Coronary angiography identification of circumflex artery bleeding mimicking left ventricular rupture after mitral valve repair: a case report

Background Left ventricular rupture after mitral valve surgery is a rare but catastrophic complication with an extremely high mortality rate. Cases developing massive postoperative bleeding often require urgent surgical re-exploration. However, other causes of periannular bleeding, including iatrogenic coronary artery injury, should also be considered. Herein, we describe the case of a patient with periannular bleeding after mitral valve repair initially suspected to be left ventricular rupture but ultimately diagnosed as a distal left circumflex artery injury and successfully treated with coil embolization. Case presentation A 79-year-old male underwent mitral valve repair, pulmonary vein isolation, and left atrial appendage closure for severe mitral regurgitation and paroxysmal atrial fibrillation. During surgery, tissue fragility was noted and a subepicardial hematoma was observed around the circumflex artery, although no active bleeding was detected. Massive drainage bleeding occurred approximately 30 min after surgery. Left ventricular rupture and myocardial injury related to cardiac manipulation were suspected. Contrast-enhanced computed tomography revealed contrast leakage around the mitral annulus; however, the source of the bleeding could not be identified. Coronary angiography revealed contrast extravasation from the distal left circumflex artery. Selective coronary coil embolization resulted in an immediate reduction in bleeding. The patient subsequently underwent re-exploration surgery to remove the intrathoracic hematoma without additional hemostatic intervention. The postoperative course was uneventful, and the patient was discharged on postoperative day 18. Conclusions Coronary artery injury should be considered in the differential diagnosis of cases of suspected left ventricular rupture after mitral valve surgery. When hemodynamic conditions allow, coronary angiography may be useful for identifying the bleeding source and avoiding unnecessary surgical re-exploration.