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In Vivo Identifying the Relationship of the Circumflex Artery to the Mitral Valve Annulus with the Use of a Preoperative Multi-slice Electrocardiogram Gated Coronary Computed Tomography Angiography
Vincenzo D. Caruso, Antonio Bivona, Mohamed Osman, Jessica Dada, Swamy Gedela, Ben Middleton, Walter Serino, Inderpaul Birdi.
Basildon and Thurrock University Hospital, Basildon, United Kingdom.

In Vivo Identifying the Relationship of the Circumflex Artery to the Mitral Valve Annulus with the Use of a Preoperative Multi-slice Electrocardiogram Gated Coronary Computed Tomography Angiography

Background: To acquire a detailed awareness of the anatomical relationship between circumflex coronary artery (CX) and mitral valve annulus (MVA), in order to identify potentially high risk anatomy, prior mitral valve surgery.
Methods: From August 2015 to October 2016, 64 consecutive patients, electively referred for mitral valve surgery, underwent pre-operative multi-slice coronary computed tomography angiography (CCTA), with volume-rendered 3-dimensional and retrospective gated acquisition. The posterior portion of the mitral annulus was delineated using five main zones, which were numbered from 1 to 5 in anticlockwise direction: zones 1 and 5 were at level of antero-lateral and postero-medial commissures respectively, zone 2 was between zone 1 and the middle posterior annulus-zone 3- and zone 4 was between zones 3 and 5. High risk anatomy was arbitrarily defined as any zone where the CX-MVA distance was<3mm. CCTA's data were integrated with those from preoperative coronary angiogram and 3-dimensional Transoesophageal Echocardiography (3D-TOE).
Results: Right dominance was observed in 52 patients (81.25%), left dominance in 8 patients (12.5%) and balanced dominance in 4 patients (6.25%). The shortest CX-MVA distance was at Zone 1 (5.08 3.28 mm). 18 patients were identified as high risk anatomy (mean distance at zone 1: 1.55 0.77mm). Statistical difference was observed between zone 1 and all the zones (p<0.05). Left dominant and codominant coronary anatomy demonstrated a closer CX-MVA relationship and a statistical significance was seen at all the zones (p<0.05).
Conclusion: Preoperative knowledge of the anatomical relationships between MVA and CX, may be a useful tool to identify patients at potentially high-risk of CX flow disturbance during mitral valve surgery.
Figure 1. Five zones system of CX-MVA relationship.


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