Contraindications to percutaneous tracheostomy due to anomaly of aortic-arch branches origin and running: relative or absolute

initial repair, we obtained a competent valve and also severe outflow obstruction due to systolic anterior motion (SAM) that we unsuccessfully tried to address with a conventional A2–P2 Alfieri repair. SAM persisted; hence, we removed the midline A2–P2 Alfieri stitch and placed a new edge-to-edge stitch now between the A1–P1 segments as shown in the picture. Actually, in the picture, we can see the most anterolateral of the two sets of GoreTex neochordae (in the A2 scallop close to A1) used to correct the prolapse of A2. We can also see the green pledgeted Ti-Cron sutures used for the posterior annulus plication after the quadrangular resection that mark the midline of the mitral valve. With these two references, it is clear that the newly placed Alfieri stitch was moved, as explained in the text, towards the anterolateral commissure and now holds the A1–P1 scallops together. We hope this helps clarify this technique that allowed us to preserve the mitral valve in this case of complex repair for myxomatous bileaflet prolapse.