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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 9  |  Issue : 3  |  Page : 177-180

Perioperative myocardial infarction in a case of mitral valve replacement: Rare complication of a common procedure


Department of Cardiology, Jagjivan Ram Western Railway Hospital, Mumbai, Maharashtra, India

Date of Web Publication3-Dec-2019

Correspondence Address:
Dr. Saurabh Ajit Deshpande
Department of Cardiology, Jagjivan Ram Western Railway Hospital, RBI Staff Colony, MM Marg, Mumbai Central, Mumbai - 400 008, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JICC.JICC_33_19

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  Abstract 


A 56-year-old female underwent mitral valve replacement for severe symptomatic rheumatic mitral stenosis. There was perioperative myocardial infarction as evidenced by the regional echocardiogram (ECG) and echocardiographic changes (left anterior descending [LAD] territory) and hemodynamic instability. The patient was immediately taken up for coronary angiogram to find complete occlusion of mid-segment of the LAD artery. Thrombus aspiration and intracoronary nitrates were given to restore thrombolysis in myocardial infarction (TIMI) III flow in the vessel. The patient was discharged after 10 days without any other complications. On follow-up ECG, the regional wall motion abnormality persisted. Repeat coronary angiogram done for the same revealed no lesions in coronary vessels with TIMI III flow.

Keywords: Mitral valve replacement, myocardial infarction, thrombus aspiration


How to cite this article:
Reddy MV, Roul SK, Deshpande SA. Perioperative myocardial infarction in a case of mitral valve replacement: Rare complication of a common procedure. J Indian coll cardiol 2019;9:177-80

How to cite this URL:
Reddy MV, Roul SK, Deshpande SA. Perioperative myocardial infarction in a case of mitral valve replacement: Rare complication of a common procedure. J Indian coll cardiol [serial online] 2019 [cited 2019 Dec 13];9:177-80. Available from: http://www.joicc.org/text.asp?2019/9/3/177/272170




  Introduction Top


Perioperative myocardial infarction (MI) during mitral valve surgeries, namely mitral valve repair and mitral valve replacement (MVR) is more common within the first year (incidence around 0.5%–1%).[1] There have been a few case reports involving MI in the early postoperative period of mitral valve surgeries.[2],[3],[4],[5],[6] The real incidence cannot be computed as there have been no studies available. There are multiple causes sited for MI in the perioperative period of MVR including coronary artery spasm and coronary embolism. We present such a rare case of coronary artery spasm in the immediate postoperative period.


  Case Report Top


A 56-year-old female was on follow-up with our department for rheumatic mitral stenosis for 6–7 months. She presented to us with worsening dyspnea on exertion New York Heart Association Functional Class III. Echocardiogram (ECG) was suggestive of severe mitral stenosis with severe valve calcification and subvalvular disease (Wilkin's Score 11/16). There was no evidence of clot. Atrial fibrillation was ruled out by the inpatient ECG monitoring. She was planned for MVR. She was taken up for routine preoperative coronary angiogram. It showed no atherosclerotic lesions.

During MVR surgery, ECG on monitor showed ST-segment changes for a few seconds, while coming off pump. Hence, she was again put on pump, and a transthoracic Echocardiogram was done on the operating table. It showed no regional wall motion abnormalities (RWMA) with good mitral valve function. The ECG changes resolved on their own. The procedure was then completed, and she was shifted to the intensive care unit (ICU) after half an hour. Immediate postoperative ECG was then taken. It showed ST-segment elevation in the anterior leads (V1–V5, I and aVL) [Figure 1]. It was diagnosed as acute anterior wall MI. She developed hemodynamic instability in form of tachycardia and hypotension. Repeat bedside Echocardiogram showed RWMA in apical and apical-septal wall with left ventricular (LV) ejection fraction of around 45% [Figure 2].
Figure 1: Immediate postoperative Electrocardiogram

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Figure 2: Immediate postoperative echocardiogram

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She was immediately rushed into the cardiac catheterization laboratory. Systolic blood pressure was around 90 mmHg. The patient was intubated and kept on mechanical ventilation. The checkshot showed total occlusion of mid-segment of the left anterior descending (LAD) artery [Figure 3]. The vessel was wired with a floppy tip wire (Runthrough NS) which crossed without much trouble. Postwiring coronary angiogram was also showing total occlusion of LAD. Thrombus aspiration (TA) was done [Figure 4]. No thrombus could be retrieved. After TA, coronary flow was better. Intracoronary nitroglycerin and nicorandil was then given. After this, the coronary flow was TIMI Grade III [Figure 5]. Systolic blood pressure was still maintained around 90–100 mmHg. She was shifted back to the ICU after the procedure. Postprocedure ECG showed no ST-segment elevation, but R-waves were lost in V1 to V5, I, aVL leads [Figure 6].
Figure 3: Coronary angiogram

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Figure 4: Thrombus aspiration

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Figure 5: Postthrombus aspiration

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Figure 6: Post Angioplasty Electrocardiogram

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The patient developed hypotension in the evening without any ECG changes. The intra-aortic balloon pump was inserted in early morning hours for acute hemodynamic support. It could be weaned off within the next day. She was extubated on the next day. The patient developed derangements in liver and kidney function tests (the shock liver and kidney). The patient improved within the next 5–7 days and shifted to the ward. She was discharged home on single antiplatelet and oral anticoagulant. She was kept on beta-blockers and angiotensin-converting enzyme (ACE) inhibitors.

ECG done after a month on follow-up showed persistent RWMA with fair LV systolic function. Coronary angiogram was repeated which showed no coronary lesions [Figure 7]. She was kept on oral anticoagulant, aspirin, and anti-remodeling therapy with beta-blockers and ACE inhibitors.
Figure 7: Follow-up coronary angiography

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  Discussion Top


MI during the perioperative period of valve surgeries is a rare occurrence. There has been a study done by McGregor et al.,[7] in 1984, which tried to find out the incidence of MI in the perioperative period in valve replacement surgeries. Of fifty patients studied, none of the patients of MVR had any perioperative ischemia as evaluated with ECG, creatine kinase-MB levels, and technetium-99m-pyrophosphate scans.

There are a few nonatherosclerotic causes of MI. In the case reports of MIs in the immediate postoperative period [Table 1], the causes cited are either spontaneous[2],[3],[4],[5],[6] or iatrogenic.[8] Spontaneous may be due to coronary spasm (in most cases)[2],[3],[4],[5] or coronary embolism.[6] Iatrogenic is mainly due to the damage to circumflex vessel[8] while taking mitral annular stitch or obstruction of coronary ostia due to the valve.[1],[9]
Table 1: Perioperative MI during mitral valve replacement

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Most of the cases had coronary artery spasm as a cause of MI, which reverted with intracoronary nitrates (ICNs). Only one case died out of many described before, which means it carries a good prognosis. Furthermore, most of these patients had the recovery of MI after variable time period postindex event.

The only difference in our case was the use of TA along with ICN. Our patient still has RWMA that can be explained by stunning of the myocardium. Our case had both the components – coronary embolism and spasm, as a cause of MI.


  Conclusion Top


MI in the perioperative period of mitral valve surgeries is a rare event. ICN is the most common treatment advisable in such situation. In either case, suspicion of the event and early coronary angiography is a must in such cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Habibian M, Batra R, Mengel C, Sweeny A, Walters D. Cardiologists Beware: An unusual cause of myocardial infarction after aortic valve replacement. J Heart Lung and Circulation. 2016;25:S35.   Back to cited text no. 1
    
2.
Kanno M, Kurihara H, Satoh H, Hamawaki M, Honda M. Coronary artery spasm after mitral valve replacement: A case report. Kyobu Geka 1994;47:315-8.  Back to cited text no. 2
    
3.
Casquero E, Durán D, Asorey V, Casais R. Coronary artery spasm after mitral and tricuspid annuloplasty. Eur J Cardiothorac Surg 2009;36:191.  Back to cited text no. 3
    
4.
Antevil JL, Karavas AN, Selby JH, Byrne JG. Use of a hybrid operating room to diagnose and treat delayed coronary spasm after mitral valve repair. J Thorac Cardiovasc Surg 2010;140:e25-7.  Back to cited text no. 4
    
5.
Pragliola C, Gaudino M, Farina P, Massetti M. Postoperative coronary artery spasm after mitral valve replacement. Int J Surg Case Rep 2015;8C:185-8.  Back to cited text no. 5
    
6.
Preveden A, Kovacevic M, Susak S, Redzek A, Velicki L. Coronary embolism causing myocardial infarction after heart valve surgery. Vojnosanit Pregl 2018;180.  Back to cited text no. 6
    
7.
McGregor CG, MacLeod MD, Muir AL, Smith AF, Hannan WJ, Miller HC. Myocardial infarction related to valve replacement surgery. Br Heart J 1984;51:612-7.  Back to cited text no. 7
    
8.
Grande AM, Fiore A, Massetti M, Viganò M. Iatrogenic circumflex coronary lesion in mitral valve surgery: Case report and review of the literature. Tex Heart Inst J 2008;35:179-83.  Back to cited text no. 8
    
9.
Turillazzi E, Di Giammarco G, Neri M, Bello S, Riezzo I, Fineschi V. Coronary ostia obstruction after replacement of aortic valve prosthesis. Diagn Pathol 2011;6:72.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
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