Objective: To provide, with the use of preoperative coronary computed tomography angiography, an in vivo anatomical characterization of the relationship between the circumflex artery and mitral valve annulus to identify different risk classes and to increase the surgical awareness of those anatomical relations.Methods: Ninety-five (mean age: 64.2 AE 11.7) consecutive patients, initially referred for elective minimally invasive mitral valve surgery, underwent preoperative coronary computed tomography angiography. The distance between the circumflex artery and mitral annulus was assessed using 6 points designed on the posterior mitral annulus, starting from the anterolateral to the posteromedial commissure; this design created an ideal 5-zone system. High-risk anatomy was defined as a distance less than 3 mm between the circumflex artery and the mitral valve annulus. Results:The shortest distance between the circumflex artery and mitral valve annulus was observed at the area between the anterolateral commissure and the midpoint of P1 scallop, so-called zone 1 (5.49 AE 3.13 mm), whereas the longest distance occurred at zone 5 (12.03 AE 4.93). Twenty-four patients (25%) were identified with high-risk anatomy (mean distance 1.94 AE 0.8 mm). Left dominant and co-dominant hearts demonstrated a shorter circumflex artery-mitral valve annulus distance at all the zones. At multinomial logistic regression, the pattern of coronary dominance and the size of the circumflex artery were independent factors for high-risk anatomy.Conclusions: Coronary computed tomography angiography is a useful investigation to identify patients at risk of circumflex artery flow disturbance; for high-risk anatomy, this knowledge may enhance a safer operative technique. (JTCVS Techniques 2020;4:122-9) The "five zones" system designed along the posterior mitral leaflet. CENTRAL MESSAGECoronary computed tomography angiography gives information about the distance between the circumflex artery and the mitral valve annulus, identifying patients at high risk of circumflex artery injury. PERSPECTIVEThe consequence of circumflex artery injury during mitral valve surgery could be severe with important clinical implications. The knowledge of preoperative distance between the circumflex artery and the mitral valve annulus may help to identify patients at high risk of circumflex flow disturbance following mitral valve surgery.See Commentaries on pages 130 and 132. Video clip is available online.Mitral valve surgery is known to be associated with the potential risk of disturbance of circumflex artery (CX) flow, as its course is intimately related to the mitral valve annulus (MVA). [1][2][3][4][5][6] The true mechanism for this is still unclear, with authors suggesting direct suturing, 3 laceration, or annuloplasty device distortion during mitral valve repair. 7 The perioperative diagnosis can be extremely difficult to detect until the lateral wall injury to the left ventricle

Injury or distortion of the circumflex coronary artery can occur during mitral valve surgery, due to its proximity to the mitral valve annulus. We present the case of a 72-year-old male patient with symptomatic mitral regurgitation, who underwent minimally invasive mitral valve surgery. The initial reparative gesture was complicated by intraoperative infarct due to a distortion of the circumflex artery (CX) caused by the rigidity of the ring used; the mainstay of the treatment was the removal of the previous device implanted in favor of a flexible one with restitutio ad integrum of the CX patency. K E Y W O R D S annuloplasty devices, circumflex artery, mitral valve repair | CARUSO ET AL.

Background The ease of implantation of the rapid deployment (RD) and sutureless valves has contributed to the adoption of anterior right thoracotomy (ART) approach for aortic valve replacement (AVR). Aim of the study This study evaluates the safety and haemodynamic performance of minimally invasive AVR through ART using the RD valves. Methods This is a retrospective, single‐center review of a total of 50 consecutive patients who received RD‐AVR through ART. Results The median age of patients was 75 years (interquartile range [IQR]: 69‐80), and median Euroscore II was 5.1 (IQR: 2.4‐7.5). ART RD‐AVR was successfully performed in all cases with no conversion to sternotomy, paravalvular leaks or need for valve explantation. The mean size of the implanted valve was 23.2  ± 2.3 mm. In‐hospital mortality was 2%. The mean and maximum pressure gradients across the aortic prosthesis were 10 mm Hg (IQR: 9‐12) and 19 mm Hg (IQR: 16‐23). Conclusions Rapid deployment aortic valve replacement can be safely performed through anterior right thoracotomy wit excellent haemodynamic performance and low postoperative complications rate.

A pericardial cyst is a rare and benign cause of a mediastinal mass. They are frequently asymptomatic and are usually incidental findings on imaging. Symptoms may include persistent cough, atypical chest pain, dysphagia, and dyspnea. Diagnosis is usually established with the aid of imaging, including a chest x-ray, a computed tomography (CT) scan, and magnetic resonance imaging (MRI). Therapeutic options include surgical resection or aspiration for large and/or symptomatic cysts, whereas conservative management with routine follow-up is advised for small or asymptomatic cysts. We herein describe the case of a 48-year-old lady, who presented with clinical features suggestive of acute cholecystitis, with an incidental finding of a pericardial cyst, measuring approximately 10.1 cm x 8.7 cm x 10.7 cm. The patient underwent video-assisted thoracoscopic surgery (VATS) for excision of the pericardial cyst. She had an uneventful recovery and was discharged on the second post-operative day. At six months, there was no evidence of disease recurrence.

A solitary fibrous tumour of the pleura (SFTP) is a rare pathology, frequently benign in nature, and is usually diagnosed incidentally on imaging. We herein describe the case of a previously fit and well, 35-year-old Caucasian lady, who presented to us with a history of progressively worsening shortness of breath. Her chest X-ray showed a near-complete opacification of the right hemithorax, with displacement of the mediastinum towards the left. This study was supplemented by a computed tomography (CT), which demonstrated a wellcircumscribed, non-homogenous mass, occupying the entirety of the right hemithorax. A large, smooth, encapsulated tumour was surgically resected via a posterolateral thoracotomy, measuring approximately 23.1 cm x 21.0 cm x 11.5 cm and weighing 3640 grams. Histopathology confirmed the diagnosis of a benign SFTP with an intermediate malignant potential. At six months, a follow-up CT scan demonstrated no evidence of disease recurrence.