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On physical examination: holosystolic mitral murmur (3+/6+) spreading to the axilla with no other relevant changes. Preoperative electrocardiogram (ECG) with atrial fibrillation, right branch conduction disturbance, axis at +60o. Preoperative echocardiography: severe biatrial increase, severe eccentric reflux, maximum gradient of 20 mmHg, average gradient of 7 mmHg and valve area of 1.7 cm2, preserved biventricular function with left ventricular ejection fraction (LVEF) of 60%, pulmonary artery systolic pressure (PASP) of 71 mmHg.

Primary Percutaneous Coronary Intervention of Anomalous Circumflex Artery after Mitral Valve Replacement