COMMENT
Acute iatrogenic complications of MV repair depend on the techniques
applied by the surgeons to correct the valvular lesions (SAM) and on the
position of the stitches used to implant a ring or band to reshape the
annulus (CX injury).
SAM is specific of the correction of degenerative MR, while CX injury
can happen every time stitches are passed close to the mitral annulus.
SAM has been widely studied and many strategies have been suggested to
prevent or to correct it. However, even if surgeons are aware of this
possibility, the prevalence of SAM has remained more or less the same on
the last decades, being 9.1% in 1994 [26], 8.4% in 2007 [27],
and 8.1% in 2017 [28]. In the most recent experience [4], the
prevalence was 13%, but, after adequate surgical or medical treatment,
still 3.7% of the patients with MV repair were discharged with SAM.
CX injury is surely less frequent, but possibly underdiagnosed, but it
has to be suspected any time there is a difficult weaning from CPB or
there are sign of ischemic event. However, it is not part of the
surgeons’ mentality the necessity to have a preoperative diagnosis on
the CX relationships with the annulus. The mechanism of injury,
moreover, is not always the same. A short distance between the CX and
the annulus exposes to the danger of passing a stitch trough the artery,
whereas attracting the CX towards the annulus can happen independently
from the CX position. It is evident that, to cause occlusion or severe
stenosis by attraction, the CX has to be far from the annulus, as in the
case shown in Figure 2. Intraoperative echocardiographic evaluation of
the CX flow is the most helpful tool we have to diagnose the
complication independently from the mechanism, and to promptly react to
avoid or to limit a dangerous perioperative myocardial infarction.