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Advanced imaging preparation for endoscopic mitral valve surgery - analysis of circumflex anatomy and associated

Jacqueline Kruse1, Marwan Hamiko1, Ömür Akhavuz1

  • 1department of cardiac surgery, University hospital Bonn, Bonn, Germany.

Interdisciplinary Cardiovascular and Thoracic Surgery
|October 6, 2025
PubMed

Insights

Preoperative CT scans can identify patients at risk for circumflex artery injury during mitral valve surgery. A distance of 4mm or less between the artery and mitral annulus indicates increased risk.

Area of Science:

  • Cardiovascular Surgery
  • Medical Imaging
  • Interventional Cardiology

Background:

  • Iatrogenic injury to the circumflex artery during mitral valve surgery occurs in 0.3-1.8% of cases.
  • Minimally invasive mitral valve surgery necessitates precise anatomical understanding to mitigate risks.

Purpose of the Study:

  • To analyze the anatomical relationship between the circumflex artery and mitral annulus using advanced imaging.
  • To predict peri-operative risk of circumflex artery injury in patients undergoing endoscopic mitral valve surgery.

Main Methods:

  • Computed tomography (CT) analysis using 3mensio software in 315 patients undergoing minimally invasive mitral valve surgery.
  • Calculation of a prediction index for circumflex artery injury to identify at-risk individuals.

Main Results:

  • The mean distance between the left circumflex artery and mitral annulus was 6.97 ± 3.85 mm.
  • A critical distance < 4 mm was observed in 23.5% of patients, with a 2.71% rate of circumflex obstruction.
  • An injury prediction index ≤ 0.2 correlated with male sex, larger annular dimensions, and elevated injury risk.

Conclusions:

  • Preoperative CT-based measurement of the circumflex artery-mitral annulus distance is feasible for risk stratification.
  • A distance ≤ 4 mm or an injury prediction index ≤ 0.2 identifies patients at elevated risk for iatrogenic injury.
  • Routine CT imaging combined with coronary angiography is recommended for risk stratification before mitral valve surgery.
Abstract

Keywords:
CT imagingCircumflex arterycoronary artery injuryendoscopic mitral valve surgery

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