Sudden, new-onset aortic regurgitation during off pump coronary bypass surgery.

During off pump coronary artery bypass grafting surgery, it is common to observe mitral or tricuspid regurgitation due to heart displacement. But it's very unusual to notice new onset aortic regurgitation in OPCABG.

A 65-year-old male patient presented with shortness of breath on moderate exertion. He underwent coronary angiography, which revealed double vessels coronary artery disease. Patient was scheduled for off-pump coronary artery bypass grafting (OPCABG) surgery. Preoperative echocardiogram showed left ventricular (LV) ejection fraction of 55% with no regional wall motion abnormalities nor any valvular regurgitation in different views [Clip 1]. After anesthesia induction, sternotomy was performed and left internal mammary artery (LIMA) was harvested. LIMA was anastomosed with left anterior descending artery. Heart was elevated using starfish heart stabilizer and was given the proper position to visualize obtuse marginal (OM) artery. Surgeon found it difficult to achieve adequate exposure of the target vessel due to increasing size of the left ventricle. Transesophageal echocardiogram (TEE) was performed [Figure 1 and Clip 2]. Newly appearing moderate aortic regurgitation (AR) was observed and confirmed in two different views of TEE.

Figure 1

Transesophageal echocardiography long-axis view showing significant AR after elevating the heart

Owing to elevated position of the heart for OM grafting, there was distortion of aortic valve that led to malcoaptation of aortic valve leaflets resulting in AR. As the heart was given normal position, AR disappeared. Surgeon preferred to perform the grafting on pump beating empty heart. Cardiopulmonary bypass was established and LV vent was introduced through right superior pulmonary vein. Heart was again given the position for grafting of OM vessel. TEE again revealed AR, but LV could have been decompressed by venting. Saphenous vein graft was anastomosed with OM artery followed by proximal anastomosis with aorta.

OPCABG needs cardiac displacement for proper exposure of target site to perform coronary anastomosis of the graft. Placing gauzes posterior to the heart raises the position and stabilizer application can aid the proper exposure.[1] Enucleating the heart using a suction device or pulling the posterior pericardium with stitches are also commonly used techniques.[23]

During OPCABG, vertical position of the heart bent intracardiac structures mainly at the atrioventricular groove. This creates distortions of the mitral and tricuspid annuli potentially causing significant regurgitation.[4] However, it is very uncommon to observe AR during OPCABG. We believe that heart elevation by suction device might have deformed the left ventricular outflow tract-aortic valve axis. This resulted in geometrical distortion of aortic valve with malcoaptation causing AR.

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