On average, someone in the U.S. dies of a stroke every 3 minutes and 14 seconds. If there is a history of A.Fib, please address the left atrial appendage at the time of cardiac surgery!

Pericardial thickness… 2 mm = Normal 4 mm = Possible Constriction 6 mm = ⬆️ Specificity Constriction

The Brockenbrough-Braunwald-Morrow sign. This sign is characterized by a ⬇️ in arterial pulse pressure after a premature ventricular contraction, accompanied by a significant ⬆️ in peak left ventricular systolic pressure.

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One of the most important slides for all CT Fellows to study!!!

It is not uncommon to see a partial or complete LBBB after myectomy. Watch out for a pre-existing RBBB as this carries increased risk of requiring PPM after myectomy. The asterisks indicates the initial site of myectomy (nadir of the RCC…it is then carried CCW to the AMVL).

Principles of repair: 1. Preserve leaflet mobility 2. Reduce height of PMVL 3. Reduce annular dilatation 4. Restore leaflet coaptation 5. Prevent SAM

When should you advise surgical myectomy for HCM? 1. Effort induced symptoms are unresponsive to medical Rx (beta blockers, calcium channel blockers, disopyramide). 2. Patient is intolerant to medicine (meds make them feel worse).

Severe mitral annular calcification. How do you manage this when performing MVR? Debridement with or without patch? Suture around the calcium bar? Suture into the leaflet? Suture to left atrium? Whatever you can to get a good valve in with no perileak.

Aortic valve regurgitation repair in a Bicuspid valve. Plicate (or limited resection) to eliminate conjoined cusp redundancy, close the sub-commissural triangles (5 0 Ethibond with Teflon pledgets) and resuspend the commissures.

Ingenuity starts with a simple idea.

Looking at a CTA to assess candidacy for robotic mitral repair. What’s the abnormality?

Myectomy specimen(s). I use a #10 knife blade with the aortotomy carried very low into the non-coronary sinus…what do you use?

Doesn’t expecting the unexpected make the unexpected expected!

Full metal jacket at age 50…very sad & disappointing

Why do we prefer Isuprel over Dobutamine to elicit LVOT gradients in HCM patients with latent obstruction? Dobutamine has beta-1,2 activity which ⬆️ contractility/HR but also has alpha-1 effect which ⬆️ afterload & this may not elicit gradient. Isuprel is a b-1,2 agonist only

How can you confirm the presence of provocable LVOT obstruction when echo or inducible (post PVC) gradients are labile in the OR? Give Isoproterenol. It has B1 and B2 agonist properties…⬆️ contractility and HR with ⬇️ afterload…very useful!

Extended trans-aortic septal myectomy. The “depth”of myectomy is less of the focus (7-8 mm, the width of a #10 blade is enough), as compared to the “length” of the myectomy (need to extend apically enough to see the base of the papillary muscles).

A picture doesn’t quite capture the grandeur of the sun setting over the Na Pali Coast in Kauai…but it comes close.