[HSF] bagged Cx

Wed Jan 24 01:58:27 EST 2007

Dear Ed,
We all know the circumflex can be reached from the mitral annulus. However if you place your annuloplasty sutures from close to the annulus through into the ventr. cavity and back out again into the atrium about 2 mm from the atrial-leaflet junction I venture to say that you cannot reach the circ. in a virgin case. 
I have seen the circ. kinked off by an annuloplasty in a patient with a chronic very dilated annulus. (I was able todefend this case succesfully as the expert witness by quoting Cooley's original description of this complication). I would not rule out embolism. Do you wear your loupes when you do a mitral? I never did because I wanted to have a broad field of vision so that I could notice any stray particles of anything.
I would strongly reccommend a follow up angiogram which would be in the patient's interest.
Don's suggestion may be right in which case you shpold see a normal circ.
Bob

-----Original Message-----
From: donross at bigpond.com
To: OpenHeart-L at lists.hsforum.com
Sent: Tue, 23 Jan 2007 8:18 AM
Subject: Re: [HSF] bagged Cx

I have seen severe Cx spasm after MVR relieved at cath with nitroglycerine. 
Don 
On 23/01/2007, at 11:48 AM, DukeB60 at aol.com wrote: 

> 68 yo Caucasian female with severe AI, severe MR and severe TR > with dilated 
> annulae of each. She was is AF for years. Cors were normal as > was the LVEF. 
> PAP elevated but not bad. 
> At surgery, done last Thursday, she also had a previously > unrecognized 
> ascending aortic dilation at 4.2 cm. so I elected to replace her > ascending 
> aorta as well with a Hemashield graft. Initially I attempted to > repair the 
> aortic valve with the 28mm Hemashield graft to reposition the ST > junction 
> (annulus measured 25mm on TEE) along with shortening of the non-> coronary cusp, which 
> didn't coapt in the center, but ultimately she still had 2+ AI so > I replaced 
> the aortic valve with a Magna pericardial. The leaflets were > somewhat 
> thickened and sclerotic so a long term repair was probably > unlikely anyway so I 
> had no problem with that. 
> I put in a 28mm Physio ring in the Mitral to completely > eliminate the MR 
> and a 30mm MC3 ring in the Tricuspid to completely eliminate the > TR even 
> though she had a pacer lead for her VVI pacer. (confirmed on post-> op echo in 
> addition to intra-op TEE. Also LV is normal now) I also did a > full Maze and 
> came off pump with atrial contraction and AV paced with bi-atral > epicardial 
> wires as she had an AV nodal ablation years ago with a VVI pacer > for her chronic 
> AF. She remains with atrial capture of the epicardial pacer on > POD # 3. At 
> surgery I also over sewed the LA appendage with a linear simple > double 
> layer, as always. 
> My question is as to how I bagged the Cx. coronary inasmuch as > when we 
> tried to come off pump she had lots of VT/VF and severe lateral > and inferior 
> wall motion abnormalities on TEE which got better only after a > vein graft to 
> the OM and the PD of her very left dominant system. 
> I implanted the mitral ring with non-pledgeted horizontal > mattress 
> sutures in the annulus and didn't think I took bites that deep and > routinely close 
> the LA appendage with the double layer simple suture but with one > or the 
> other must have gotten the Cx. There was plenty of room between > the appendage 
> and the mitral ring so it wasn't at all technically difficult. 
> I have heard of encircling the Cx. with deep sutures around a > calcified 
> mitral annulus but never with a very routine and seemingly easy > mitral 
> annuloplasy ring. The other possibility is an embolic etiology > but the annulus 
> wasn't very calcified so I doubt that. 
> Any one have thoughts about bagging the Cx. with seemingly > superficial 
> sutures. She is doing great now as demonstrated on the post-op > TTE and 
> hopefully EP will convert her pacer to a DDD instead of the VVI > with the success of 
> the Maze but I'm puzzled as to the obvious Cx. occlusion and am > interested 
> in others' thoughts. 
> 
> 
> Ed 
> 
> Edward P. Raines, M.D., J.D. 
> BryanLGH Cardiothoracic Surgery 
> BryanLGH Medical Center East 
> 1600 South 48th Str. 
> Lincoln, Nebraska 68506 
> Office: 402-481-8430 
> Cell: 402-730-9242 
> Fax: 402-481-8429 
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