Coronary Artery Injury During Novel Mitral Annular Enlargement Procedure
Ashok Muralidaran, MD, Irving Shen, MD.
Oregon Health & Science University, Portland, OR, USA.
Objective(s): To demonstrate a novel left atrioventricular valve annular enlargement procedure that was complicated by inadvertent injury to the circumflex coronary artery.
Methods: Four year old male with complete atrioventricular septal defect repaired in infancy, underwent a 17 mm mechanical Mitral valve replacement with a 20 mm Teflon sleeve at age 2 years with the subsequent development of patient prosthetic mismatch resulting in severe stenosis. After prosthetic valve and Teflon cuff explantation and annular debridement, the residual annulus was still only 17 mm. An incision was made into the interventricular septum, cutting down into the posterior aspect of the previously placed VSD patch and into the muscular septum (Figure 1). The cut edges were incorporated into the circumference of the Mitral annulus enabling the placement of a 21 mm mechanical valve.
Results: During the extensive left atriotomy along the roof required for valve exposure, the circumflex coronary artery was inadvertently injured leading to significant LV dysfunction and ECMO institution on the evening of surgery. The patient came off ECMO on postoperative day 9 with severely depressed left ventricular function and discharged home on day 27.
Conclusions: We describe a novel annular enlargement technique for the left atrioventricular valve in a patient with atrioventricular septal defect. The "nightmare" scenario was inadvertent circumflex coronary artery injury resulting in left ventricular dysfunction with incomplete recovery. 
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