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Noninvasive Evaluation of Coronary Sinus Anatomy and Its
Relation to the Mitral Valve Annulus
Implications for Percutaneous Mitral Annuloplasty
Laurens F. Tops, MD; Nico R. Van de Veire, MD, PhD; Joanne D. Schuijf, MSc; Albert de Roos,
MD, PhD; Ernst E. van der Wall, MD, PhD; Martin J. Schalij, MD, PhD; Jeroen J. Bax, MD, PhD
Background—Percutaneous mitral annuloplasty has been proposed as an alternative to surgical annuloplasty. In this
respect, evaluation of the coronary sinus (CS) and its relation with the mitral valve annulus (MVA) and the coronary
arteries is relevant. The feasibility of evaluating these issues noninvasively with multislice computed tomography was
determined.
Methods and Results—In 105 patients (72 men, age 59⫾11 years), 64-slice multislice computed tomography was
performed for noninvasive evaluation of coronary artery disease. Thirty-four patients with heart failure and/or severe
mitral regurgitation were included. Three-dimensional reconstructions and standard orthogonal planes were used to
assess CS anatomy and its relation with the MVA and circumflex artery. In 71 patients (68%), the circumflex artery
coursed between the CS and the MVA with a minimal distance between the CS and the circumflex artery of
1.3⫾1.0 mm. The CS was located along the left atrial wall, rather than along the MVA, in the majority of the patients
(ranging from 90% at the level of the MVA to 14% at the level of the distal CS). The minimal distance between the
CS and MVA was 5.1⫾2.9 mm. In patients with severe mitral regurgitation, the minimal distance between the CS and
the MVA was significantly greater as compared with patients without severe mitral regurgitation (mean 7.3⫾3.9 mm
versus 4.8⫾2.5 mm, P⬍0.05).
Conclusion—In the majority of the patients, the CS courses superiorly to the MVA. In 68% of the patients, the circumflex
artery courses between the CS and the mitral annulus. Multislice computed tomography may provide useful information
for the selection of potential candidates for percutaneous mitral annuloplasty. (Circulation. 2007;115:1426-1432.)
Key Words: imaging 䡲mitral valve 䡲tomography, x-ray computed 䡲coronary vessels
Mitral annuloplasty is the most commonly performed
surgical procedure for ischemic mitral regurgitation
(MR).
1
Recently, a percutaneous approach to mitral annulo-
plasty was proposed. Validation studies in animals have
shown the feasibility of the percutaneous transvenous mitral
annuloplasty.
2–5
In addition, preliminary results of the first
human experience with percutaneous mitral annuloplasty
have been described.
6
Clinical Perspective p 1432
However, anatomic studies have demonstrated the variable
relation between the coronary sinus (CS) and the mitral valve
annulus (MVA).
7–9
It was noted that the CS may course
adjacent to the posterior wall of the left atrium rather than
along the MVA. Furthermore, a close relation between the CS
and the left circumflex coronary artery (LCX) was detected,
which potentially limits the use of percutaneous mitral
annuloplasty. However, these anatomic studies were per-
formed on structurally normal hearts.
Evaluation of the CS anatomy and its relation to the MVA
and the coronary arteries may be of value in patients who are
considered for percutaneous mitral annuloplasty. Multislice
computed tomography (MSCT) can provide an accurate
noninvasive evaluation of the anatomy of the CS.
10
Recent
preliminary data suggest a potential use of MSCT scanning in
patients considered for percutaneous mitral annuloplasty.
11
Accordingly, the purpose of the present study was to
evaluate the relation between the CS, the MVA, and the
coronary arteries by 64-slice MSCT in patients with structur-
ally normal hearts and in patients with severe MR.
Methods
Study Population
The study population comprised 105 consecutive patients referred
for MSCT coronary angiography. The total study population was
divided into 3 groups: group I (controls, n⫽35) included patients
without coronary artery disease (CAD) and without structural heart
disease; group II (CAD, n⫽36) comprised patients with either a
Received November 21, 2006; accepted January 5, 2007.
From the Department of Cardiology (L.F.T., N.R.V.d.V., J.D.S., E.E.v.d.W., M.J.S., J.J.B.), and the Department of Radiology (A.d.R.), Leiden
University Medical Center, Leiden, the Netherlands.
Correspondence to Jeroen J. Bax, MD, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The
Netherlands. E-mail jbax@knoware.nl
© 2007 American Heart Association, Inc.
Circulation is available at http://www.circulationaha.org DOI: 10.1161/CIRCULATIONAHA.106.677880
1426
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history of myocardial infarction/percutaneous transluminal coronary
angioplasty/coronary artery bypass grafting, or a significant stenosis
in ⱖ1 coronary artery on the MSCT scan; group III (heart failure,
n⫽34) included patients with severe heart failure (left ventricular
ejection fraction ⱕ35%).
Data Acquisition
Multislice Computed Tomography
MSCT was performed with a Toshiba Multislice Aquilion 64 system
(Toshiba Medical Systems, Tokyo, Japan) with a collimation of
64⫻0.5 mm and a rotation time of 400 to 500 ms, depending on the
heart rate. The tube current was 300 mA at 120 kV. Nonionic
contrast material (Iomeron 400, Bracco, Altana Pharma, Konstanz,
Germany) was administered in the antecubital vein, in an amount of
80 to 110 mL, depending on the total scan time, and a flow rate of
5.0 mL/s. Automated peak enhancement detection in the descending
aorta was used to time the contrast bolus. After the threshold level of
⫹100 Hounsfield units was reached, data acquisition was automat-
ically initiated. Data acquisition was performed during an inspiratory
breath-hold of ⬇8to⬇10 seconds, and the ECG was recorded
simultaneously to allow retrospective gating of the data. The data set
was reconstructed at 75% of the RR interval, with a slice thickness
of 0.5 mm and a reconstruction interval of 0.3 mm.
Data Analysis
Data analysis was performed on a remote postprocessing workstation
(Vitrea 2, Vital Images, Plymouth, Minn). Volume-rendered
3-dimensional reconstructions and standard orthogonal planes were
used to assess the anatomy and the course of the CS and its
tributaries. Furthermore, the course of the coronary arteries and the
coronary artery dominance (right, left, or balanced) was assessed. In
particular, the course of the LCX in relation to the CS (inferior or
superior) was determined (Figure 1). The axial slices were studied to
assess the minimal distance between the LCX and the CS.
Anatomic and Quantitative Analyses
With the use of reconstructed long-axis 2- and 4-chamber views and
volume-rendered 3-dimensional reconstructions, the relation be-
tween the CS and the MVA was assessed (Figure 2). The position of
the CS in relation to the MVA (superior/inferior/same level) and the
minimal distance between the CS and the MVA were determined
(Figure 3). The anatomic and quantitative data were assessed at 3
different levels: at the proximal CS, the distal CS, and at the level of
the MVA. The proximal CS was defined as the site where the CS
makes an angle with the right atrium. The distal CS was defined as
the site where the CS makes a sharp angle anteriorly and continues
as the anterior interventricular vein.
12
The level of the MVA was
reconstructed with the long-axis 2- and 4-chamber views.
Figure 1. Volume-rendered reconstructions
show the relation between the CS and the left
circumflex coronary artery (Cx). A, The Cx
courses deeper than the CS and lies between
the CS and the mitral valve annulus. B, The Cx
courses superiorly to the CS.
Figure 2. Long-axis 2-chamber (A) and
4-chamber (B) views were used to assess the
course of the CS (white arrow) in relation to the
MVA and the diameter of the MVA (black
arrow). Furthermore, at the reconstructed level
of the MVA (C), the CS location and the MVA
perimeter were determined. D, Volume-
rendered 3-dimensional reconstruction demon-
strates the course of the CS and its relation to
the MVA and the left circumflex coronary
artery.
Tops et al MSCT of Coronary Sinus and Mitral Valve Annulus 1427
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Furthermore, the diameter of the MVA was derived from the
long-axis 2- and 4-chamber views (Figure 2A and 2B); the
perimeter of the MVA was assessed on the reconstructed level of
the MVA (Figure 2C). In addition, the anterior–posterior diameter
and the superior–inferior diameter of the proximal and distal CS
were determined as previously described.
10
The analyses of the
anatomic relations and the quantitative data were performed by 2
independent observers who were blinded to the clinical data of the
patients.
Echocardiography
Standard 2-dimensional echocardiograms were obtained with pa-
tients in the left lateral decubitus position with a commercially
available system (Vingmed Vivid 7, General Electric-Vingmed,
Milwaukee, Wis). Images were obtained with a 3.5-MHz transducer
at a depth of 16 cm in the parasternal (long- and short-axis) and
apical (2- and 4-chamber) views. Standard 2-dimensional images and
color Doppler data triggered to the QRS complex were digitally
stored in cine-loop format. Left ventricular ejection fraction was
calculated from apical 2- and 4-chamber images with the biplane
Simpson’s rule.
13
The severity of MR was graded semiquantitatively
by color-flow Doppler in the conventional parasternal long-axis and
apical 4-chamber images.
14
MR was characterized as: minimal, 1⫹
(jet area/left atrial area ⬍10%), moderate, 2⫹(jet area/left atrial area
10% to 20%), moderate–severe, 3⫹(jet area/left atrial area 20% to
45%), or severe, 4⫹(jet area/left atrial area ⬎45%).
14
Statistical Analysis
Continuous data are presented as mean values ⫾SD; categorical data
are presented as frequencies and percentages. Differences between
the 3 groups were compared with 1-way ANOVA with Scheffé post
hoc testing for continuous variables, and
2tests for dichotomous
variables. Differences between patients with and without severe MR
were evaluated with the Mann-Whitney Utest (continuous vari-
ables), or Fisher exact tests (dichotomous variables). All statistical
analyses were performed with SPSS software (version 12.0, SPSS
Inc., Chicago, Ill). All statistical tests were 2-sided, and a Pvalue
⬍0.05 was considered statistically significant.
The authors had full access to and take responsibility for the
integrity of the data. All authors have read and agree to the
manuscript as written.
Results
Study Population
A total of 105 patients (age 59⫾11 years, 72 men) were
studied. The study population was divided into 3 groups:
controls (n⫽35), patients with CAD (n⫽36), and patients
with severe heart failure (n⫽34: 19 (56%) with ischemic
cardiomyopathy, 15 (44%) with idiopathic cardiomyopathy).
The baseline characteristics of the patients are listed in Table
1.
Anatomic Observations
Coronary Arteries and Relation With CS
Right coronary artery dominance was observed in 91
patients (87%), left coronary dominance in 13 patients
(12%), and balance in 1 patient (1%). In 71 patients (68%),
the LCX coursed inferiorly to the CS (ie, between the CS
and the mitral annulus). In 34 patients (32%), the LCX
coursed superiorly to the CS (Figure 1). The minimal
distance between the CS and the LCX was 1.3⫾1.0 mm.
The mean number of marginal branches was 1.2⫾0.6; No
differences existed in number of marginal branches be-
tween the 3 groups or between the patients with right or
left coronary dominance.
Anatomic Relation Between the CS and MVA
At the level of the MVA, the CS was located more
superiorly in 95 patients (90%), more inferiorly in 1
patient (1%), and at the same level in 9 patients (9%). The
minimal distance from the CS to the MVA was
Figure 3. Volume-rendered 3-dimensional recon-
structions were used to assess the position of the
CS (white arrow) in relation to the MVA. At the
proximal CS (A) and at the distal CS (B), the rela-
tive position (superior/same level/inferior) of the
CS was determined.
TABLE 1. Baseline Characteristics of the 3 Patient Groups
Controls
(n⫽35)
CAD
(n⫽36)
HF
(n⫽34)
Age, y, mean⫾SD 54⫾11 61⫾10* 63⫾11*
Gender, M/F 21/14 25/11 26/8
LVEF, %, mean⫾SD 62⫾561⫾927⫾7†‡
Previous MI, n (%) 0 9 (25) 19 (56)
Risk factors, n (%)
Diabetes mellitus 12 (34) 14 (39) 6 (18)
Hypertension 15 (43) 17 (47) 14 (41)
Hypercholesterolemia 14 (40) 22 (61) 17 (50)
Smoking 5 (14) 15 (42) 17 (50)
Positive family history 11 (31) 10 (28) 11 (32)
HF indicates heart failure; LVEF, left ventricular ejection fraction; and MI,
myocardial infarction.
*P⬍0.05 vs controls; †P⬍0.001 vs controls; ‡P⬍0.001 vs CAD.
1428 Circulation March 20, 2007
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5.1⫾2.9 mm (range 1.4 to 16.8 mm). Also, the relation of
the CS and the MVA was determined at the proximal and
the distal CS. At the proximal CS, the CS was located more
superiorly to the MVA in 57 patients (54%), more inferi-
orly in 7 patients (7%), and at the same level in 41 patients
(39%). The minimal distance between the CS and the
MVA at the proximal CS was 8.3⫾2.3 mm (range 2.2 to
15.3 mm). At the distal CS, the CS was located more
superiorly to the MVA in 15 patients (14%), more inferi-
orly in 31 patients (30%), and at the same level in 59
patients (56%). The minimal distance between the CS and
the MVA at the distal CS was 8.8⫾3.4 mm (range 2.6 to
18.6 mm).
No statistical differences existed between the 3 groups with
regard to the location of the CS in relation to the MVA at any
level. In contrast, the minimal distance between the CS and the
MVA was significantly greater in the heart failure patients than
in the control patients and the patients with CAD (Table 2).
CS and MVA: Quantitative Observations
The mean diameter of the MVA at the 2-chamber view was
40.8⫾4.7 mm, the mean diameter at the 4-chamber view was
36.4⫾4.6 mm. The mean perimeter of the MVA was
119.4⫾13.3 mm.
The mean diameter of the CS at the proximal part was
10.0⫾2.8 mm in the anterior–posterior direction and
14.4⫾3.1 mm in the superior–inferior direction. The diameter
of the CS at the distal part was 3.9⫾0.7 mm in the
anterior–posterior direction and 4.0⫾0.9 mm in the superior–
inferior direction. No significant differences in diameter of
the CS were observed between the 3 groups (Table 2). With
the use of multiplanar reformatted images, the total length of
the CS was calculated. The mean length was 113⫾18 mm
(range 76 to 170 mm). The mean CS length was significantly
larger in the heart failure patients than in the controls and the
patients with CAD (Table 2).
Mitral Regurgitation
In the total study population, 50 patients (48%) had no MR,
30 patients (29%) had MR grade 1⫹, and 10 patients (9%)
had MR grade 2⫹; MR was characterized as 3⫹in 13
patients (12%) and 4⫹in 2 patients (2%). To detect differ-
ences in the anatomic and quantitative data between patients
with and without severe MR, the study population was
divided into 2 groups: patients with MR grade ⱕ2⫹(n⫽90)
and patients with MR grade 3⫹or 4⫹(n⫽15).
No differences existed between the 2 groups in the ana-
tomic relation between the CS and MVA at any level.
Furthermore, no significant differences in diameters of the CS
were noted. However, the minimal distance between the CS
and the MVA at all levels was significantly greater in the
patients with severe MR than in the patients without severe
MR (Table 3). In addition, the diameters of the MVA and the
total length of the CS were significantly larger in the patients
with severe MR than in the patients without severe MR
(Table 3).
Discussion
In the present study, the relation between the CS, the MVA,
and the coronary arteries was evaluated noninvasively with
MSCT. The major findings of the study are as follows: In
68% of the patients, the LCX courses between the CS and the
MVA. In the majority of the patients, the CS courses
superiorly to the MVA. In addition, the minimal distance
between the CS and the MVA is greater in patients with heart
failure and severe MR. The findings of the present study have
important implications for percutaneous mitral annuloplasty.
Anatomic Observations
CS and Coronary Arteries
A close relation between the CS and the LCX may limit the
use of percutaneous mitral annuloplasty. Circumflex artery
compression has been reported as a serious complication in
one of the first animal studies on percutaneous mitral annu-
loplasty.
4
Previous anatomic studies have reported the rela-
tion between the CS, the coronary arteries, and the MVA.
8,9
Maselli et al
9
demonstrated that the LCX coursed between the
CS and the MVA in 63.9% of the 61 human hearts that were
TABLE 2. Quantitative Analyses of the CS and the MVA in the
3 Patient Groups
Controls
(n⫽35)
CAD
(n⫽36)
HF
(n⫽34) P*
Minimal distance between CS and MVA
At MVA level 4.4⫾2.2 4.9⫾2.7 6.2⫾3.4† 0.019
At proximal CS 7.6⫾1.6 7.9⫾2.1 9.3⫾2.8† 0.006
At distal CS 7.3⫾3.3 8.5⫾3.2 10.7⫾3.0‡§ ⬍0.001
CS diameter at proximal CS
AP diameter 10.5⫾2.7 9.7⫾2.3 9.9⫾3.3 0.5
SI diameter 15.0⫾3.2 14.0⫾3.0 14.2⫾3.0 0.3
CS diameter at distal CS
AP diameter 3.9⫾0.7 3.9⫾0.6 4.0⫾0.7 0.7
SI diameter 4.1⫾0.9 3.9⫾0.7 4.0⫾0.9 0.7
Total CS length 108⫾12 106⫾14 126⫾19‡储⬍0.001
AP indicates anterior–posterior; SI, superior–inferior.
*Assessed by ANOVA with Scheffe´ post hoc testing.
†P⬍0.05 vs controls; ‡P⬍0.001 vs controls; §P⬍0.05 vs CAD; 储P⬍0.001
vs CAD.
TABLE 3. Quantitative Analyses of the CS and the MVA in
Patients With and Without Severe Mitral Regurgitation
Patients Without
Severe MR
(n⫽90)
Patients With
Severe MR
(n⫽15) P*
Minimal distance between CS and MVA
At MVA level 4.8⫾2.5 7.3⫾3.9 0.005
At proximal CS 8.1⫾2.4 9.3⫾1.9 0.019
At distal CS 8.3⫾3.1 12.1⫾3.6 ⬍0.001
MVA diameter (2-chamber view) 40.2⫾4.7 44.3⫾3.3 0.001
MVA diameter (4-chamber view) 35.8⫾4.4 39.9⫾4.4 0.002
MVA perimeter 118.1⫾12.6 127.6⫾14.7 0.020
Total CS length 110.1⫾16.6 128.6⫾14.6 ⬍0.001
*As assessed with Mann-Whitney Utest.
Tops et al MSCT of Coronary Sinus and Mitral Valve Annulus 1429
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studied. Of note, when the LCX coursed inferiorly to the CS,
the number of marginal branches of the LCX was larger.
However, no data on the minimal distance between the CS
and the LCX were provided.
These anatomic observations have previously been con-
firmed with electron-beam computed tomography.
15,16
Mao et
al
15
reported that the LCX coursed inferiorly to the CS in
80.8% of the studied patients. Furthermore, it was demon-
strated that the overlapping segment of the CS and the LCX
was ⬎30 mm in 17.8% of the cases. However, once again no
data on the minimal distance between the CS and the LCX
were provided.
In the present study, the LCX coursed inferiorly to the CS
in 68% of the patients, with a minimal distance between the
CS and the LCX of 1.3⫾1.0 mm. The close relation between
the CS and the LCX may limit the use of percutaneous mitral
valve annuloplasty, particularly when the LCX courses infe-
riorly to the CS over a long distance (Figure 4).
CS and MVA
Several anatomic studies have addressed the relation between
the CS and the MVA.
7–9
Shinbane et al
7
studied 10 normal
adult cadaver hearts and reported variable distances between
the CS and the MVA along the course of the CS. Mean
distances between the CS and the MVA were 14.1⫾3.1 mm,
10.2⫾4.9 mm, and 10.7⫾3.5 mm at distances of 20, 40, and
60 mm, respectively, from the ostium of the CS. El-
Maasarany et al
8
studied the distances between the CS and the
MVA in 32 normal cadaver hearts. Distances were assessed
in 6 separate regions along the course of the CS. Mean
distance was highly variable for the 6 regions; the shortest
distance (5.8 mm) was observed at the anterolateral commis-
sure of the MVA. Unfortunately, no data were provided about
the position of the CS in relation to the MVA (superior/infe-
rior/same level). In the largest anatomic study reported,
Maselli et al
9
also noted variable distances between the CS
and the MVA. At the level of the P2 and P3 scallops of the
mitral valve, mean distances between the CS and the MVA of
5.7⫾3.3 mm and 9.7⫾3.2 mm were reported.
In the present study, the highly variable relation between
the CS and the MVA was assessed noninvasively with
MSCT. The CS was located more superiorly to the MVA in
the majority of the patients (ranging from 90% at the level of
the MVA to 14% at the level of the distal CS). Furthermore,
minimal distances between the CS and the MVA were
assessed at the proximal and the distal CS and appeared to be
highly variable (Table 2). Although this finding confirms the
previous anatomic studies, the use of different reference
points makes a direct comparison between the present study
and previous in vitro studies difficult. Importantly, in patients
with severe MR, the minimal distance between the CS and the
MVA may increase significantly. In particular, the use of
percutaneous mitral annuloplasty may be not feasible in
patients where the CS courses along the left atrial wall
(Figure 5).
It should be noted that in the present study images were
routinely reconstructed at 75% of the RR interval. However,
the diameter and the distance between the CS and the MVA
may vary during the cardiac cycle. Nevertheless, the present
study shows that MSCT can accurately depict CS anatomy
and its relation with the MVA and thereby provides important
information on patients who are being considered for percu-
taneous mitral annuloplasty.
Implications for Percutaneous Mitral Annuloplasty
The present study shows the feasibility of the noninvasive
evaluation of the CS anatomy and its relation with the MVA
and the coronary arteries. In previous in vitro
7–9
and in
vivo
15,16
studies, the relation between the CS, the MVA, and
Figure 4. In this patient, the Cx courses between the CS and the MVA (A, 4-chamber view). The volume-rendered reconstruction (B)
and the reconstructed MVA level (C) show that the Cx courses inferiorly to the CS over a long distance. Percutaneous mitral annulo-
plasty may result in compression of the Cx.
Figure 5. In this patient, the CS courses along the left atrial (LA)
posterior wall rather than along the MVA.
1430 Circulation March 20, 2007
Downloaded from http://ahajournals.org by on December 5, 2019
the coronary arteries has been investigated. However, none of
these studies included patients with severe MR. The present
study emphasizes the variability in the relation between the
CS and MVA. More importantly, it demonstrates that, in
patients with severe MR, the minimal distance between the
CS and the MVA is larger than in control patients (Table 3).
The close relation between the CS and the LCX and the
variable distance between the CS and the MVA may hamper
the clinical use of the percutaneous mitral annuloplasty in
selected patients.
4
MSCT may identify the patients in whom
percutaneous transvenous mitral annuloplasty may not be
feasible. In 68% of the patients, the LCX courses between the
CS and the MVA (Figure 4), with a potential risk of
compression of the LCX when percutaneous mitral annulo-
plasty is applied. Furthermore, in a large number of patients
the CS courses along the left atrial posterior wall rather than
along the MVA (Figure 5). In addition, in patients with severe
calcifications of the MVA (Figure 6), a surgical approach
may be preferred over a percutaneous approach.
Our findings coincide with recent data that demonstrate the
feasibility of noninvasive evaluation with MSCT of the CS
anatomy in relation to the MVA.
11
As in the present study,
large variability in the distance between the CS and the MVA
was noted.
11
Novelties of the present study include the use of
a 64-slice MSCT scanner, whereas in the previous study a
16-slice CT scanner (with a collimation of 4⫻1 mm) was
used. In addition, in the present study, patients with heart
failure and patients with severe left ventricular dilatation and
subsequent functional MR were included. Therefore, a sub-
stantial part of the present study population consisted of
potential candidates for percutaneous mitral annuloplasty.
Both studies show that MSCT can accurately depict CS
anatomy and its relation with the MVA and thereby provide
important information on patients who are considered for
percutaneous mitral annuloplasty.
Conclusions
The relation between the CS, the MVA, and the LCX can be
evaluated noninvasively with MSCT. In 68% of the patients,
the LCX coursed between the CS and the mitral annulus.
Furthermore, at the level of the MVA, the CS was located
more superiorly in 90% of the patients. In the patients with
severe MR, the minimal distance between the CS and the
MVA was significantly greater at all levels than in the
patients without severe MR. MSCT may provide useful
information on the selection of potential candidates for
percutaneous mitral annuloplasty.
Sources of Funding
Dr Schuijf is supported by grant 2002B105 from the Dutch Heart
Foundation.
Disclosures
None.
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CLINICAL PERSPECTIVE
Mitral annuloplasty is the most commonly performed surgical procedure for ischemic mitral regurgitation. Recent studies
have shown the feasibility of a percutaneous alternative to mitral annuloplasty. In percutaneous mitral annuloplasty, a
device is placed in the coronary sinus (CS) to remodel the mitral valve annulus (MVA). However, previous anatomic
studies have demonstrated that the CS may be at variable distance from the MVA. In the present study, the relation between
the CS, the MVA, and the circumflex artery was studied noninvasively with multislice computed tomography. Our results
indicate that, in the majority of the patients, the CS is located along the left atrial wall rather than along the MVA. In
addition, the circumflex artery courses between the CS and the MVA in the majority of the patients. Importantly, we noted
that, in patients with severe mitral regurgitation, the minimal distance between the CS and the MVA is larger than in control
patients. The close relation between the CS and the circumflex artery and the variable distance between the CS and the
MVA may hamper the clinical use of the percutaneous mitral annuloplasty in selected patients. Multislice computed
tomography may be a valuable tool to depict CS anatomy and its relation with the MVA and the circumflex artery, thus
providing important information in patients who are considered for percutaneous mitral annuloplasty.
1432 Circulation March 20, 2007
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