Atrial myxomas: pathologic types, tumor location, and presenting symptoms

BACKGROUND: Atrial myxoma is the most common cardiac neoplasm. Although not widely reported, two anatomic types have been observed: solid and papillary. We examined whether differences in gross or microscopic appearance and location correlated with symptomatology, specifically congestive heart failure (CHF), neurologic symptoms, and embolic events. METHODS: We performed a retrospective review of atrial myxomas removed from 1972 to 2002, recording the clinical presentation, diagnostic modality, tumor location, gross, and microscopic features for each patient. Twenty-six patients (16 females and 10 males) had atrial myxomas excised. Two patients (one female and one male) were excluded due to unavailable pathologic slides. RESULTS: In 24 patients there were 15 solid and 9 papillary tumors. CHF was more prevalent in solid myxomas, while neurologic symptoms and embolic events were more common in papillary tumors. Tumor location further correlated with presenting symptoms. Ninety-two percent of patients presenting with CHF had tumors attached to the atrial septum. Extraseptal myxomas more frequently presented with neurologic (80% vs. 29%) and embolic features (50% vs. 25%). All patients exhibiting clefted tumor surface had a history of embolization. A higher percentage of solid myxomas (93%) showed hemorrhage within the tumor than with papillary (56%). CONCLUSIONS: CHF was more common with solid myxomas, and neurologic and embolization events were more common in the papillary type. Septal tumor location showed strong association with CHF, while extraseptal location correlated with neurologic events. We speculate that the various gross and microscopic patterns reflect secondary changes within these neoplasms over the course of their natural history.     

Papillary fibroelastoma of the interatrial septum: a case report

Primary cardiac tumors are rare, with benign lesions outnumbering malignant ones by a margin of over four to one. Amongst the benign cardiac neoplasms, papillary fibroelastomas are reported second only to myxomas. Papillary fibroelastomas commonly rise from heart valves and their size ranges from a few millimeters to well over 2.0 cm in diameter. While myxomas commonly arise from the interatrial septum, we present the rare example of a large papillary fibroelastoma arising from the left side of the interatrial septum.     

Ultrasonic sensor concept to fit a ventricular assist device cannula evaluated using geometrically accurate heart phantoms

Future left ventricular assist devices (LVADs) are expected to respond to the physiologic need of patients; however, they still lack reliable pressure or volume sensors for feedback control. In the clinic, echocardiography systems are routinely used to measure left ventricular (LV) volume. Until now, echocardiography in this form was never integrated in LVADs due to its computational complexity. The aim of this study was to demonstrate the applicability of a simplified ultrasonic sensor to fit an LVAD cannula and to show the achievable accuracy in vitro. Our approach requires only two ultrasonic transducers because we estimated the LV volume with the LV end‐diastolic diameter commonly used in clinical assessments. In order to optimize the accuracy, we assessed the optimal design parameters considering over 50 orientations of the two ultrasonic transducers. A test bench was equipped with five talcum‐infused silicone heart phantoms, in which the intra‐ventricular surface replicated papillary muscles and trabeculae carnae. The end‐diastolic LV filling volumes of the five heart phantoms ranged from 180 to 480 mL. This reference volume was altered by ±40 mL with a syringe pump. Based on the calibrated measurements acquired by the two ultrasonic transducers, the LV volume was estimated well. However, the accuracies obtained are strongly dependent on the choice of the design parameters. Orientations toward the septum perform better, as they interfere less with the papillary muscles. The optimized design is valid for all hearts. Considering this, the Bland‐Altman analysis reports the LV volume accuracy as a bias of ±10% and limits of agreement of 0%–40% in all but the smallest heart. The simplicity of traditional echocardiography systems was reduced by two orders of magnitude in technical complexity, while achieving a comparable accuracy to 2D echocardiography requiring a calibration of absolute volume only. Hence, our approach exploits the established benefits of echocardiography and makes them applicable as an LV volume sensor for LVADs.     

A physiological approach to surgery for acute rupture of the papillary muscle

There is controversy regarding the optimal management of patients in whom acute papillary muscle rupture develops. This study evaluates the effect of division of the anterolateral papillary muscle on left ventricular (LV) function and compares two methods of treatment--mitral valve replacement (MVR) and mitral valve repair. Thirteen pigs were placed on cardiopulmonary bypass, and interventions were performed in an isolated beating heart preparation. LV function was assessed with a compliant intraventricular balloon at baseline, after division of the anterolateral papillary muscle (Divided), after repair of the divided papillary muscle (Repair), and finally after MVR. Division of the anterolateral papillary muscle caused a significant deterioration in LV function. Function was maintained at this level after mitral valve repair but deteriorated with MVR. Developed pressure measured at baseline was 179 +/- 13 mm Hg; Divided, 148 +/- 11 mm Hg (p less than 0.05 versus baseline); Repair, 149 +/- 15 mm Hg; and MVR, 95 +/- 8 mm Hg (p less than 0.05 versus Divided) at a balloon volume of 20 ml. These results suggest that LV function is impaired by papillary muscle rupture. Repair of the ruptured papillary muscle is associated with better LV function than is MVR.     

显微外科与腹腔镜两种手术治疗精索静脉曲张的疗效及并发症的对比观察

目的:比较显微外科与腹腔镜途径精索静脉结扎术治疗精索静脉曲张的疗效及并发症。方法:将72例精索静脉曲张患者随机分为显微外科精索静脉结扎术组(36例)和腹腔镜精索静脉结扎术组(36例),比较术前、术后3个月的精液质量、术后并发症,以及术后配偶妊娠率。结果:显微外科组手术时间明显长于腹腔镜组(P<0.05);术后住院天数显微外科组为(2.2±0.7)d,腹腔镜组为(2.8±0.8)d,两组无明显差别;两组术后精子浓度、存活率和(a+b)级精子百分率均较术前明显提高(P均<0.05),但两组间无统计学差异。配偶妊娠率显微外科组为65.2%,腹腔镜组57.1%。术后阴囊水肿发生率显微外科组为0,腹腔镜组为16%;复发率两组无明显差异(P>0.05)。结论:与腹腔镜精索静脉结扎术比,显微外科精索静脉结扎术创伤更小、恢复更快、麻醉经济、术后并发症少、复发率低,是更值得推广的安全有效的术式。     

Mitral valve repair for infective endocarditis

OBJECTIVE: This study investigated the feasibility of mitral valve (MV) repair in patients with active or healed infective endocarditis (IE) with mitral regurgitation and evaluated effects on left ventricular (LV) function and structure. METHODS: Subjects comprised 19 patients who underwent MV operations for IE between December 2004 and September 2007. MV repair was performed for acute IE in 10 of 15 patients (67%) and for healed IE in 4 of 4 patients (100%). RESULTS: No early or late postoperative deaths were encountered. One patient underwent redo MV repair owing to severe mitral regurgitation 1 month postoperatively. Postoperative echocardiography after MV repair demonstrated less than trivial (acute IE in seven, healed IE in three) or mild (acute IE in three, healed IE in one) mitral regurgitation. In patients with MV replacement, the postoperative left atrial dimension (LAD) was decreased (51.5 +/- 39.2 vs. 39.2 +/- 1.9 mm, P = 0.007); however LV end-diastolic dimension (LVDD) and LV end-systolic dimension were unchanged. In patients with MV repair, LVDD (57.5 +/- 6.5 vs. 46.0 +/- 5.6 mm, P < 0.001), LV end-systolic dimension (36.1 +/- 5.2 vs. 32.4 +/- 6.2 mm, P = 0.04), LAD (43.1 +/- 8.1 vs. 33.6 +/- 7.7 mm, P = 0.003) were reduced. Postoperative ejection fraction (55.3 +/- 13.5% vs. 41.8% +/- 10.0%, P = 0.03) and fraction shortening (30.1% +/- 9.2% vs. 20.7% +/- 5.5%, P = 0.03) were better in patients with MV repair than those with MV replacement. CONCLUSIONS: MV repair is feasible in patients with both active and healed IE. MV repair preserves better LV function and structure postoperatively.     

Cardiovascular adjustments to pulmonary vascular injury in dogs

The hemodynamic effects of blood volume augmentation and mechanical ventilation (MV) with positive end-expiratory pressure (PEEP) were studied in nine Beagles anesthetized with halothane before and after thrombin-induced pulmonary hypertension. The effect of therapy with dopamine, norepinephrine with and without nitroglycerin (NTG), and intraaortic balloon pumping (IABP) were studied in a second series of six Beagles. Before thrombin, dextran (35 ml.kg-1) caused a significant increase in right and left ventricular end-diastolic and end-systolic volumes (RV and LVEDV, and RV and LVESV). However, RV and LV performance, as estimated by ejection fraction, was unchanged during volume loading and MV with PEEP when the pulmonary vasculature was intact. The response to volume loading and MV with PEEP was altered significantly once PVR had been increased with the administration of thrombin. Stroke volumes were decreased, and remained so, despite volume loading and MV with PEEP. LVEDV decreased without a decrease in LVEDP, indicating a decreased LV compliance. Dopamine and norepinephrine with and without NTG increased stroke volumes and RV ejection fraction in contrast to IABP. Assessment of LV performance, according to the Frank-Starling mechanism, requires a measure of end-diastolic volume when diffuse pulmonary vasoconstriction leads to RV distension and LV hypovolemia secondary to septal shift. Measurement of LV filling pressures can provide misleading values to estimate changes in LV volume in this setting. Measurement of ventricular volumes is required for optimal management of patients with severe acute respiratory failure and pulmonary hypertension.     

Ischemic mitral valve repair: correlations between the mechanisms of mitral regurgitation and left ventricular function prior to and following surgery

OBJECTIVE: To define the mechanisms of ischemic mitral regurgitation (MR) and its correlation with left ventricular (LV) function prior to and 1 year following mitral valve (MV) repair. DESIGN: Fifty-three patients (pts) underwent echocardiographic evaluation of the MR mechanism according to Carpentier's classification; quantification of MR and LV function. RESULTS: Forty-one, 5% of pts had Type I (annulus dilation), 20, 5% had Type II (commissural prolapse) and 38% had Type IIIb MR (predominant posterior leaflet restriction). Preoperative LV function was slightly better preserved in pts with Type II and IIIb MR. Despite similar MV repair efficiency intraoperatively, after 1 year Type I MR progressed vs the remaining types. LV function, including dimensions, ejection fraction and pulmonary artery pressure had a tendency to worsen in pts with Type I and markedly improved in Type II and IIIb MR. CONCLUSIONS: Ischemic MR of Type I is associated with more marked LV dysfunction preoperatively, its further deterioration and MR progression after MV repair. Type II and IIIb MR correlates with better preserved LV function preoperatively and its incremental improvement late after surgery.     

The impact of hospital volume on the number of nodes retrieved and outcome in colorectal cancer

We sought to examine the impact of hospital surgical volume on the number of nodes harvested and survival in colorectal cancer (CRC). Between January 1994 and December 2004, a total of 8567 patients with T1, 2, 3, and 4 primary tumors and N0, N1, or N2 disease were studied. Hospitals were stratified into very low volume (VLV) (<33 cases/year), low volume (LV) (33-56 cases/year), and medium volume (MV) (57-84 cases/year). Surgery for CRC was performed most commonly at VLV hospitals: 3488 (40.7%) VLV centers versus 2359 (27.5%) LV centers versus 2720 (31.7%) MV centers. The mean number of nodes retrieved for VLV centers was 8.6, for LV centers 9.4, and MV centers 10.2 (P < 0.0002). Actuarial 5-year survival for VLV centers was 71.4 per cent, for LV centers 75.6 per cent, and for MV 77.0 per cent (P < 0.00001). By Cox proportional hazards analysis, hospital volumes (P < 0.0011) and the number of lymph nodes harvested (P < 0.0034) remain significant predictors of disease specific survival. The number of nodes retrieved is impacted by hospital volumes. Hospital volumes impact survival in CRC. These findings cannot be attributed solely to improved staging due to increased node retrieval in VLV, LV, and MV hospitals.     

Ischemic mitral valve repair: Correlations between the mechanisms of mitral regurgitation and left ventricular function prior to and following surgery

Objective.?To define the mechanisms of ischemic mitral regurgitation (MR) and its correlation with left ventricular (LV) function prior to and 1 year following mitral valve (MV) repair. Design.?Fifty-three patients (pts) underwent echocardiographic evaluation of the MR mechanism according to Carpentier's classification; quantification of MR and LV function. Results.?Forty-one, 5% of pts had Type I (annulus dilation), 20, 5% had Type II (commissural prolapse) and 38% had Type IIIb MR (predominant posterior leaflet restriction). Preoperative LV function was slightly better preserved in pts with Type II and IIIb MR. Despite similar MV repair efficiency intraoperatively, after 1 year Type I MR progressed vs the remaining types. LV function, including dimensions, ejection fraction and pulmonary artery pressure had a tendency to worsen in pts with Type I and markedly improved in Type II and IIIb MR. Conclusions.?Ischemic MR of Type I is associated with more marked LV dysfunction preoperatively, its further deterioration and MR progression after MV repair. Type II and IIIb MR correlates with better preserved LV function preoperatively and its incremental improvement late after surgery.     

Early recovery of left ventricle following coronary artery bypass grafting and mitral valve repair in a case of anomalous origin of left coronary artery from pulmonary artery

Anomalous origin of Left Coronary Artery from Pulmonary Artery (ALCAPA) is a rare congenital malformation, which can result in myocardial infarction, congestive heart failure and sudden death if left untreated. Reports of myocardial revascularization and Mitral Valve (MV) repair following ALCAPA repair in infants are uncommon. We report a critically ill infant with ALCAPA needing myocardial revascularization and MV repair after which there was early recovery of Left Ventricular (LV) function. At two years follow up, the child is clinically well; the postoperative cardiac catheterization shows good flow in the Left Internal Mammary Artery (LIMA) and Left Anterior Descending artery (LAD), good LV function and competent mitral valve.     

Surgical treatment for ischemic mitral regurgitation: strategy for a tethered valve.

Recently, ischemic mitral regurgitation (IMR) has been shown to be an individual risk factor for ischemic heart disease. The main mechanism of IMR is tethering of the leaflet secondary to left ventricular (LV) dilatation. In this situation, surgical treatment for IMR has been limited to ring annuloplasty with varying degrees of effectiveness. However, mid-term follow-up studies have shown that the results obtained with this approach are not satisfactory. Therefore, there has been a need to develop additional techniques to achieve more secure repair of IMR. The characteristics of the mitral leaflet configuration in IMR are apical displacement of the leaflets relative to the annulus, concavity of the leaflets, and a dilated annulus. Our basic strategy for a tethered mitral valve is rigid ring annuloplasty and inward correction of the outwardly displaced papillary muscle. For the latter correction, we employ the overlapping method or septal anterior ventricular exclusion (SAVE) procedure for LV volume reduction in cases of broad antero-septal infarction, or elevate the posterior papillary muscle by folding the LV wall at the root of the posterior papillary muscle via a small incision in the inferior wall in cases of infero-posterior infarction. An additional procedure is chordal cutting in combination with rigid ring annuloplasty and papillary muscle imbrication in combination with LV volume reduction. We have successfully combined these methods with the aid of detailed echocardiographic studies in individual patients. However, long-term follow-up will be necessary before this approach can be routinely adopted.     

Cardiac myxomas: experience over one decade

Abstract Background: This single‐center study reviews our experience with cardiac myxomas over the past decade. Methods: Sixty‐two patients (23 male) with median age 38 years (range: 8 to 69 years) underwent excision of primary or recurrent cardiac myxomas between 2000 and 2009. Patients were evaluated with echocardiography preoperatively and annually postoperatively. Follow‐up is current for all survivors (range 13 months to 10 years). Results: Fifty‐two patients had left atrial myxomas, seven right atrial, two biatrial, and one right ventricular. Three cases were familial. Maximum number of myxomas in a single patient was four. Symptom duration ranged from two to eight months. Two early deaths were due to low cardiac output and embolic cerebrovascular accident; one late death was due to a noncardiac cause. Actuarial survival was 96.8 ± 1.8% at 10 years. Most patients were asymptomatic following surgery. No sporadic, multiple, or biatrial myxomas recurred. Recurrence occurred in two familial cases, both with single, left atrial myxoma. Freedom from reoperation was 98.4 ± 1.3% at five years and 96.8 ± 1.8% at 10 years. Conclusions: Biatrial involvement or multiplicity of myxomas does not mandate recurrence. Surgical excision has excellent overall survival and freedom from reoperation rates, but annual follow‐up including echocardiographic surveillance is recommended as familial cases tend to recur. (J Card Surg 2011;26:355‐359)     

Should Mild‐to‐Moderate and Moderate Ischemic Mitral Regurgitation Be Corrected in Patients with Impaired Left Ventricular Function Undergoing Simultaneous Coronary Revascularization?

INTRODUCTION: Mitral valve regurgitation (MR) occurring as a result of myocardial ischemia and global left ventricular (LV) dysfunction predicts poor outcome. This study assessed the feasibility of mitral valve (MV) surgery concomitant with coronary artery bypass grafting (CABG) in patients with mild-to-moderate and moderate ischemic MR and impaired LV function. MaTERIALS AND METHOD: From January 1996 to July 2000, 49 patients (group 1) and 50 patients (group 2) with grade II and grade III ischemic MR and LV ejection fraction (EF) between 17% and 30% underwent combined MV surgery and CABG (group 1) or isolated CABG (group 2). LVEF (%), LV end-diastolic diameter (EDD) (mm), LV end-diastolic pressure (EDP) (mmHg), and LV end-systolic diameter (ESD) (mm) were 27.5 +/- 5, 67.7 +/- 7,27.7 +/- 4, and 51.4 +/- 7, respectively in group 1 versus 27.8 +/- 4, 67.5 +/- 6, 27.5 +/- 5, and 51.2 +/- 6, respectively in group 2. Groups 1 and 2 were divided into Groups 1A and 2A with mild-to-moderate MR (22 [45%] and 28 [56%] patients, respectively) and groups 1B and 2B with moderate MR (27 [55%] and 22 [46%], respectively). In group 1, MV repair was performed in 43 (88%) patients and MV replacement in 6 (12%) patients. RESULTS: Preoperative data analysis did not reveal any difference between groups. Five (10%) patients in group 1 died versus 6 (12%) in group 2 (p = ns). Within 6 months after surgery, LV function and its geometry improved significantly in group 1 versus group 2 (LVEF, p < 0.001; LVEDD, p = 0.002; LVESD, p = 0.003; and LVEDP (p < 0.001) improved significantly in group 1 instead of a mild improvement in Group 2). The regurgitation fraction decreased significantly in group 1 patients after surgery (p < 0.001). There was an inverse strong correlation between postoperative forward cardiac output and regurgitation fraction (p < 0.001). LVEF and LVESD improved significantly in group 1 versus group 2 patients (p = 0.04 and p = 0.02, respectively). The cardiac index increased significantly in group 1 and 2 (p < 0.001 and p = 0.03, respectively). LV function and geometry improved significantly postoperatively in group 1B versus group 2B (LVEDD, p = 0.027; LVESD, p = 0.014; LVEDP, p = 0.034; and LVEF, p = 0.02), instead of a mild improvement in group 1A versus group 2A (LVESD, p = 0.015; LVEF, p = 0.046; and LVEDD and LVEDP, p = 0.05). At follow-up, 4 (67%) of 6 patients undergoing MV replacement died versus 5 (11.5%) of 43 patients undergoing MV repair in group 1 (p = 0.007). The overall survival at 3 years in Group 2 was significantly lower than group 1 (p < 0.009). Conclusion: MV repair and replacement-preserving subvalvular apparatus in patients with impaired LV function offered acceptable outcomes in terms of morbidity and survival. Surgical correction of mild-to-moderate and moderate MR in patients with impaired LV function should be taken into consideration since it yields better survival and improved LV function.     

Myocardial perfusion as assessed by thallium-201 scintigraphy during the discontinuation of mechanical ventilation in ventilator-dependent patients

Patients who cannot be separated from mechanical ventilation (MV) after an episode of acute respiratory failure often have coexisting coronary artery disease. The authors hypothesized that increased left ventricular (LV) wall stress during periods of spontaneous ventilation (SV) could alter myocardial perfusion in these patients. Using thallium-201 (201TI) myocardial scintigraphy, the authors studied the occurrence of myocardial perfusion abnormalities during periods of SV in 15 MV-dependent patients (nine women, six men; aged 71 +/- 7 yr, mean +/- SD). Fourteen of these patients were studied once with 201TI myocardial scintigraphy during intermittent mechanical ventilation (IMV) and again on another day, after at least 10 min of SV through a T-piece. One patient was studied during SV only. Thirteen of 14 of the patients (93%) studied during MV had abnormal patterns of initial myocardial 201TI uptake, but only 1 patient demonstrated redistribution of 201TI on delayed images. The remainder of the abnormalities observed during MV were fixed defects. SV produced significant alterations of myocardial 201TI distribution or transient LV dilation, or both, in 7 of the 15 patients (47%). Four patients demonstrated new regional decreases of LV myocardial thallium concentration with redistribution of the isotope on delayed images. The patient studied only during SV also had myocardial 201TI defects with redistribution. Five patients (3 also having areas of 201TI redistribution) had transient LV dilation during SV.(ABSTRACT TRUNCATED AT 250 WORDS)     

Diverticulum of the left ventricle: etiology and surgical treatment

Congenital left ventricular (LV) diverticula are rare findings, particularly when first diagnosed in adulthood. We describe successful surgical repair of an isolated congenital apical LV diverticulum associated with an abnormal submitral apparatus in a young adult who received his diagnosis following a peripheral embolism. We intraoperatively identified an abnormally originating belly of the posteromedial papillary muscle, which arose from the interventricular septum, causing partition of the LV cavity and forming an apical aneurysmal communicating chamber. This anatomy of abnormal papillary muscle bifurcation was possibly the mechanism for the development of the apical diverticulum and to the best of our knowledge has not previously been described. Reattachment of the abnormal belly to its normal position preserved mitral valve competence, and an endoventricular patch repair restored LV volume and geometry.     

The papillary muscles as shock absorbers of the mitral valve complex. An experimental study.

OBJECTIVE: Although it is known that the papillary muscles ensure the continuity between the left ventricle (LV) and the mitral apparatus, their precise mechanism needs further study. We hypothesize that the papillary muscles function as shock absorbers to maintain a constant distance between their tips and the mitral annulus during the entire cardiac cycle. MATERIALS AND METHODS: Sonomicrometry crystals were implanted in five sheep in the mitral annulus at the trigones (T1 and T2), mid anterior annulus (AA) mid posterior annulus (PA), base of the posterior lateral scallops (P1 and P2), tips of papillary muscles (M1 and M2), and LV apex. LV and aortic pressures were simultaneously recorded and used to define the different phases of the cardiac cycle. RESULTS: No significant distance changes were found during the cardiac cycle between each papillary muscle tip and their corresponding mitral hemi-annulus: M1-T1, (3.5+/-2%); M1-P1 (5+/-2%); M1-PA (5+/-3%); M2-T2 (2.7+/-2%); M2-P2 (6.1+/-3%); and M2-AA (4.2+/-3%); (p>0.05, ANOVA). Significant changes were observed in distances between each papillary muscle tip and the contralateral hemi-mitral annulus: M1-T2 (1.7+/-3%); M1-P2 (23+/-6%); M1-AA (6+/-3%); M2-T1 (8+/-3%); M2-P1 (10.5+/-6%); and M2-PA (12.6+/-8%); (p<0.05 ANOVA). The distance changes between LV apex and each papillary muscle tip were significantly different: apex-M1 (12.9+/-1%) and apex-M2 (10.5+/-1%) and different from the averaged distance change between the LV apex and each annulus crystal (8.3+/-1%) with p<0.05. CONCLUSION: The papillary muscles seem to be independent mechanisms designed to work as shock absorbers to maintain the basic mitral valve geometry constant during the cardiac cycle.     

Mitral Valve Re‐Repair in an Adolescent Patient with Prosthetic Ring Endocarditis: Posterior Leaflet Augmentation and Posterior Strip Annuloplasty

Abstract Endocarditis after mitral valve (MV) annuloplasty is uncommon. The ring used in MV annuloplasty is often inadequate because it opposes the growth of the MV leaflets and annulus. We report a 15‐year‐old male that required redo surgery for prosthetic ring endocarditis 40 months after a previous MV annuloplasty. After the previous ring was removed, the undergrown posterior leaflet was repaired with pericardial augmentation and the posterior annulus was stabilized with a Mitra‐Lift® supra‐annular strip to preserve a flexible valve orifice and allow the anterior MV annulus and the commissures to grow in relation to body size. (J Card Surg 2012;27:560‐562)     

Benefits of submitral procedures for ischemic mitral regurgitation

The surgical strategy for ischemic mitral regurgitation (MR) remains controversial. Ischemic MR is a secondary valve disease caused by left ventricular (LV) remodeling and subsequent papillary muscle displacement, usually without structural valve lesions. Reduction annuloplasty is the standard surgical procedure for this condition, though it cannot clearly provide a survival benefit for those with LV dysfunction and is associated with a high prevalence of late recurrence of MR. The valvular procedure alone could be insufficient to treat ischemic MR in terms of long-term survival and the prevention of recurrence because ischemic MR is primarily a ventricular disorder. Thus, recent studies have focused on alternative procedures that target the primary cause of ischemic MR, the papillary muscles and left ventricle. We believe that the appropriate selection of surgical procedures among valvular, subvalvular, and even ventricular ones, considering the severity of LV remodeling for each patient would be more beneficial. Here we review recent studies featuring various surgical approaches to ischemic MR, especially with submitral procedures.     

Combined mitral valve repair, LVOT myectomy and left atrial cryoablation therapy

Asymmetric septal hypertrophy (ASH) is a common cause of left ventricular (LV) outflow tract obstruction. Mitral valve (MV) regurgitation is present in 30% of those patients as well as biatrial enlargement. Furthermore, paroxysmal or chronic atrial fibrillation (AF) occurs in up to 22%. Two male patients were admitted for shortness of breath and decreased physical ability. Hypertrophic obstructive cardiomyopathy (HOCM) with ASH, severe MV regurgitation and chronic AF were diagnosed in both patients; present for 8 years in patient 1 and 1 year in patient 2. Both received MV annuloplasty, transaortic septal resection using the modified Morrow et al.'s technique and left atrial cryoablation therapy via median sternotomy. Intraoperative measurement revealed no residual gradients and competent MV, furthermore, both patients were discharged in sinus rhythm.