Author's reply.

To the Editor,

We thank you for your interest and positive reviews on our article entitled “Effect of percutaneous mitral balloon valvuloplasty on right ventricular functions in mitral stenosis: Short- and mid-term results” (1) published in the Anatol J Cardiol 2015; 15: 289-96.

Firstly, the diagnosis of rheumatoid diseases may have been delayed in some patients because of individual and sociocultural differences in the patient group in the current study and also because the indication for intervention may have been delayed in some patients. As the risk of coronary artery disease (CAD) accompanying this age group is high, we added CAD to the exclusion criteria. At the beginning of the study, the patients were evaluated, and coronary angiography was performed in eight patients. The angiograph was found to be consistent with CAD in six patients, and these were not included in the study. CAG was indicated in the one-year follow-up of five patients, and severe vascular occlusion was detected in three of them; they were excluded from the study. A total of four patients who had non-critical stenosis were included to the study. As these patients would not directly affect the study data, they were not further mentioned in the text.

Secondly, as you have mentioned, the effects of parameters such as systolic and diastolic blood pressures and heart rate on many echocardiographic data are inevitable. Thus, homogeneity was achieved in basal and follow-up parameters. There is no statistically significant difference between the basal and follow-up values in patients included in the study.

Thirdly, as mentioned in the last ACC/AHA valve guideline, measurement of valve area with pressure half-time (PHT) is not recommended immediately after percutaneous mitral balloon valvuloplasty (PMBV) (2) because many factors such as heart rate, cardiac output, left atrial pressure, and mitral regurgitation could affect this measurement (3). Different results have been obtained in previous studies related to this subject. When Chen et al. (4) compared measurements taken immediately after PMBV with the Gorlin formula, they found significant differences, but they also found measurements performed 48-72 h after PMBV close to the Gorlin formula. Pitsavos et al. (5) performed their interventions in a retrograde manner to exclude the left atrial decompression effect of iatrogenic ASD, and they found that PHT measurements taken 48-72 h after the retrograde intervention was similar to the Gorlin measurements; they attributed this to the iatrogenic ASD. In the current study, we also planned to take the measurements 48-72 h after PMBV by considering the differences that could develop during the acute period immediately after PMBV. This may be the reason the PHT and planimetric measurements were similar. The mechanism of this may be acute changes in the left atrium and left ventricle compliance, which develop because of dramatic changes in transmitral gradient immediately after PMBV. We know that iatrogenic ASD produced during the procedure usually has no clinical importance teorically and causes left-to-right shunt in a small percentage of patients. Thus, it is difficult to explain the contribution of iatrogenic ASD to the decrease in transmitral gradient through left atrial decompression. Furthermore, Pitsavos et al. (5) took the measurements 48-72 hours after the procedure.

Finally, to expect AF development in mitral stenosis is not a surprise. In the current study to more homogenously evaluate left ventricle function, we included patients who are in sinus rhythm and we excluded those in whom AF developed during the follow-up.