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Total Arterial Complete Revascularization with Bilateral IMA and Ischemic Mitral Regurgitation Repair with Posterior Ring

Wednesday, January 27, 2016

A 60-year-old female was admitted with acute lateral wall myocardial infarction. A coronary angiogram revealed severe triple vessel disease. On transthoracic echocardiogram, she was found to have moderate left ventricular dysfunction with severe mitral regurgitation. The patient was stabilized via medical management and intra-aortic balloon pump, and was scheduled for coronary artery bypass grafting with mitral valve repair. The plan was to harvest both internal mammary arteries and use the LIMA RIMA Y as the composite graft. Coronary artery bypass grafting was done on the beating heart. LIMA was grafted to the diagonal 1 as longitudinal parallel anastomosis, and then LIMA to LAD as end-to-side graft. The RIMA was grafted to use marginal 1 as the longitudinal parallel anastomosis, and then RIMA to posterior descending artery as end-to-side anastomosis. The mitral valve repair was done via transeptal approach with a 40 mm posterior trigone to trigone tailored St. Jude band. The patient was weaned off of cardiopulmonary bypass with moderate ionotropic support. There was no mitral regurgitation on intraoperative TEE. She was gradually extubated and weaned of all inotropic support and intra-aortic balloon pump was removed. The patient remained stable and was subsequently discharged.


All coronary anastomosis were done pump assisted without cross clamp 1 to prevent prolonged global ischemia time. 2 To facilitate graft positioning and configuration . 3 regional ischemia was prevented by intracoronary shunt .
Mitral regurgitation is primarily a myocardial problem in this case which is why ideally. From the echo it seems its a type I MR with a issue of annular dilatation and thus lack of co-aptation and a normal leaflet motion. Ideally in these cases IMR should be used and downsizing the ring by one size.
IMR in this case seems to be due to annular dilatation, Echo images were to quick and is not possible to asses an eventual leaflets tethering. Why don't you use a complete rigid or semi-rigid ring to perform the annuloplasty?

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