Reply to Pradegan et al.

Dear Editor,

Pradegan et al. [1] wrote an interesting Letter to the editor on our article reporting the 5-year results of our minimally invasive mitral surgery programme of patients with Barlow’s disease [2]. The authors suggested including additional preoperative echocardiographic characteristics to our data to improve the understanding of the outcomes. We value their point that additional echocardiographic data might provide more granularity and would definitely help to specify the characterization of our patients. They imply that the success of the presented repair techniques might depend on the underlying echo findings. We agree with the authors that this might be the case; however, the presented data are retrospective data, and due to the nature of retrospective research, some data were simply missing and therefore not available for analysis. Moreover, all patients underwent meticulous surgical valve analysis, which answers most of the questions regarding the extend of prolapse/flail, the dimensions of the annulus and the height of the posterior leaflet. One should keep in mind that the study reviews a long period of the treatment of Barlow’s disease, which includes the refinement of echocardiographic analysis for this complex pathology. Obviously, the quality of echocardiographic evaluation was not the same throughout the study period. In addition, the goal of our manuscript was to compare the safety and long-term outcome of different techniques in this specific patient population, irrespective of underlying echo findings. Current literature suggests that only patients with a central jet may benefit from a ring-only strategy [3, 4]. However, a symmetric pathology is only present in 10–20% of the Barlow patients. We want to emphasize that considering every Barlow patient as a possible candidate for the ring-only technique is risky, as only a minority of those patients will benefit from it. All others are subjected to the risk of perioperative systolic anterior movement or decreased coaptation length and residual regurgitation.

As a second comment, Pradegan et al. suggest including transapical neochord implantation as an alternative option [5]. Although this promising technology is available for more than 10 years, only preliminary data from single-centre studies with mid-term follow-up is available. Mitral valve disease due to Barlow’s is highly associated with mitral annular disjunction, which is successfully treated by annular stabilization using ring annuloplasty. Untreated mitral annular disjunction may lead to chronic annular calcification, further myocardial fibrosis and ventricular arrhythmias as well as recurrent mitral regurgitation through chordal rupture [6]. However, we agree that it might be a valuable option for selected patients.

Altogether, many aspects of the complex pathology of Barlow’s disease are still a mystery. We strongly believe that minimally invasive mitral valve surgery is a safe and feasible method to treat patients with Barlow’s and that future studies will help to uncover the mysteries of this fascinating pathology.

Conflict of interest: none declared.

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