Late Presentation of Recurrent Monomorphic Ventricular Tachycardia following Minimally Invasive Mitral Valve Repair due to Epicardial Injury

We report a 73-year-old male with late onset monomorphic ventricular tachycardia following mitral valve repair (MVR). Typically, injury to epicardial arteries following mitral valve repair/replacement presents immediately as ventricular tachycardia/fibrillation, difficulty weaning from cardiopulmonary bypass, worsening ECG changes, increasing cardiac biomarkers, or new wall motion abnormalities. Our case illustrates a “late complication” of a distorted circumflex artery following mitral valve repair and the importance of early diagnostic angiography and percutaneous intervention. 1. Introduction In experienced centers mitral valve repair has low mortality rates and excellent outcomes. The Cleveland Clinic and Mayo Clinic report 30 day mortality rates of 0.3% and 0.9%, respectively [1, 2]. Injury to the circumflex artery during MVR is a recognized complication, albeit rare. The proximity of the circumflex artery to the anterolateral commissure of the mitral valve predisposes the artery to injury during mitral valve surgery [3, 4]. Acute occlusion of the circumflex artery may manifest immediately as ventricular arrhythmia, difficulty weaning from cardiopulmonary bypass, ST elevation myocardial infarction, or new wall motion abnormality [5]. We report a late onset sustained monomorphic ventricular tachycardia (SMVT) secondary to distortion of the circumflex artery following mitral valve repair. 2. Case Report A 73-year-old male with mitral regurgitation presented to his primary cardiologist with symptoms of increasing dyspnea on exertion. As part of the diagnostic workup, a transthoracic echocardiogram (TTE) was performed which revealed significant pulmonary hypertension (estimated pulmonary artery pressures of 50–55？mmHg), not previously seen on prior TTE. Moderate mitral valve insufficiency with prolapse of the posterior leaflet and normal right ventricular function was also present. Past medical history was significant for hyperlipidemia, chronic obstructive pulmonary disease, chronic kidney disease (stage 3), and benign prostatic hypertrophy. The decision was made by the primary cardiologist to refer the patient for mitral valve repair. In anticipation of the aforementioned procedure a left and right cardiac catheterization was performed which showed a left dominant system with nonobstructive coronary artery disease, normal left ventricular function, right ventricular pressures of 68/9？mmHg, pulmonary artery pressures of 63/30？mmHg, and a pulmonary capillary wedge pressure of 21？mmHg. The patient was then referred for cardiothoracic surgeon