Hybrid management of iatrogenic right coronary artery occlusion during minimally invasive tricuspid valve repair

Tricuspid band annuloplasty ring with culprit sutures that injured the RCA.

Central Message.

When RCA injury complicates tricuspid valve surgery, rapid recognition, coordinated teamwork, and access to a hybrid OR enable timely intervention and help avoid serious complications.

Intraoperative right coronary artery (RCA) injury after tricuspid valve repair requires swift action. The use of a hybrid operating room (OR) enables rapid diagnosis and intervention, thereby preventing myocardial infarction and optimizing patient outcomes.

Case Summary

We present the case of an otherwise-healthy 69-year-old man with asymptomatic severe mitral regurgitation with a declining left ventricular ejection fraction of 50% to 55% with end-systolic and end-diastolic dimensions of 33/48 mm, respectively. The patient provided written informed consent to publish this case, waiving the need for institutional review board approval.

Transesophageal echocardiogram (TEE) demonstrated bileaflet mitral valve prolapse with new severe tricuspid insufficiency and a dilated annulus of 50 mm. Preoperative computed tomography angiogram demonstrated no significant coronary artery disease. Given his declining left ventricular function and worsening valvular regurgitation, his surgery was expedited. We planned for a minimally invasive, endoscopic repair of the mitral and tricuspid valves.

Our standard technique includes a 3-cm right anterolateral minithoracotomy port, 5-mm endoscope, percutaneous right internal jugular superior vena cava cannulae, and femoral arterial access with an 8-mm Dacron side graft and 25-Fr venous cannula. We repaired the mitral valve with neochordae loop reconstruction and a 36-mm complete ring annuloplasty. Saline test demonstrated a competent mitral valve, and the left atriotomy was closed. The vena cavae were snared, and the right atrium was opened vertically. There were no structural abnormalities in the tricuspid valve leaflets, but the annulus was clearly dilated. Overlapping 2-0 braided tricuspid annuloplasty sutures were placed from the 10-o'clock to 6-o'clock position, 2 mm from the tricuspid leaflet insertion point. Then, we implanted a 30-mm Medtronic Tri-Ad band. A subsequent saline test demonstrated a competent tricuspid valve.

After removal of the aortic crossclamp and allowing for a period of reperfusion, 5-mm inferior and inferolateral ST elevations with reciprocal changes were noted (Figure 1). Interestingly, no segmental wall motion abnormalities were observed on TEE. The patient was briefly weaned from cardiopulmonary bypass; however, ST-segment elevations persisted despite reperfusion. To be safe, we decided to swing in our robotic fluoroscopy. Via femoral arterial access, the coronary arteries were imaged. We identified an acute distal right coronary occlusion with Thrombolysis In Myocardial Infarction (TIMI) 0 flow before the bifurcation of the posterior descending/posterolateral branch (Video 1). We identified offending sutures that were localized with the use of fluoroscopy and RCA injection. We reopened the right atrium and the two most medial sutures toward the septal leaflet were subsequently removed through the minithoracotomy port, on the beating heart (Figure 2).

Figure 1.

Early postoperative electrocardiogram demonstrated ST-segment elevations in inferior and inferolateral leads with clear reciprocal changes in leads V1, V2, AVR, and AVL, all of which resolved shortly thereafter.

Figure 2.

Intraoperative photo of tricuspid band annuloplasty ring with culprit sutures highlighted in the yellow box (left). Illustration of the tricuspid band annuloplasty with the 2 offending sutures removed in the red box (right).

Although distal flow was restored, we implanted a 4-mm × 18-mm Xience Pro S drug-eluting stent to ensure patency. Final result demonstrated excellent TIMI 3 flow down the posterior descending and posterolateral branches of the RCA (Video 1). The patient was reweaned easily from cardiopulmonary bypass, with excellent biventricular function noted. The patient was administered 600 mg of clopidogrel and will remain on dual antiplatelet therapy for 1 year. The total cardiopulmonary bypass time was 272 minutes, crossclamp 110 was minutes, and no blood products were administered by the end of the case.

Postoperative TEE demonstrated excellent mitral valve reconstruction with no regurgitation and mean and peak gradients of 3 and 7 mm Hg, respectively. The tricuspid valve repair had a mean gradient of 2 mm Hg and peak gradient of 4 mm Hg with trace TR and unchanged left ventricular ejection fraction of 50% to 55% in sinus rhythm. Postoperatively, he did well. He was extubated the evening of surgery, transferred to the ward on the first day, and returned home in 7 days. At 3-month follow-up, he is doing well, functioning at New York Heart Association class I with no mitral or tricuspid insufficiency and normal biventricular function.

Discussion

RCA injury during tricuspid valve surgery is uncommon. Still, it can lead to severe complications, including right ventricular dysfunction, ventricular arrhythmias, and myocardial infarction, all of which may necessitate urgent revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG).1, 2, 3 The most common injury mechanisms are thought to be RCA occlusion or kinking related to blind suture ligation, or annuloplasty band distortion of the native coronary artery. Risk factors for RCA injuries during tricuspid valve surgery include depth of suture placement, particularly in the posterior and inferior annulus⁴ and anatomical variants where the RCA or its branches are closely associated with the tricuspid annulus.⁵ Previously, it was understood that the annulus subtending the posterior leaflet was closest to the RCA; however, this case identifies that the RCA can be injured as medially as on the septal leaflet annular sutures. The most important part of this case to highlight is that the last 2 sutures on the lateral edge of the septal leaflet were in an area that was believed not at high risk of injuring the RCA, underscoring anatomic variability and need for vigilance. Usually, the RCA lies between 11 and 3 o'clock, an area that we carefully try to avoid when placing annuloplasty sutures. Although superficial annuloplasty suturing and recognition of these risk factors preoperatively may theoretically help reduce potential coronary injuries, the blind nature of suture annuloplasty from the endocardial side suggests that this injury may be unavoidable.

The most important action is the early recognition of potential RCA injury with comprehensive evaluation of the ST-segment changes and segmental wall motion abnormalities after adequate reperfusion and deairing. If a sternotomy approach is used, epicardial ultrasound could help to evaluate coronary flow. Ultimately, rapid decision-making is vital to avoid myocardial infarction and achieve an accurate diagnosis. Although rapid coronary angiography may not always be achievable as we did in our hybrid OR, direct transfer of a patient with a high index of suspicion of RCA injury to the catheterization laboratory can help save myocardium and avoid deleterious patient complications. Alternative strategies, such as CABG, should be considered if PCI is not feasible or can even be used prophylactically without angiographic confirmation if the patient is unstable. This case highlights the value and importance of hybrid ORs, where immediate coronary assessment and intervention can occur without delay or patient transfer.

Conclusions

Although coronary artery injuries are more commonly documented after mitral valve repair as the result of circumflex artery proximity, RCA injury during tricuspid valve repair is a rare but serious event. Immediate recognition and intervention are crucial to prevent myocardial infarction and long-term cardiac dysfunction. This case highlights the pivotal role of a hybrid OR setup, real-time coronary assessment, and interdisciplinary collaboration in achieving optimal patient outcomes. The entire sequence from recognition of injury to definitive PCI was completed in a hybrid OR without patient transfer, providing a logistical advantage; however, this technology may not be available in all centers, limiting its generalizability. Fortunately, immediate recognition allowed for swift intervention with PCI, preventing further cardiac compromise and ensuring a favorable outcome.

We present the following 2 take-home messages. First, when significant ST-segment elevation or abnormal wall motion abnormalities occur after tricuspid valve surgery, a high index of suspicion for RCA injury is necessary, irrespective of the absence of wall motion abnormalities. Prompt communication between the anesthesia, cardiology, and cardiac surgery teams ensures timely recognition and resolution of intraoperative complications. Second, swift diagnosis and treatment, including removal of the offending sutures and possible PCI or CABG, are essential to prevent adverse outcomes if flow restoration does not occur. A hybrid OR enables immediate coronary assessment and intervention, if necessary, thereby improving patient safety and surgical outcomes.

Conflict of Interest Statement

The authors reported no conflicts of interest.

The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

Supplementary Data

Video 1

Intraoperative fluoroscopy and coronary angiography demonstrating an acute occlusion of the distal right coronary artery with TIMI 0 flow proximal to the posterior descending and posterolateral branches. Following removal of the offending sutures, distal flow remained suboptimal. Implantation of a drug-eluting stent restored normal antegrade perfusion with TIMI 3 flow. Video available at: https://www.jtcvs.org/article/S2666-2507(25)00450-X/fulltext.