

冠状动脉异常起源于肺动脉的外科治疗

目的总结冠状动脉异常起源于肺动脉的外科治疗经验及疗效随访分析。方法从1999年4月至2005年8月共对12例冠状动脉异常起源于肺动脉的患者进行了外科治疗,其中左冠状动脉起源异常8例,右冠状动脉起源异常4例。异常起源的冠状动脉直接吻合到主动脉9例,应用Takeuchi技术,即肺动脉内隧道重建冠状动脉3例。有7例左冠状动脉起源异常的患者,因中、重度二尖瓣关闭不全同期行二尖瓣成形;1例合并房间隔缺损的右冠状动脉起源异常的患者,同期在非体外循环下行房间隔缺损封堵术。结果无死亡及术后并发症,随访7~83个月,平均(32±24)个月,左冠状动脉起源异常的患者,左室舒张末径从术前的(45±7)mm减小至术后的(39±6)mm(P=0.011),左室短轴缩短率从术前的0.21±0.09增加至术后的0.35±0.06(P=0.006),7例二尖瓣成形的患者术后二尖瓣反流程度均减轻;所有患者活动能力正常,均无症状。结论外科治疗冠状动脉异常起源于肺动脉,需恢复2个冠状动脉系统供血;左冠状动脉起源异常的患者,术后左室功能明显改善,对中、重度二尖瓣关闭不全的患者,需同期行二尖瓣成形;外科治疗早、中期效果良好,远期结果需进一步随访。     

Cleft mitral valve in association with anomalous left coronary artery arising from pulmonary artery

An anomalous origin of the left coronary artery from the pulmonary artery is commonly associated with mitral valve insufficiency. Usually this is secondary to left ventricular dysfunction or papillary muscle ischemia. We describe the association of an anomalous left coronary artery from the pulmonary artery with structural abnormalities of the mitral valve (cleft mitral leaflet) in 2 children, both of whom were being investigated for primary mitral valve disease. Both underwent successful operations for coronary transfer and mitral valve repair.     

A case of mitral valve replacement with a collar-reinforced prosthetic valve for heavily calcified mitral annulus.

Mitral valve replacement in the presence of extensive calcification of the mitral annulus is a technical challenge. Dense calcification of the annulus can cause a great difficulty in the insertion of a prosthetic valve and later periprosthetic leakage. A radical calcium debridement may cause left circumflex coronary artery injury, atrioventricular rupture, and thromboembolic events. We report a case of a 65-year-old woman suffering from mitral regurgitation with a severely calcified mitral annulus. She underwent mitral valve replacement using a collar-reinforced prosthetic valve, which allowed the surgeon to safely insert a prosthetic valve, avoiding the calcification completely without any major complications. We recommend this method as a feasible technique for mitral valve replacement in the presence of heavily calcified or disrupted fragile mitral annulus.     

Comparative morbidity of mitral valve repair versus replacement for mitral regurgitation with and without coronary artery disease

Mitral valve repair has been increasingly used at our hospital for mitral regurgitation with and without coronary disease. From January, 1984, to June, 1987, of 338 patients undergoing all forms of mitral valve surgery, 140 had first-time surgery for pure mitral regurgitation: 75 had valve repair, and 65 had valve replacement. Thirty-three of 75 (44%) had concomitant coronary bypass in the repair group, while 21 of 65 (32%) had coronary bypass in the replacement group. The mean functional class (3.4 versus 3.5), age (60 versus 61 years), and preoperative hemodynamics were similar in both groups. The cause of mitral regurgitation in the repair group was myxomatous change in 32 patients, ischemia in 27, rheumatic valve disease in 12, and endocarditis in 4. A Carpentier ring was used in 46, a Duran ring was used in 11, and none was used in 18. The operative mortality was 3 of 75 patients (4%) in the repair group, all with coronary artery bypass grafting, versus 2 of 65 patients (3%) in the replacement group, 1 of whom had undergone coronary artery bypass grafting. The mean postoperative functional class 15 months postoperatively was 1.12 in the repair group versus 1.15 in the replacement group. There were 7 late deaths in the replacement group and only 3 late deaths in the repair group. Actuarial survival at 30 months was 85 +/- 6% for the replacement group and 94 +/- 4% for the repair group. There were 5 late emboli (1 fatal, 4 nonfatal) after valve replacement and none after valve repair (p = 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)     

Coronary artery spasm during mitral valve replacement

Coronary artery spasm has been reported as a cause of myocardial ischaemia and necrosis during and after coronary revascularisation [1-4, 9, 11, 13, 14], but not after valve replacement. We report a case in which profound myocardial ischaemia after mitral valve replacement leading to difficulty in terminating cardiopulmonary bypass was caused by coronary vasospasm. It is suggested that coronary vasospasm has to be considered among the causes of myocardial insufficiency after cardiopulmonary bypass, even in the absence of coronary artery disease, and effective treatment may be obtained by coronary vasodilating drugs.     

Coronary artery and mitral valve surgery in Takayasu's arteritis: a case report

Concomitant coronary artery disease and mitral valve disease are rare in Takayasu's Arteritis. Our patient had Takayasu's Arteritis diagnosed 9 years ago. She had an inferior myocardial infarction and double stent implantation 8 months ago. She was admitted to the hospital for chest pain, and 3 vessel diseases were diagnosed with significant mitral regurgitation due to anterior leaflet prolapse. In this report, we present perioperative management of our patient who underwent coronary artery bypass grafting and mitral valve replacement.