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Anomalies of the mitral valve apparatus in hypertrophic cardiomyopathy are an important cause of systolic anterior motion. Patients with significant residual obstruction due to systolic anterior motion after myectomy and anterior mitral leaflet plication may end up having mitral valve replacement. We describe the case of a 52-year-old man who underwent posterior mitral leaflet plication to correct residual systolic anterior motion after anterior mitral leaflet plication.

Green construction projects are initiated in complex and dynamic environments resulting in circumstances of high level of uncertainty with respect to cost and duration. This is attributed to the fact that construction of green buildings requires stricter norms in terms of environmental conservation, carbon emission, construction footprint, pollution, etc. which can cause an addition to ‘cost and duration’. This paper describes a systematic way to identify and quantify uncertainty in the green construction process based on the LEED rating system adopted by the Indian Green Building Council (IGBC). The system incorporates knowledge and experience acquired from many experts, projectspecific information, decision analysis techniques, and a simulation model to predict risks for different green ratings in the construction schedule at the conception stage of a project. The model provides sensitivity analysis for different outcomes wherein the effect of critical and significant risk factors can be evaluated. The study focuses on lessons learned from past projects and describes a risk assessment process involving typical inputs and expected outputs.

Trans-aortic septal myectomy is the gold standard for septal reduction therapy. This technique has low peri-procedural mortality and excellent long-term survival. Moreover, it relieves the heart failure symptoms and improves the quality of life. Secondary chordal cutting along with septal myectomy has shown to improve the outcome but can potentially cause deterioration of left ventricular function. In patients with relatively thin inter-ventricular septum, abnormalities of mitral valve apparatus may be the main reason for systolic anterior motion and left ventricular outflow tract obstruction. These patients may require additional procedures on the mitral valve to shift the coaptation plane away from outflow tract. Mitral valve replacement should be performed only in patients with intrinsic mitral valve abnormalities that are not suitable for repair and its routine use along with limited septal myectomy should be discouraged. Minimal access surgery although attractive in concept requires more robust data before universal application.