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Because the left ventricular outflow tract is bounded anatomically by the ventricular septum and the anterior mitral leaflet, the dynamic obstruction of hypertrophic obstructive cardiomyopathy (HOCM) can be relieved by resecting either component. During recent years, most surgeons have practiced a traditional transaortic septal myectomy, as popularized by Morrow and associates (1,2). However, Cooley and colleagues have advocated a routine resection of the anterior mitral leaflet with low-profile valve replacement, especially in patients with significant mitral regurgitation (MR) (3,4). Recent experience suggests that, while both of these approaches perform well, each has a significant incidence of residual problems. Mitral replacement is associated with early and late prosthetic valverelated complications, and the more recently described ‘extended myectomy’, although effective in acutely reducing gradients, can be fraught with persistent systolic anterior motion (SAM), recurrent gradients, residual MR and a modest pacemaker requirement (5,6). Herein is reported a more comprehensive procedure that addresses all of these issues, and could improve late results, especially in patients with pronounced mitral abnormalities.