MitraClip as bridge to mitral valve replacement in the setting of ischemic cardiogenic shock and papillary muscle rupture.

MitraClip implantation has been reported in severe mitral regurgitation following ischemic papillary muscle rupture in surgically high-risk patients with cardiogenic shock. Here we present a case of a 68-year-old female patient who suffered an ischemic papillary muscle rupture resulting in severe mitral prolapse and had a MitraClip implanted. Three months later, due to progressive symptoms, she was taken to surgery and had an elective minimally invasive mitral valve replacement. Informed consent was given and ethics board approval was obtained.

Mortality rates of surgical techniques for correcting atrioventricular disjunction

Abstract We compared the mortality rates of two surgical techniques for correction of atrioventricular disjunction in 10 out of 720 patients who underwent mitral valve replacement from 2005 to 2012. In group I, the mitral annulus was fixed with bovine pericardial strips; in group II, a 'patch' of bovine pericardium was sutured and extended from the base of the lateral and medial papillary muscles, covered the posterior wall of the left ventricle, went through the posterior mitral annulus, and ended in the posterior wall of the left atrium adjacent to the mitral ring. The group II technique showed a lower mortality.

Mortality Rates of Surgical Techniques for Correcting Atrioventricular Disjunction.

We compared the mortality rates of two surgical techniques for correction of atrioventricular disjunction in 10 out of 720 patients who underwent mitral valve replacement from 2005 to 2012. In group I, the mitral annulus was fixed with bovine pericardial strips; in group II, a 'patch' of bovine pericardium was sutured and extended from the base of the lateral and medial papillary muscles, covered the posterior wall of the left ventricle, went through the posterior mitral annulus, and ended in the posterior wall of the left atrium adjacent to the mitral ring. The group II technique showed a lower mortality.

Traumatic tricuspid valve papillary muscle case with concomitant acquired patent foramen ovale and covert right atrial rupture. / Ruptura traumática de músculo papilar da valva tricúspide com forame oval patente adquirido e ruptura atrial direita oculta.

Cardiac trauma often occurs in motor vehicle accidents. A 50-year-old female driver was transported to our hospital with multiple trauma after a high-speed car accident. After admission to the intensive care unit, cardiac ultrasound examination revealed traumatic tricuspid valve papillary muscle rupture and patent foramen ovale, while Lancisi's sign was noted on physical examination. Surgical treatment was performed with valve annuloplasty and closure of the patent foramen ovale and a covert right atrial defect that was detected intraoperatively.

O traumatismo cardíaco é comum em acidentes com veículos automotores. Uma mulher com 50 anos de idade foi transportada para nosso hospital após sofrer múltiplos traumatismos em um acidente de automóvel quando dirigia em alta velocidade. Após admissão à unidade de terapia intensiva, uma ultrassonografia cardíaca revelou ruptura traumática de músculo papilar da valva tricúspide e forame oval patente, enquanto se observou, no exame físico, o sinal de Lancisi. Foi realizado tratamento cirúrgico com anuloplastia da valva e fechamento do forame oval patente; durante o ato cirúrgico, diagnosticou-se ruptura oculta do átrio direito.

Ruptura traumática de músculo papilar da valva tricúspide com forame oval patente adquirido e ruptura atrial direita oculta / Traumatic tricuspid valve papillary muscle case with concomitant acquired patent foramen ovale and covert right atrial rupture

RESUMO O traumatismo cardíaco é comum em acidentes com veículos automotores. Uma mulher com 50 anos de idade foi transportada para nosso hospital após sofrer múltiplos traumatismos em um acidente de automóvel quando dirigia em alta velocidade. Após admissão à unidade de terapia intensiva, uma ultrassonografia cardíaca revelou ruptura traumática de músculo papilar da valva tricúspide e forame oval patente, enquanto se observou, no exame físico, o sinal de Lancisi. Foi realizado tratamento cirúrgico com anuloplastia da valva e fechamento do forame oval patente; durante o ato cirúrgico, diagnosticou-se ruptura oculta do átrio direito.

ABSTRACT Cardiac trauma often occurs in motor vehicle accidents. A 50-year-old female driver was transported to our hospital with multiple trauma after a high-speed car accident. After admission to the intensive care unit, cardiac ultrasound examination revealed traumatic tricuspid valve papillary muscle rupture and patent foramen ovale, while Lancisi's sign was noted on physical examination. Surgical treatment was performed with valve annuloplasty and closure of the patent foramen ovale and a covert right atrial defect that was detected intraoperatively.

Anatomical Connections Between the Papillary Muscles and the Ventricular Myocardium: Correlation With QRS Variability of Ventricular Arrhythmias.

BACKGROUND: Papillary muscles (PM) ventricular arrhythmias (VAs) exhibit QRS variability, attributed to anisotropy. ECG inconsistencies such as late precordial transition (TZ) and discordant QRS axis may not be solely explained by anisotropic conduction. We sought to determine the presence of anatomic connections of the PM and correlate them with ECG inconsistencies and ablation results. METHODS: Patients with prior PM VAs catheter ablation (N=33/66 PMs) were prospectively evaluated with cardiac resonance for the presence of muscular connection (PMCs) away from the PM base. Specific ECG characteristics including early (consistent TZ) and late (inconsistent-ITZ) TZ or inconsistent (IQA) or consistent QA QRS axis were correlated with PMCs. RESULTS: Thirty-five PMs exhibited clinical VAs (N=29 posteromedial PM and N=6 anterolateral PM). PM VAs with ITZ and IQA were observed in 11 and 9 PMs, respectively. In total, 41 PMs (62%) exhibited 90 PMCs. Arrhythmogenic PMs (N=35) exhibited higher number of PMCs (72 versus 18; P=0.01). Patients with ITZ and IQA exhibited 100% prevalence of PMCs. Those with consistent TZ and consistent QA showed 40% and 26% prevalence of PMCs, respectively. ITZ and IQA predicted the presence of PMCs with 59% of 28% sensitivity; and 100% of 100% specificity, respectively. Type-specific PMCs were more prevalent in patients with ECG inconsistencies. Those PMs are exhibiting clinical recurrence after ablation presented higher prevalence of PMCs (91% versus 60%; P=0.04). CONCLUSIONS: PMCs are highly prevalent in patients with PM VAs. A direct correlation exists between PM VAs ECG inconsistencies and type-specific PMCs. Patients with ITZ or IQA exhibited PMC 100% prevalence. Recurrence was higher among patients with PMCs.

Correction of left ventricular outflow tract obstruction caused by anomalous papillary muscle and subaortic membrane

Abstract This paper presents a case study of a 30-year-old male patient with dyspnea on exertion had echocardiographic diagnosis of aortic subvalvar stenosis. Discrete mitral regurgitation and aortic valve dysplasia with mild to moderate insufficiency and hypertrophic cardiomyopathy were also noted. During surgery, a rare condition was identified: presence of papillary muscle anomaly associated with the subaortic membrane as a cause of obstruction of the left ventricular outflow tract. With the resection of these structures and a mitral valve annuloplasty, the patient evolved with a significant improvement of clinical condition and heart failure, with no residual mitral insufficiency.

Correction of Left Ventricular Outflow Tract Obstruction Caused by Anomalous Papillary Muscle and Subaortic Membrane.

This paper presents a case study of a 30-year-old male patient with dyspnea on exertion had echocardiographic diagnosis of aortic subvalvar stenosis. Discrete mitral regurgitation and aortic valve dysplasia with mild to moderate insufficiency and hypertrophic cardiomyopathy were also noted. During surgery, a rare condition was identified: presence of papillary muscle anomaly associated with the subaortic membrane as a cause of obstruction of the left ventricular outflow tract. With the resection of these structures and a mitral valve annuloplasty, the patient evolved with a significant improvement of clinical condition and heart failure, with no residual mitral insufficiency.

Results of Cryoenergy and Radiofrequency-Based Catheter Ablation for Treating Ventricular Arrhythmias Arising From the Papillary Muscles of the Left Ventricle, Guided by Intracardiac Echocardiography and Image Integration.

BACKGROUND: Catheter radiofrequency ablation of ventricular arrhythmias (VAs) arising from the left ventricle's papillary muscles has been associated with inconsistent results. The use of cryoenergy versus radiofrequency has not been compared yet. This study compares outcomes and complications of catheter ablation of VA from the papillary muscles of the left ventricle with either cryoenergy or radiofrequency. METHODS AND RESULTS: Twenty-one patients (40±12 years old; 47% males; median ejection fraction 59±7.3%) with drug refractory premature ventricular contractions or ventricular tachycardia underwent catheter cryoablation or radiofrequency ablation. VAs were localized using 3-dimensional mapping, multidetector computed tomography, and intracardiac echocardiography, with arrhythmia foci being mapped at either the anterolateral papillary muscle or posteromedial papillary muscles of the left ventricle. Focal ablation was performed using an 8-mm cryoablation catheter or a 4-mm open-irrigated radiofrequency catheter, via transmitral approach. Acute success rate was 100% for cryoenergy (n=12) and 78% for radiofrequency (n=9; P=0.08). Catheter stability was achieved in all patients (100%) treated with cryoenergy, and only in 2 (25%) patients treated with radiofrequency (P=0.001). Incidence of multiple VA morphologies was observed in 7 patients treated with radiofrequency (77.7%), whereas none was observed in those treated with cryoenergy (P=0.001). VA recurrence at 6 months follow-up was 0% for cryoablation and 44% for radiofrequency (P=0.03). CONCLUSIONS: Cryoablation was associated with higher success rates and lower recurrence rates than radiofrequency catheter ablation, better catheter stability, and lesser incidence of polymorphic arrhythmias.

Rotura de músculo papilar: una complicación mecánica del infartoagudo de miocardio / Papillary muscle rupture: a mechanical complication of acute myocardial infarction

La rotura de músculo papilar (RMP) es una complicación mecánica infrecuente (1-5 por ciento) del infarto agudo de miocardio (IAM). Se manifiesta en el contexto de un paciente infartado, como una insuficiencia mitral aguda, con descompensación hemodinámica grave y edema pulmonar agudo, con el consiguiente shock cardiogénico. PRESENTACIÓN DEL CASO: Paciente de género masculino, de 71 años de edad, sordomudo, sin antecedentes mórbidos cardiovasculares conocidos, que consultó por cuadro súbito de disnea. El examen físico de ingreso mostró palidez, sudoración y tiraje, con un soplo holosistólico IV/VI en el foco mitral. Electrocardiograma evidenció infarto con supra desnivel ST anteroseptoapical, con enzimas cardíacas compatibles. Radiografía de tórax mostró infiltrados pulmonares difusos compatibles con edema agudo pulmonar. Ecocardiograma informó insuficiencia mitral masiva, con prolapso del velo anterior asociada a posible RMP. Coronariografía evidenció lesiones significativas en arterias descendente anterior y coronaria derecha. Debido a la gravedad del cuadro clínico, se decidió tratamiento quirúrgico de urgencia con Reemplazo de Válvula Mitral y Cirugía de Revascularización Miocárdica. DISCUSIÓN: La RMP es la complicación mecánica más grave del IAM, llegando a presentar una mortalidad del 75 por ciento en las primeras 24 horas, razón por la cual es importante tener un alto índice de sospecha. El tratamiento de elección es quirúrgico, aunque tiene una alta mortalidad (50 por ciento), es mejor opción que el tratamiento médico, cuya mortalidad puede alcanzar cifras superiores al 90 por ciento...

Papillary muscle rupture is a rare mechanical complication (1-5 percent) of acute myocardial infarction and is a major cause of acute mitral regurgitation. It manifests itself in the context of an infarcted patient, as acute mitral regurgitation with severe hemodynamic decompensation and acute pulmonary edema, leading to cardiogenic shock. CASE REPORT: A71 years old man, deaf, without known cardiovascular history, who presented with sudden onset of dyspnea. Physical examination at admission showed pallor, sweating and circulation, highlighting the presence of a holosystolic murmur IV / VI. Electrocardiogram showed ST-elevation myocardial antero septoapical with cardiac enzymes compatible. Chest radiography showed diffuse pulmonary infiltrates consistent with acute pulmonary edema. Echocardiogram reported massive mitral regurgitation with anterior leaflet prolapse associated with possible rupture of papillary muscle. Coronary angiography showed severe lesions in left anterior descending artery, posterior, right coronary artery and first diagonal. Due to the severity of symptoms, emergency surgery was decided with Mitral Valve Replacement and Myocardial Revascularization Surgery. DISCUSSION: papillary muscle rupture is the most serious mechanical complication, presenting a 75 percent mortality in the first 24 hours, reason why it is important to have a high index of suspicion. The treatment of choice is surgery, although it has a high mortality (50 percent), is superiorto medical treatment, which has a mortality higher than90 percent...

A trileaflet "mitral valve" with three papillary muscles: brand new echocardiographic finding.

Congenital mitral valve malformations are rare, but are well known and described entities. Mitral valve malformations involve mitral valve apparatuses (leaflets and annulus) and subvalvar apparatuses (chordae and papillary muscle). Case reports of accessory mitral leaflets were already described, but were usually an appendix of the normal valve. We describe here a case report and present the images of a trileaflet mitral valve sustained by three papillary muscles in a young girl with subaortic stenosis.

[Surgery of post myocardial infarction papillary muscle rupture]. / Cirugía de la rotura de músculo papilar por infarto miocárdico.

BACKGROUND: Papillary muscle rupture is a serious complication of myocardial infarction whose only treatment is surgery. AIM: To analyze our most recent surgical experience with papillary muscle rupture. PATIENTS AND METHODS: The database of our Service was reviewed for the period 1995-2005, to identify patients with papillary muscle rupture. Then, the clinical records and operating protocols were analyzed. Survival and functional class of patients were assessed. RESULTS: Twelve patients (7 men), aged 52 to 89 years, had papillary muscle rupture. They represented 2.2% of all mitral procedures for mitral insufficiency and 8.8% of mitral surgeries for ischemic mitral regurgitation, during the study period. In eight cases myocardial infarction was inferior, in three lateral and in one, anterior. In 10 patients, a mitral replacement was carried-out and in two the mitral valve was repaired. In seven patients, myocardial revascularization was performed. Mean lapse between infarction and surgery was 13.5 days (1 to 85). Two patients died in the perioperative period. Follow-up ranged from 1.7 to 120.4 months. Four patients died during follow-up, 2 due to a cardiovascular cause. Thus, at the end of follow-up 6 patients were alive. All were in functional class I-II. CONCLUSIONS: Papillary muscle rupture is an uncommon complication of myocardial infarction, with considerable operative and long-term mortality. However, survivors have good quality of life.

Cirugía de la rotura de músculo papilar por infarto miocárdico / Surgery of post myocardial infarction papillary muscle rupture

Background: Papillary muscle rupture is a serious complication of myocardial infarction whose only treatment is surgery. Aim: To analyze our most recent surgical experíence with papillary muscle rupture. Patients and Methods: The datábase of our Service was reviewed for the period 1995-2005, to identify patients with papillary muscle rupture. Then, the clinical records and operating protocols were analyzed. Survival and functional class of patients were assessed. Results: Twelve patients (7 men), aged 52 to 89 years, had papillary muscle rupture. They represented 2.2 percent of all mitral procedures for mitral insufficiency and 8.8% of mitral surgeries for ischemic mitral regurgitation, during the study períod. In eight cases myocardial infarction was inferior, in three lateral and in one, anterior. In 10 patients, a mitral replacement was carried-out and in two the mitral valve was repaired. In seven patients, myocardial revascularization was performed. Mean lapse between infarction and surgery was 13.5 days (1 to 85). Two patients died in the perioperative period. Follow-up ranged from 1.7 to 120.4 months. Four patients died during follow-up, 2 due to a cardiovascular cause. Thus, at the end of follow-up 6 patients were alive. All were in functional class III. Conclusions: Papillary muscle rupture is an uncommon complication of myocardial infarction, with considerable operative and ¡ong-term mortality. However, survivors have good quality of life.

Mitral valve replacement with crossed papillopexy and annular constriction in heart failure patients.

OBJECTIVE: To analyze the short-term and mid-term follow-ups of patients with heart failure and moderate to severe mitral valve insufficiency and who have undergone mitral valve replacement with crossed papillopexy and annular constriction. METHODS: Thirteen patients in NYHA functional class III or IV, with a mean age of 54.1 years and with idiopathic etiology, underwent mitral valve replacement with ring constriction and crossed papillopexy. Echocardiograph parameters, functional class and survival actuarial curve were analyzed. RESULTS: There were no deaths during surgery or in the postoperative period. The mean left ventricular diastolic diameter was reduced from 71 +/- 8.6 mm to 65.3 +/- 8.6 mm (p=0.049) and the mean left ventricular systolic diameter was reduced from .1 +/- 8.5 mm to 50.4 +/- 11.1 mm (p=0.002). The atrial diameters varied from 49.4 +/- 6.4 mm to 44 +/- 5.9 mm (p=0.017); the percentage of the left ventricular shortening was 17 +/- 4 % to 24 +/- 8.3% (p=0.014); the ejection fraction varied statistically and significantly from 34 +/- 9% to 45 +/- 14% (p=0.008). Eleven (84.6%) patients were in FC I and II. At 1, 6 and 12 months after follow-up surgery, the survival rate was 100%, 82.6%, 71.6%, respectively. This rate was maintained at 7.6% for more than 36 months. CONCLUSION: The results obtained from patients with heart failure and moderate to severe mitral valve insufficiency and who underwent mitral valve replacement with crossed papillopexy and annular constriction presented evidence of improved heart remodeling and significant improvement in left ventricular performance.

Crossed papillopexy with graft in mitral valve replacement: case report.

The aim of this study is to present the crossed papillopexy technique using bovine pericardial graft in mitral replacement caused by intense valvar and subvalvar fibrosis and calcification. This technique allows the functional preservation of the mitral subvalvar apparatus and was successfully applied, by the first time as far as we known, in a patient with calcified rheumatic mitral stenosis, who underwent mitral valve replacement surgery. The patient had an uneventful recovery and was discharged home on postoperative day 6. Echocardiography controls showed normal left ventricular function without any interference on the mitral prosthesis dynamics.

[Massive tricuspid valve insufficiency after blunt chest trauma: report of one case]. / Rotura de válvula tricúspide con insuficiencia masiva secundaria a traumatismo torácico cerrado: Caso clínico.

Cardiac valve lesions after a blunt chest trauma are rare and less than 1% of cardiac lesions because of chest trauma affect the tricuspid valve. We report a 70 year-old female that suffered a severe chest trauma in a car accident. During the repair of the multiple skeletal lesions, the patient had a severe hemodynamic decompensation. A myocardial trauma with pericardial effusion and massive tricuspid insufficiency, due to anterior leaflet prolapse, was diagnosed on echocardiography. After discharge the patient remained in functional class II, with hepatomegaly, jugular ingurgitation and lower limb edema. A control echocardiogram, performed six months after the accident, showed dilatation of right heart chambers and massive tricuspid insufficiency. The patient was operated, and a tricuspid valve repair was performed suturing the ruptured papillary muscle to the ventricular wall and performing a tricuspid annuloplasty with a prosthetic ring. After 15 months of follow up, the patient remains asymptomatic.

Substituição valvar mitral com papilopexia cruzada e constrição anular em pacientes com insuficiência cardíaca / Mitral valve replacement with crossed papillopexy and annular constriction in heart failure patients

OBJETIVO: Analisar os resultados em curto e médio prazo de pacientes portadores de insuficiência cardíaca e insuficiência mitral moderada/grave submetidos a substituição valvar mitral com a técnica da papilopexia cruzada e constrição anular. MÉTODOS: Treze pacientes em classe funcional III ou IV (NYHA), idade média de 54,1 anos, etiologia idiopática, foram submetidos a substituição valvar mitral com constrição do anel e papilopexia cruzada. Foram analisados os parâmetros ecocardiográficos, classe funcional e curva atuarial de sobrevivência. RESULTADOS: Não houve mortes no período trans e pósoperatório imediato. A média dos diâmetros diastólicos e sistólicos ventricular esquerdo reduziu de 71 ± 8,6 mm para 65,3 ± 8,6 mm (p=0,049) e de 59,1 ± 8,5 mm para 50,4 ± 11,1 mm (p=0,002), respectivamente. Os diâmetros atriais variaram de 49,4 ± 6,4 mm para 44 ± 5,9 mm (p=0,017); o percentual de encurtamento sistólico do ventrículo esquerdo foi de 17 ± 4 por cento para 24 ± 8,3% (p=0,014), a fração de ejeção variou de 34 ± 9% para 45 ± 14% (p=0,008), todos estatisticamente significativos. Onze (84,6%) pacientes se encontram em classe funcional I e II. A sobrevivência foi de 100%, 82,6%, 71,6%, respectivamente para 1, 6 e 12 meses após a cirurgia de seguimento, mantendo-se 71,6% em período superior a 36 meses. CONCLUSÃO: Os resultados obtidos, em pacientes com insuficiência cardíaca e insuficiência mitral moderada/grave submetidos a substituição valvar mitral com papilopexia cruzada e constrição anular, apresentaram evidências de remodelamento cardíaco favorável e significativa recuperação funcional ventricular esquerda.

OBJECTIVE: To analyze the short-term and mid-term follow-ups of patients with heart failure and moderate to severe mitral valve insufficiency and who have undergone mitral valve replacement with crossed papillopexy and annular constriction. METHODS: Thirteen patients in NYHA functional class III or IV, with a mean age of 54.1 years and with idiopathic etiology, underwent mitral valve replacement with ring constriction and crossed papillopexy. Echocardiograph parameters, functional class and survival actuarial curve were analyzed. RESULTS: There were no deaths during surgery or in the postoperative period. The mean left ventricular diastolic diameter was reduced from 71 ± 8.6 mm to 65.3 ± 8.6 mm (p=0.049) and the mean left ventricular systolic diameter was reduced from .1 ± 8.5 mm to 50.4 ± 11.1 mm (p=0.002). The atrial diameters varied from 49.4 ± 6.4 mm to 44 ± 5.9 mm (p=0.017); the percentage of the left ventricular shortening was 17 ± 4% to 24 ± 8.3%(p=0.014); the ejection fraction varied statistically and significantly from 34 ± 9% to 45 ± 14% (p=0.008). Eleven (84.6%) patients were in FC I and II. At 1, 6 and 12 months after follow-up surgery, the survival rate was 100%, 82.6%, 71.6%, respectively. This rate was maintained at 7.6% for more than 36 months. CONCLUSION: The results obtained from patients with heart failure and moderate to severe mitral valve insufficiency and who underwent mitral valve replacement with crossed papillopexy and annular constriction presented evidence of improved heart remodeling and significant improvement in left ventricular performance.

Papilopexia cruzada com enxerto na substituição da valva mitral: relato de caso / Crossed papillopexy with graft in mitral valve replacement: case report

O objetivo deste artigo é mostrar a técnica da papilopexia cruzada com o uso de enxerto de pericárdio bovino na substituição mitral por fibrose e calcificação intensa valvar e subvalvar. Esta técnica permite a preservação funcional do aparelho subvalvar mitral e foi aplicada pela primeira vez, na literatura alcançada, em paciente portador de estenose mitral reumática calcificada, submetido a troca valvar mitral. O paciente evoluiu sem complicações, com alta hospitalar em seis dias. Controles ecocardiográficos mostraram função ventricular esquerda preservada sem interferência na dinâmica da prótese mitral.

The aim of this study is to present the crossed papillopexy technique using bovine pericardial graft in mitral replacement caused by intense valvar and subvalvar fibrosis and calcification. This technique allows the functional preservation of the mitral subvalvar apparatus and was successfully applied, by the first time as far as we known, in a patient with calcified rheumatic mitral stenosis, who underwent mitral valve replacement surgery. The patient had an uneventful recovery and was discharged home on postoperative day 6. Echocardiography controls showed normal left ventricular function without any interference on the mitral prosthesis dynamics.

Rotura de válvula tricúspide con insuficiencia masiva secundaria a traumatismo torácico cerrado: caso clínico / Massive tricuspid valve insufficiency after blunt chest trauma: report of one case

Cardiac valve lesions after a blunt chest trauma are rare and less than 1 percent of cardiac lesions because of chest trauma affect the tricuspid valve. We report a 70 year-old female that suffered a severe chest trauma in a car accident. Duríng the repair of the múltiple skeletal lesions, the patient had a severe hemodynamic decompensation. A myocardial trauma with pericardial effusion and massive tricuspid insufficiency, due to anterior leaflet prolapse, was diagnosed on echocardiography. After discharge the patient remained in functional class II, with hepatomegaly, jugular ingurgitation and lower limb edema. A control echocardiogram, perfomed six months after the accident, showed dilatation of right heart chambers and massive tricuspid insufficiency. The patient was operated, and a tricuspid valve repair was performed suturing the ruptured papillary muscle to the ventricular wall and performing a triscuspid annuloplasty with a prosthetic ring. After 15 months of follow up, the patient remains asymptomatic.