Optical Coherence Tomography Evaluation of Extraluminal Left Circumflex Artery Compression Following Mitral Valve Replacement
Bibliographic record
Abstract
The left circumflex artery (LCx) follows the atrioventricular groove, which causes it to curve around the posterior annulus of the mitral valve (MV), making it susceptible to injury during MV surgery. LCx injury following MV surgery is rare, with a reported incidence of approximately 0.5%.1Husain A. Alsanei A. Tahir M. et al.Left circumflex artery injury post mitral valve surgery, single center experience.J Saudi Heart Assoc. 2019; 31: 94-99Crossref PubMed Scopus (8) Google Scholar The multiple mechanisms of injury include direct injury from a suture, air embolism, and extra luminal compression. We report a case of a 34-year-old male patient with known rheumatic heart disease. He had previously undergone MV commissurotomy and tricuspid valve repair at the age of 25 years and presented to the hospital with congestive heart failure. An echocardiogram demonstrated severe tricuspid regurgitation with a severely dilated right ventricle, moderate aortic insufficiency, and moderate-severe mitral stenosis with a mitral valve area of 1.2 cm2. Following review at heart team rounds, the decision was made to offer this patient complex valve surgery. A preoperative angiogram demonstrated normal epicardial coronary arteries with a left-dominant system (Fig. 1). The patient subsequently underwent aortic valve replacement with a 21-mm On-X mechanical valve (On-X Life Technologies Inc, Austin, TX), mitral valve replacement with a size 27/29 On-X mechanical valve, and a tricuspid valve replacement with a 31-mm Edwards Mitris bioprosthetic valve (Edwards Lifesciences, Irvine, CA). While attempting to wean off pump use, the patient had significant hypotension and a transesophageal echocardiogram demonstrated a new wall motion abnormality. Therefore, the patient was brought to the cardiac catherization lab for further assessment. Coronary angiography demonstrated a haziness in the LCx (Supplemental Fig. S1), which was new compared to his preoperative angiogram. To evaluate this finding further, optical coherence tomography was performed, which demonstrated normal 3-layer vessel architecture with extraluminal compression (Video 1 , view video online; Fig. 2). The minimal lumen area within the compressed area was measured to be 2.35 mm,2 with a reference area, measured for comparison, of 7.35 mm2. Based on the optical coherence tomography findings, the patient was taken back to the operating room for emergent bypass of the obtuse marginal. Unfortunately, the patient’s postoperative course was complicated by sepsis resulting in multi-organ failure, and the patient died on postoperative day 12. The LCx injury is a rare occurrence during MV surgery. Optical coherence tomography can be used to evaluate the mechanism of injury and guide further management.Novel Teaching Point•Optical coherence tomography can be used to evaluate the mechanism of coronary injury following cardiac surgery, and guide management. The authors have no funding sources to declare.
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.001 | 0.000 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.001 |
| Bibliometrics | 0.000 | 0.000 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.002 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".