Advanced imaging preparation for endoscopic mitral valve surgery — analysis of circumflex anatomy and associated procedural risks

OBJECTIVES Iatrogenic injury to the circumflex artery during mitral valve surgery occurs in 0.3–1.8% of cases. This study analyzed the circumflex artery’s anatomical relationship to the mitral annulus using advanced imaging to predict peri-operative risk in patients undergoing endoscopic mitral valve surgery. METHODS A computed tomography (CT) analysis using 3mensio software was performed in 315 patients (2019–2023) undergoing minimally invasive mitral valve surgery. A prediction index for circumflex artery injury was calculated to identify at-risk individuals. RESULTS Circumflex artery anatomy was assessable in all patients (n = 315). The mean age was 62.84 ± 11.34 years; median annulus area was 12.97 ± 5.69 cm2. 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% (74/315), among whom circumflex obstruction occurred in 2.71% (2/74), compared to 0% in those with ≥ 4 mm distance (p = 0.05). Percutaneous coronary intervention was required in 0.32% (1/315). A low injury prediction index (≤ 0.2) was found in 27.31% (86/315), correlating with male sex, larger annular dimensions, and elevated injury risk. CONCLUSIONS Preoperative CT-based measurement of the circumflex artery’s distance from the mitral annulus is feasible and may identify patients at elevated risk for iatrogenic injury. A distance ≤ 4 mm or injury prediction index ≤ 0.2 indicates increased risk. Routine CT imaging, combined with coronary angiography, is recommended for risk stratification before mitral valve surgery.