Emergency surgical correction of severe mitral incompetence complicating acute myocardial infarction still remains a therapeutic challenge for various reasons including the poor hemodynamic condition of these patients preoperatively, the potentially limited amount of residual viable myocardium, and the technical difficulties associated with the surgical procedure. On the basis of a clinical experience that encompasses 25 patients who underwent emergency surgery for acute ischemic mitral incompetence, we address the main surgical issues that continue to be raised by this life-threatening clinical entity.

The first part of this paper deals with the general anatomy of the postero-septal area of the heart, with particular emphasis on the relationships between the mitral and tricuspid anuli and the right fibrous trigone, between the conducting system and the interatrial septum, and between the right atrium and the posterior superior process of the left ventricle. In the second part, we describe the operative procedure that has been developed for dividing right and left posteroseptal Kent bundles. The key to this technique is the opening of the right atrium along the tricuspid anulus down to the orifice of the coronary ostium; this offers an excellent exposure on the posterior aspect of the septal area, and allows dissection of the sulcus fat pad from the muscular portion of the interventricular septum and the adjacent posterior superior process of the left ventricle down to the level of the mitral anulus. This planned dissection increases the likelihood of interrupting the anomalous pathways without injury to the normal conducting system which remains encompassed within the interatrial septum and the right fibrous trigone.

Hypothermic potassium cardioplegia is now widely used for preserving the heart during surgical ischemic arrest. However, the increased intracellular Ca2+ concentration associated with the K+-induced membrane depolarization has been shown to trigger Ca2+-uptake mechanisms (1) with a subsequent breakdown of high-energy phosphates (HEPs). This study was thus undertaken to assess the influence of different electrolytes on HEP metabolism and mechanical recovery after a single period of cardioplegic arrest.

The operative indications in acute coronary insufficiency remain con­troversial. The long-term results of 191 patients after surgical treatment of acute coronary insufficiency are reported in this study operated on between 1970 and 1976 at the Clinic for Cardiovascular Surgery of the Broussais Hospital, Paris.