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Purpose: During surgical mitral valve repair distortion or damage of the circumflex coronary artery (CX) is a rare but well known complication. One of the possible risk factors is the proximity of the CX to the mitral annulus which varies from patient to patient. Aim of this study was to investigate the feasibility to define the anatomical relationship between the CX and the mitral annulus with the help of Real Time (RT) 3D TOE.Methods: After induction of anaesthesia a 3D TOE probe (iE 33, Philips Amsterdam, The Netherlands) was introduced and additionally to a comprehensive perioperative 2D TOE a RT 3D FV dataset and 3D zoom loop were recorded in midoesophageal four chamber view and long axis view. The distance between CX and the mitral annulus, the diameter of the CX and the height of the CX in relation to mitral annuls were measured offline by two independent examiners using Qlab software® (Philips, Netherlands). All patients included in this study underwent preoperative angiographic evaluation of their coronary anatomy. Values are expressed as means with minimal and maximal values.Results: After approval of the local ethic committee and written informed consent 30 patients with a mean age of 66 ± 12 years undergoing elective minimally invasive mitral valve repair were included in this study. Measurements of the CX were possible in all patients. The distance between the CX and the mitral annulus was 0,80mm ranging from 0,36 to 1,16. The diameter of the CX was 0,32 ranging from 0,13 to 0,54mm. Interobserver variability was 0,01mm for both measurements. Mean height of the CX in relation to the mitral annulus was 0,16 ranging from -0,4 to 0,54 with an interobservervariability of 0,1mm.Conclusions: This study shows that it is feasible to measure the relationship between CX and the mitral annulus with the help of RT 3D TOE.