Background:

Due to its close anatomical proximity to the annular plane, the right coronary artery is at risk to injury and distortion during surgical and interventional repair of the tricuspid valve. Recently, reversible, non-flow limiting, purse-string like deformations of the right coronary artery following percutaneous tricuspid valve (TV) annuloplasty have been described and are thought to result from the contraction of a markedly enlarged annulus perimeter. In contrast, there are only anecdotal reports on RCA deformation following conventional TV surgery.

Therefore, we sought to review our institutional experience with iatrogenic RCA affections following TV surgery.

Methods and results:  A retrospective analysis of all patients undergoing TV surgery in our hospital between January 1^st, 2009 and May 1^st, 2019 was performed including all patients who received a post-operative coronary angiography in our final analysis.

We screened 1383 patients, the majority of them (1248 patients, 90.2%) had a TV reconstruction and 308 patients underwent isolated TV surgery. Due to suspected myocardial ischemia 65 patients underwent postoperative coronary angiography within 48 hours after surgery (mean age 70.6 ±10.8 years, 43% females, median EuroSCORE II 7.99% (IQR 13.1)). Fifty-eight patients (89%) underwent TV reconstruction (8 isolated and 50 combined procedures) and seven patients underwent TV replacement (3 isolated). Coronary angiographies of all 65 patients were reviewed and compared to baseline before surgery.

A pathological finding of the RCA was observed in 24 patients (36.9%). A new RCA deformation with no flow-impairment or vascular damage was found in 16 patients (24.6%) (Figure 1) and was managed conservatively. Eight patients showed RCA deformation accompanied by a subtotal occlusion (n=2, Figure 2) and a total RCA-occlusion (n=6, Figure 3) and were thus revascularized.

RCA deformation occurred exclusively after TV reconstruction while no cases were observed after TV replacement (18 of 58 patients after TV reconstruction compared to 0 of 7 patients after replacement, p=0.09). Rate of RCA deformation was not significantly different between isolated and combined procedures (5 of 11 isolated procedures and 13 of 54 combined procedures, p=0.16 in Fischer’s exact test).

Conclusion:

Comparable to interventional TV annuloplasty coincidental RCA deformation was detected at a relatively high rate (24.6%) in patients with suspected myocardial ischemia after TV surgery and interestingly occurred only after TV reconstruction but not TV replacement, which might be due to more extensive annular reduction.

Figure 1: Example of postoperative RCA deformation without flow limitation

Figure 2: Example of RCA deformation with additional RCA-occlusion postoperatively

Figure 3: Example of postoperative RCA-occlusion without deformation