Pseudoaneurisma ventricular esquerdo ­ uma complicação do infarto agudo do miocárdio / Left ventricular pseudoaneurysm - a complication of acute myocardial infarction

INTRODUÇÃO: O pseudoaneurisma ventricular é resultado da ruptura completa de todas as camadas do tecido cardíaco a qual é contida por estrita camada de pericárdio ou tecido fibroso. Entre suas principais etiologias, destacam-se trauma, endocardite infecciosa e a mais frequente, infarto agudo do miocárdio. MÉTODOS: Trata-se de um relato de caso acerca da apresentação de pseudoaneurisma ventricular esquerdo após síndrome coronariana aguda. O presente relato foi aprovado pelo comitê de ética local, com consentimento informado assinado. RESULTADOS: Reportamos um caso de paciente de 69 anos, admitido por quadro de dispneia importante. Ecocardiograma transtorácico solicitado evidenciou pseudoaneurisma em região apical, medindo 96x116mm associado a derrame pericárdico difuso de grau moderado, com lâmina de 16mm com sinais incipientes de repercussão hemodinâmica. Paciente foi encaminhado a sala cirúrgica. Devido à presença de derrame pericárdico, a equipe cirúrgica optou por realizar a esternotomia mediana em assistência circulatória, no entanto, não se evidenciou tal achado no intraoperatório. Procedeu-se, desta forma, correção cirúrgica do pseudoaneurisma com utilização de pericárdio bovino e ancoragem do orifício ventricular utilizando polipropileno 3-0. Paciente foi encaminhado para unidade de terapia intensiva com alta hospitalar 17°DPO. CONCLUSÃO: O presente relato ressalta a importância de considerar o pseudoaneurisma como complicação do infarto do miocárdio, referido como dilema por alguns autores. A apresentação e os exames complementares são inespecíficos e exigem suspeição pela equipe assistente. As complicações decorrentes demandam manejo cirúrgico adequado a fim de evita-las.

Left Ventricular Reconstruction Surgery in Candidates for Heart Transplantation.

OBJECTIVE: To report our center's experience in the surgical treatment of ventricular reconstruction, an effective and efficient technique that allows patients with end-stage heart failure of ischemic etiology to have clinical improvement and increased survival. METHODS: Observational, clinical-surgical, sequential, retrospective study. Patients with ischemic cardiomyopathy and left ventricular aneurysm were attended at the Heart Failure, Ventricular Dysfunction and Cardiac Transplant outpatient clinic of the Dante Pazzanese Cardiology Institute, from January 2010 to December 2016. Data from 34 patients were collected, including systemic arterial hypertension, ejection fraction, New York Heart Association (NYHA) functional classification (FC), European System for Cardiac Operative Risk Evaluation (EuroSCORE) II value, Society of Thoracic Surgeons (STS) score, ventricular reconstruction technique, and survival. RESULTS: Overall mortality of 14.7%, with hospital admission being 8.82% and late death being 5.88%. Total survival rate at five years of 85.3%. In the preoperative phase, NYHA FC was Class I in five patients, II in 18, III in eight, and IV in three vs. NYHA FC Class I in 17 patients, II in eight, III in six, and IV in three, in the postoperative period. EuroSCORE II mean value was 6.29, P≤0.01; hazard ratio (HR) 1.16 (95% confidence interval [CI] 1.02-1.31). STS mortality/morbidity score mean value was 18.14, P≤0.004; HR 1.19 (95% CI 1.05-1.33). Surgical techniques showed no difference in survival among Dor 81% vs. Jatene 91.7%. CONCLUSION: Surgical treatment of left ventricular reconstruction in candidates for heart transplantation is effective, efficient, and safe, providing adequate survival.

Left ventricular reconstruction surgery in candidates for heart transplantation

OBJECTIVE: To report our center's experience in the surgical treatment of ventricular reconstruction, an effective and efficient technique that allows patients with end-stage heart failure of ischemic etiology to have clinical improvement and increased survival. METHODS: Observational, clinical-surgical, sequential, retrospective study. Patients with ischemic cardiomyopathy and left ventricular aneurysm were attended at the Heart Failure, Ventricular Dysfunction and Cardiac Transplant outpatient clinic of the Dante Pazzanese Cardiology Institute, from January 2010 to December 2016. Data from 34 patients were collected, including systemic arterial hypertension, ejection fraction, New York Heart Association (NYHA) functional classification (FC), European System for Cardiac Operative Risk Evaluation (EuroSCORE) II value, Society of Thoracic Surgeons (STS) score, ventricular reconstruction technique, and survival. RESULTS: Overall mortality of 14.7%, with hospital admission being 8.82% and late death being 5.88%. Total survival rate at five years of 85.3%. In the preoperative phase, NYHA FC was Class I in five patients, II in 18, III in eight, and IV in three vs. NYHA FC Class I in 17 patients, II in eight, III in six, and IV in three, in the postoperative period. EuroSCORE II mean value was 6.29, P

Cirurgia de reconstrução do ventrículo esquerdo em pacientes candidatos à transplante de coração / Left ventricular reconstruction surgery in heart transplant candidates

INTRODUÇÃO: O tratamento cirúrgico de reconstrução ventricular em pacientes candidatos à transplante de coração, é considerada como uma das técnicas, permitindo aos pacientes portadores de insuficiência cardíaca terminal de etiologia isquêmica ter melhora clínica e aumento da sobrevivência. Reportamos assim a experiência do nosso centro. OBJETIVO: Descrever o resultado da cirurgia de reconstrução do ventrículo esquerdo em pacientes candidatos à transplante de coração. MÉTODOS: Estudo analítico, clínico-cirúrgico, sequencial, retrospectivo. Pacientes portadores de miocardiopatia isquêmica com aneurisma do ventrículo esquerdo, acompanhados no ambulatório de insuficiência cardíaca, disfunção ventricular e transplante cardíaco do Instituto Dante Pazzanese de Cardiologia desde Janeiro de 2010 até Dezembro de 2016. Dados de 34 pacientes foram coletados entre eles HAS, Fração de Ejeção (F), Classe Funcional da NYHA (CF), EuroSCORE II, STS Score, técnica de reconstrução ventricular e sobrevivência. RESULTADOS: Mortalidade geral de 14,7 %, sendo a hospitalar de 8,82 % e a tardia de 5,88 %. Sobrevivência total aos 5 anos de 85,3%. Na CF Pré I: 5, II: 18, III: 8, IV: 3 vs. CF Pós I: 17, II: 8, III: 6, IV: 3. EuroSCORE II valor médio de 6,29 P≤ 0,01,HR 1,16 (IC 95 % 1,02 - 1,31) e STS escore mortalidade/morbidade valor médio de 18,14, P≤ 0,004; HR 1,19( IC 95% 1,05 - 1,33). Técnicas cirúrgicas não mostraram diferencia de sobrevida entre elas Dor 81% vs. Jatene 91.7 %. CONCLUSÃO: Tratamento cirúrgico de reconstrução do ventrículo esquerdo em pacientes candidatos a transplante de coração é efetivo, eficaz e seguro em relação proporcionando sobrevivência e mortalidade adequadas. (AU)

Long-term Mortality Predictors in Patients with Small Aortic Annulus Undergoing Aortic Valve Replacement with a 19- or 21-mm Bioprosthesis.

Introduction: Replacement of the aortic valve in patients with a small aortic annulus is associated with increased morbidity and mortality. A prosthesis-patient mismatch is one of the main problems associated with failed valves in this patient population. Objective: To evaluate the long-term mortality predictors in patients with a small aortic annulus undergoing aortic valve replacement with a bioprosthesis. Methods: In this retrospective observational study, a total of 101 patients undergoing aortic valve replacement from January 2000 to December 2010 were studied. There were 81 (80.19%) women with a mean age of 52.81±18.4 years. Severe aortic stenosis was the main indication for surgery in 54 (53.4%) patients. Posterior annulus enlargement was performed in 16 (15.8%) patients. Overall, 54 (53.41%) patients underwent concomitant surgery: 28 (27.5%) underwent mitral valve replacement, and 13 (12.7%) underwent coronary artery bypass graft surgery. Results: Mean valve index was 0.82±0.08 cm(2)/m(2). Overall, 17 (16.83%) patients had a valve index lower than 0.75 cm(2)/m(2), without statistical significance for mortality (P=0.12). The overall 10-year survival rate was 83.17%. The rate for patients who underwent isolated aortic valve replacement was 91.3% and 73.1% (P=0.02) for patients who underwent concomitant surgery. In the univariate analysis, the main predictors of mortality were preoperative ejection fraction (P=0.02; HR 0.01) and EuroSCORE II results (P=0.00000042; HR 1.13). In the multivariate analysis, the main predictors of mortality were age (P=0.01, HR 1.04) and concomitant surgery (P=0.01, HR 5.04). Those relationships were statistically significant. Conclusion: A valve index of < 0.75 cm(2)/m(2) did not affect 10-year survival. However, concomitant surgery and age significantly affected mortality.

Long-term mortality predictors in patients with small aortic annulus undergoing aortic valve replacement with a 19- or 21-mm bioprosthesis

Abstract Introduction: Replacement of the aortic valve in patients with a small aortic annulus is associated with increased morbidity and mortality. A prosthesis-patient mismatch is one of the main problems associated with failed valves in this patient population. Objective: To evaluate the long-term mortality predictors in patients with a small aortic annulus undergoing aortic valve replacement with a bioprosthesis. Methods: In this retrospective observational study, a total of 101 patients undergoing aortic valve replacement from January 2000 to December 2010 were studied. There were 81 (80.19%) women with a mean age of 52.81±18.4 years. Severe aortic stenosis was the main indication for surgery in 54 (53.4%) patients. Posterior annulus enlargement was performed in 16 (15.8%) patients. Overall, 54 (53.41%) patients underwent concomitant surgery: 28 (27.5%) underwent mitral valve replacement, and 13 (12.7%) underwent coronary artery bypass graft surgery. Results: Mean valve index was 0.82±0.08 cm2/m2. Overall, 17 (16.83%) patients had a valve index lower than 0.75 cm2/m2, without statistical significance for mortality (P=0.12). The overall 10-year survival rate was 83.17%. The rate for patients who underwent isolated aortic valve replacement was 91.3% and 73.1% (P=0.02) for patients who underwent concomitant surgery. In the univariate analysis, the main predictors of mortality were preoperative ejection fraction (P=0.02; HR 0.01) and EuroSCORE II results (P=0.00000042; HR 1.13). In the multivariate analysis, the main predictors of mortality were age (P=0.01, HR 1.04) and concomitant surgery (P=0.01, HR 5.04). Those relationships were statistically significant. Conclusion: A valve index of < 0.75 cm2/m2 did not affect 10-year survival. However, concomitant surgery and age significantly affected mortality.

Reasons for refusing a donor heart for transplantation in Brazil.

BACKGROUND: Major advances have been made in heart transplantation, but there is a discrepancy between the number of patients potentially treatable by transplantation and the limited number of viable grafts. The aim of this study was to evaluate the reasons for refusal of donor hearts. METHODS: This was a retrospective analysis of donor data from an organ procurement organization in the state of São Paulo (Brazil) between 2010 and 2012. Fisher's exact test, Student's t-test, and the Mann-Whitney U-test were used in the statistical analysis. RESULTS: Only 26 (7.9%) of 328 potential heart donors actually became donors. Most donors were men (18/26, 69.2%), Caucasians (14/26, 53.8%), and had a mean age of 23.5 yr. There were significant associations of use of donor hearts with the variables: brain death after trauma (p = 0.002), history of hypertension (p = 0.001), electrocardiographic changes (p = 0.007), and age (p = 0.001). Older age (n = 101, 33.4%) was the main reason for refusal of donor hearts, followed by poor medical history (n = 44, 14.6%), cardiac arrest of the donor during donor care (n = 25, 8.3%), use of vasopressor drugs (n = 23, 7.6%), and hemodynamic instability (n = 20, 6.6%). CONCLUSIONS: Age, poor medical history, cardiac arrest, use of vasopressors, and hemodynamic instability were the most prevalent reasons for refusal of donor hearts. Echocardiogram evaluation is a potential intervention to improve heart transplantation conversion in Brazil.

Reasons for refusing a donor heart for transplantation in Brazil

BACKGROUND:Major advances have been made in heart transplantation, but there is a discrepancy between the number of patients potentially treatable by transplantation and the limited number of viable grafts. The aim of this study was to evaluate the reasons for refusal of donor hearts. METHODS: This was a retrospective analysis of donor data from an organ procurement organization in the state of São Paulo (Brazil) between 2010 and 2012. Fisher's exact test, Student's t-test, and the Mann-Whitney U-test were used in the statistical analysis. RESULTS: Only 26 (7.9%) of 328 potential heart donors actually became donors. Most donors were men (18/26, 69.2%), Caucasians (14/26, 53.8%), and had a mean age of 23.5 yr. There were significant associations of use of donor hearts with the variables: brain death after trauma (p = 0.002), history of hypertension (p = 0.001), electrocardiographic changes (p = 0.007), and age (p = 0.001). Older age (n = 101, 33.4%) was the main reason for refusal of donor hearts, followed by poor medical history (n = 44, 14.6%), cardiac arrest of the donor during donor care (n = 25, 8.3%), use of vasopressor drugs (n = 23, 7.6%), and hemodynamic instability (n = 20, 6.6%)...

Comparative analysis of family consent to tissue donation according to two different donation form structures.

OBJECTIVE: To define donors' profile of an Organ and Tissue Procurement Center and compare the family consent for tissue donation before and after modification of the Donation Term. METHODS: A descriptive, documentary and quantitative study performed in an Organ and Tissue Procurement Center, analyzed 111 feasible donors' charts in the period from March 13 to September 13, 2010 (1st period), and from September 14, 2010 to March 14, 2011 (2nd period), based on the modification date. RESULTS: The mean age of donors was 45.2 years, being 52.3% female. The causes of death included cerebral vascular accident (stroke) (64%), head trauma (27%), anoxic encephalopathy (2.7%), firearm injuries (2.7%) and others (3.6%). The notifications were predominantly of spontaneous origin (91%). Comparing the periods before and after the modification of the Donation Term, the donation consent for cornea increased by 17.2% and the consent for skin, bones, tendons and muscles had a discreet increase by 3.1%, 9.9% and 0.4%, respectively. On the other hand, there was decrease in consent for blood vessel (0.8%) and heart valves (4.1%) between the two periods. CONCLUSION: There was increase in family consent for donation of most tissues, but it was statistically significant only for cornea donation.

Comparative analysis of family consent to tissue donation according to two different donation form structures / Análise comparativa do consentimento familiar para doação de tecidos em função da mudança estrutural do termo de doação

Objective To define donors’ profile of an Organ and Tissue Procurement Center and compare the family consent for tissue donation before and after modification of the Donation Term. Methods A descriptive, documentary and quantitative study performed in an Organ and Tissue Procurement Center, analyzed 111 feasible donors’ charts in the period from March 13 to September 13, 2010 (1st period), and from September 14, 2010 to March 14, 2011 (2nd period), based on the modification date. Results The mean age of donors was 45.2 years, being 52.3% female. The causes of death included cerebral vascular accident (stroke) (64%), head trauma (27%), anoxic encephalopathy (2.7%), firearm injuries (2.7%) and others (3.6%). The notifications were predominantly of spontaneous origin (91%). Comparing the periods before and after the modification of the Donation Term, the donation consent for cornea increased by 17.2% and the consent for skin, bones, tendons and muscles had a discreet increase by 3.1%, 9.9% and 0.4%, respectively. On the other hand, there was decrease in consent for blood vessel (0.8%) and heart valves (4.1%) between the two periods. Conclusion There was increase in family consent for donation of most tissues, but it was statistically significant only for cornea donation. .

Objetivo Traçar o perfil dos doadores viabilizados por um Serviço de Procura de Órgãos e Tecidos e comparar o consentimento familiar para doação de tecidos antes e após esta modificação do Termo de Doação. Método Estudo descritivo, documental, quantitativo, realizado em um Serviço de Procura de Órgãos e Tecidos, analisou 111 prontuários de doadores viabilizados nos períodos de 13 de março a 13 de setembro de 2010 (1o Período) e de 14 de Setembro de 2010 a 14 de Março de 2011 (2o período), selecionados com base na data desta modificação. Resultado Foi encontrada média de idade de 45,2 anos entre os doadores, sendo 52,3% do sexo feminino. As causas de morte incluem acidente vascular encefálico (64%), traumatismos cranioencefálicos (27%), encefalopatias anóxicas (2,7%), ferimentos por arma de fogo (2,7%) e outras (3,6%). As notificações foram predominantemente de origem espontânea (91%). Comparando os períodos antes e após a modificação do Termo de Doação, o consentimento para doação de córneas apresentou aumento de 17,2% e para doação de pele, ossos, tendões e músculos, discreto aumento de 3,1%, 9,9% e 0,4% respectivamente. Por sua vez, apresentou discreta diminuição o consentimento de vasos sanguíneos, de 0,8%, e valvas cardíacas de 4,1%, entre os períodos. Conclusão Obteve-se um aumento do consentimento familiar para a doação da maioria dos tecidos, porém com significância estatística apenas para doação de córneas. .

Myocardial protection with prophylactic oral metoprolol during coronary artery bypass grafting surgery: evaluation by troponin I / Proteção cardíaca com uso profilático de betabloqueador oral em cirurgia de revascularização miocárdica: avaliação pela troponina I

INTRODUCTION: Biochemical markers of myocardial injury are frequently altered after cardiac surgery. So far there is no evidence whether oral beta-blockers may reduce myocardial injury after coronary artery bypass grafting. OBJECTIVE: To determine if oral administration of prophylactic metoprolol reduces the release of cardiac troponin I in isolated coronary artery bypass grafting, not complicated by new Q waves. METHODS: A prospective randomized study, including 68 patients, divided in 2 groups: Group A (n=33, control) and B (n=35, beta-blockers). In group B, metoprolol tartrate was administered 200 mg/day. The myocardial injury was assessed by troponin I with 1 hour and 12 hours after coronary artery bypass grafting. RESULTS: No significant difference between groups regarding pre-surgical, surgical, complication in intensive care (15% versus 14%, P=0.92) and the total number of hospital events (21% versus 14%, P=0.45) was observed. The median value of troponin I with 12 hours in the study population was 3.3 ng/ml and was lower in group B than in group A (2.5 ng/ml versus 3.7 ng/ml, P<0,05). In the multivariate analysis, the variables that have shown to be independent predictors of troponin I release after 12 hours were: no beta-blockers administration and number of vessels treated. CONCLUSION: The results of this study in uncomplicated coronary artery bypass grafting, comparing the postoperative release of troponin I at 12 hours between the control group and who used oral prophylactic metoprolol for at least 72 hours, allow to conclude that there was less myocardial injury in the betablocker group, giving some degree of myocardial protection.

INTRODUÇÃO: Os marcadores bioquímicos de lesão miocárdica estão frequentemente alterados após cirurgia cardíaca. Até o momento não existem evidências de que o betabloqueador oral possa reduzir a lesão miocárdica após cirurgia de revascularização miocárdica. OBJETIVO: Determinar se a administração oral profilática de metoprolol reduz a liberação de troponina cardíaca I na cirurgia de revascularização miocárdica isolada não complicada por novas ondas Q. MÉTODOS: Estudo prospectivo, randomizado, incluindo 68 pacientes divididos em 2 grupos: Grupo A (n=33, controle) e B (n=35, betabloqueador). No grupo B, o tartarato de metoprolol foi administrado na dose de 200 mg/dia. A lesão miocárdica foi avaliada pela troponina I com 1 hora e 12 horas após a cirurgia de revascularização miocárdica. RESULTADOS: Não foi observada diferença significativa entre os grupos quanto às variáveis pré-cirúrgicas, cirúrgicas, incidência de complicações na terapia intensiva (15% versus 14%; P=0,92) e o número total de eventos hospitalares (21% versus 14%; P=0,45). O valor da mediana da troponina I com 12 horas na população estudada foi de 3,3 ng/ml e foi menor no grupo B do que no grupo A (2,5 ng/ml versus 3,7 ng/ml; P<0,05). Na análise multivariada, as variáveis que demonstraram serem preditoras independentes da liberação de troponina cardíaca I com 12 horas foram: não uso de betabloqueadores e número de vasos tratados. CONCLUSÃO: Os resultados desta investigação na cirurgia de revascularização miocárdica isolada, não complicada, comparando a liberação pós-operatória de troponina cardíaca I com 12 horas entre os grupos controle e o que usou metoprolol oral profilático por pelo menos 72 horas, permitem concluir que houve menor lesão miocárdica no grupo betabloqueador, conferindo algum grau de proteção miocárdica.

Myocardial protection with prophylactic oral metoprolol during coronary artery bypass grafting surgery: evaluation by troponin I.

INTRODUCTION: Biochemical markers of myocardial injury are frequently altered after cardiac surgery. So far there is no evidence whether oral beta-blockers may reduce myocardial injury after coronary artery bypass grafting. OBJECTIVE: To determine if oral administration of prophylactic metoprolol reduces the release of cardiac troponin I in isolated coronary artery bypass grafting, not complicated by new Q waves. METHODS: A prospective randomized study, including 68 patients, divided in 2 groups: Group A (n=33, control) and B (n=35, beta-blockers). In group B, metoprolol tartrate was administered 200 mg/day. The myocardial injury was assessed by troponin I with 1 hour and 12 hours after coronary artery bypass grafting. RESULTS: No significant difference between groups regarding pre-surgical, surgical, complication in intensive care (15% versus 14%, P=0.92) and the total number of hospital events (21% versus 14%, P=0.45) was observed. The median value of troponin I with 12 hours in the study population was 3.3 ng/ml and was lower in group B than in group A (2.5 ng/ml versus 3.7 ng/ml, P<0,05). In the multivariate analysis, the variables that have shown to be independent predictors of troponin I release after 12 hours were: no beta-blockers administration and number of vessels treated. CONCLUSION: The results of this study in uncomplicated coronary artery bypass grafting, comparing the postoperative release of troponin I at 12 hours between the control group and who used oral prophylactic metoprolol for at least 72 hours, allow to conclude that there was less myocardial injury in the betablocker group, giving some degree of myocardial protection.

Estudo anatômico do aparelho subvalvar da valva atrioventricular esquerda de corações humanos / Anatomic study of the subvalvar apparatus of the left atrioventricular valve in human hearts

Este estudo foi desenvolvido com a intenção de propor uma classificação anatômica atualizada para o aparelho subvalvar da valva atrioventricular esquerda de corações humanos. A classificação de Pomerantzeff foi desenvolvida utilizando nomes lógicos e correlatos, baseada na posição anatômica do coração e tem uma inovação: a identificação de uma nova estrutura anatômica, o músculo papilar basal. Cinquenta valvas atrioventriculares esuqredas de corações humanos normais foram examinadas através de incisões realizadas na parede do ventrículo esquerdo.

Estudo anatômico do aparelho subvalvar da valva atrioventricular esquerda de corações humanos / Anatomic study of the subvalvar apparatus of the left atrioventricular valve in human hearts

Este estudo foi desenvolvido com a intenção de propor uma classificação anatômica atualizada para o aparelho subvalvar da valva atrioventricular esquerda de corações humanos. A classificação de Pomerantzeff foi desenvolvida utilizando nomes lógicos e correlatos, baseada na posição anatômica do coração, e tem uma inovação: a identificação de uma nova estrutura anatômica, o músculo papilar basal. Cinqüenta valvas atrioventriculares esquerdas de corações humanos normais foram examinadas através de incisões realizadas na parede do ventrículo esquerdo. Foram analisados o tipo, a quantidade e a extensão das cordas, seus locais de origem e de inserção. Foi identificada a presença de três conjuntos de cordas: aposicional, basal e central. As cordas aposicionais são divididas em três subgrupos: mural, aórtico e comissural. Esses subgrupos se originam respectivamente nas cabeças mural, aórtica e comissural dos músculos papilares clássicos, aqui denominados superior-esquerdo e inferior-direito, e se inserem na região aposicional dos folhetos mural e aórtico da valva mitral e das suas comissuras superior-esquerda e inferiordireita. O conjunto de cordas basal pode ter três locais de origem: nas cabeças murais dos músculos papilares superior-esquerdo e inferior-direito ou em um músculo papilar acessório, nomeado músculo papilar basal. As cordas basais inserem-se próximas da base de implantação do folheto mural no anel valvar mitral. O terceiro conjunto é constituído pelas cordas centrais, que se originam nas cabeças aórticas dos músculos papilares superioresquerdo e inferior-direito e se implantam na porção central do folheto aórtico da valva mitral. Em cada conjunto podem ser encontrados até quatro tipos de cordas: primárias, secundárias, terciárias e quaternárias. As primárias são aquelas que têm sua origem nas pontas dos músculos papilares. As secundárias são ramificações das primárias, as terciárias são ramificações das secundárias e as quaternárias são ramificações...

The aim of this study was proposing an anatomic and present classification of the subvalvar apparatus of the left atrioventricular valve in normal human hearts. Pomerantzeffs classification uses logic and correlated names, the anatomic position of the heart, and has an innovation: the identification of a new anatomic structure, the basal papillary muscle. Fifty left atrioventricular valves of normal human hearts were examined via incisions in the left ventricle wall, visualizing the valve from below. The type, quantity and length of the chordae tendineae and their places of origin and insertion were analyzed. Was identified the presence of three groups of chordae tendineae: appositional, basal and central. The appositional group is divided in three subgroups: mural, aortic and comissural, that arise from the respective heads mural, aortic and comissural of the classic papillary muscles here named leftsuperior and right- inferior and has his insertion in the appositional portion of the mural and aortic leaflets of the mitral valve and in the commissures leftsuperior and right-inferior. The basal group of cords can have three places of origin: from the mural heads of the left-superior and right-inferior papillary muscles or from an accessory papillary muscle, named basal papillary muscle, and as his insertion near of the base of implantation of the mural leaflet in the valvar ring. The central group of cords arises from the aortic heads of the classic papillary muscles and has his insertion in the central portion of the aortic leaflet of the mitral valve. In each group described above there are four types of cordae tendineae: primary (arise from the papillary muscles), secondary (ramification of primary), tertiary (ramification of secondary) and quaternary (ramification of tertiary). This classification, clear and objective, allows easy recognition of the subvalvar structures and can be used equally by anatomists, cardiovascular surgeons...