This study aimed to compare clinical outcomes of different mitral valve (MV) management methods in thoracoscopic transmitral myectomy (TTM) and guide surgeons' decision making for hypertrophic obstructive cardiomyopathy (HOCM). Seventy-three consecutive patients (41 females; mean age, 53.7 ± 13.6 years) with HOCM who underwent TTM between January 2019 and October 2022 were enrolled and divided into 3 groups according to MV surgical strategy. Clinical outcomes were analyzed and compared among the groups. None of the patients experienced postoperative residual left ventricular outflow tract obstruction. Percentages of patients with mitral regurgitation (MR) grade ≥3+ (57.5% vs 1.4%) and systolic anterior motion (95.9% vs 2.7%) were significantly decreased postoperatively (P < .001 for both). The preoperative anterior mitral leaflet length was longer in patients in the anterior mitral leaflet direct reattachment group (median, 2.9 cm [interquartile range (IQR), 2.7-3.3 cm] vs 2.7 [IQR, 2.4-2.9 cm]; P = .018), but the postoperative coaptation length was shorter (mean, 8.3 ± 2.1 mm vs 11.1 ± 3.8 mm; P = .038). After a median echocardiography follow-up of 11.8 months, the left ventricular outflow tract gradient (LVOTG) and mitral regurgitation grades remained significantly improved in all 3 groups (P < .05 for all). Total TTM in selected patients is safe and effective, and all 3 MV management strategies can significantly reduce the LVOTG while improving MR. Mitral valvuloplasty is the preferred initial management strategy over valve replacement except in the scenario of irreparable intrinsic MV disease and valvuloplasty failure.

Reply to Surgical Strategy of Mitral Valve Repair in Transmitral Septal Myectomy for Hypertrophic Obstructive Cardiomyopathy We read with great interest the recent article by El-Sayed Ahmad et al[1] who reported the excellent results of transmitral myectomy for symptomatic hypertrophic obstructive cardiomyopathy (HOCM). The transmitral approach not only provides a good view of the septum and its relationship with subvalvular apparatus but also reduces the manipulation difficulty in complex cases, such as mid-ventricular obstruction. However, this approach has a controversy about how to manage the mitral valve. In HOCM combined with intrinsic mitral valve diseases, the transmitral approach would be beneficial for concomitant mitral valve repair or replacement. In the above study, all mitral valvuloplasty patients received patch extension with the anterior mitral leaflet (AML). The length of the AML and correspondingly the size of the AML after patch extension were not detailed in the article. In our opinion, we do not recommend patch extension for all HOCM patients, especially those who have elongated AML. A patch was aimed to move the coaptation point horizontally away from the septum, preventing systolic anterior motion (SAM). However, we observed that a prolonged AML or an oversized patch resulting in residual length of the AML beyond the coaptation point could create SAM on the contrary ([Fig. 1]). The severity of SAM increases with the length of the redundant leaflet. In such situation, directly reattached AML or Alfieri Stich is the alternative strategy. Besides, the authors elaborated that annuloplasty of mitral valve was performed in 11 patients, without any left ventricular outflow tract (LVOT) obstruction or more than moderate mitral regurgitation at last follow-up. In our experience, we supposed annuloplasty was necessary, because it has been one of the standard mitral valve repair procedures to restore annular shape. Furthermore, primitive transmitral septal myectomy, the Morrow procedure via robotic approach, also applied patch extension with annuloplasty. Then we found the efficacy of patch extension alone was satisfactory. We were more concerned the annuloplasty might restrict the motion of the posterior leaflet and displace residual leaflet into the ventricle, leaving a risk of dynamic LVOT obstruction postoperatively. Therefore, we performed annuloplasty unless mitral annular dilatation noted, which is rare in HOCM. Ahmed et al[2] reported that in HOCM with ruptured mitral chordae tendineae, mitral valve repair with or without posterior band annuloplasty showed no prominent difference in LVOT gradient. It leads to another key question: is there a difference between patch extension with and without annuloplasty in transmitral septal myectomy for HOCM? Received: 08 June 2022 Accepted: 18 July 2022 Article published online: 22 August 2022 © 2022. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Cardiogenic shock secondary to concomitant severe aortic stenosis (AS) and coronary artery disease (CAD) is a critical clinical condition requiring comprehensive management. A 75-year-old man presented with cardiogenic shock resulting from severe AS and CAD. Emergency surgery was performed. It involved initiation of extracorporeal circulatory support, followed by percutaneous coronary intervention (PCI) and, subsequently, transcatheter aortic valve replacement (TAVR) using a TaurusElite valve (Peijia Medical). This strategy resulted in marked hemodynamic improvement. This case highlights the efficacy and safety of concurrent PCI and TAVR as a lifesaving strategy for cardiogenic shock patients with concomitant severe CAD and AS. Emergency PCI with concurrent TAVR represents a viable lifesaving strategy for cardiogenic shock patients with coexisting severe CAD and AS. Prophylactic extracorporeal circulation initiation is critical in TAVR procedures for patients with cardiogenic shock to prevent circulatory collapse and maintain systemic perfusion.

Systemic inflammation plays a pivotal role in the pathogenesis and prognosis of cardiac surgery–associated acute kidney injury (CSA-AKI). The Systemic Inflammation Response Index (SIRI) has emerged as a novel biomarker reflecting immune inflammatory balance. This study aimed to explore the association between SIRI and in-hospital mortality among patients with CSA-AKI. Data of CSA-AKI patients were extracted from the MIMIC-IV 3.1 database. SIRI was calculated and divided into 3 tertiles. Restricted cubic spline (RCS) models were used to assess nonlinear associations between SIRI and mortality. Multivariate logistic regression models were constructed to evaluate the independent relationship between SIRI and outcomes after adjusting for potential confounders. A total of 5394 patients with CSA-AKI were included. Patients in the medium SIRI tertile (1.27–3.06) demonstrated the lowest mortality (1.3%) compared to the low (2.0%) and high (3.1%) tertiles. RCS analysis revealed a significant U-shaped association between SIRI levels and in-hospital mortality risk ( P for nonlinearity < .001). Below the inflection point (SIRI = 1.6899), mortality risk tended to decrease with increasing SIRI, while above this threshold, each 1-unit increase in SIRI was significantly associated with a 10% higher risk of in-hospital mortality (OR 1.10, 95% CI 1.03–1.16, P = .001) after adjustment. SIRI demonstrated a U-shaped association with mortality among patients with CSA-AKI, indicating that both immune suppression and excessive inflammation are detrimental. SIRI may serve as a simple, readily available biomarker to reflect immune homeostasis and assist in postoperative risk stratification. Further prospective studies are warranted to validate these findings.