Reply from authors: Many roads lead to Rome.

Reply to the Editor:

The Department of Cardiology received unrestricted research grants from , , BioVentrix, , Boston Scientific, , GE Healthcare and . Nina Ajmone Marsan received speakers’ fees from Abbott Vascular and GE Healthcare. All other authors reported no conflicts of interest.

The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

We would like to thank Lawrie and DeBakey for their insightful comments on our article. A rightful observation made by the authors is the use of neochords in a proportion of patients from the “resect” group. In our opinion, leaflet resection and chordal-replacement techniques are not completely interchangeable but rather complementary. Both techniques, and often a combination of these, are needed to achieve the optimal results of reconstructive mitral valve surgery, a view previously emphasized by our group. Notably, in the seminal paper by Perier and colleagues, leaflet resection used to treat, among others, excessive leaflet tissue in width was deemed inevitable by the authors in 30% to 35% of patients, further supporting our view of complementary repair techniques.

Recent studies have shown that morphologic and, hereto related, functional abnormalities of the mitral valve annulus are rather often present in patients with degenerative mitral valve disease when sophisticated cardiac imaging techniques are used. We have also shown, in line with the reports by several other authors, that stabilization of the mitral valve annulus is a reliable repair technique to resolve mitral valve leaflet prolapse in selected patients suffering from Barlow disease. Moreover, long-standing mitral valve regurgitation is known to cause annular dilation, annular flattening, and decline in sphincter-like function otherwise normally seen in the systolic phase of the cardiac cycle. Our policy of mitral valve repair has thus been focused on preventing abnormal annular motion and restoring the normal mitral valve saddle shape. As our policy of annuloplasty ring sizing is based on the size of the anterior mitral valve leaflet, the type of posterior leaflet repair will not influence annuloplasty ring sizing and hereto related posterior mitral valve annulus perimeter. The latter is in our opinion the major determinant of postrepair transmitral gradient. It should be noticed that regardless of the device used (rigid, semi-rigid, or flexible ring or band), the lack of elasticity or possibility of contraction of the materials used for annular stabilization will result in a relative fixation of the posterior annulus.

We would like to thank again Lawrie and DeBakey for their comments on our article. The authors have made several contributions to our understanding of the mitral valve apparatus, and shared efforts to improve the knowledge and results of mitral valve surgery will undoubtfully help stimulate further developments in the field.