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Reply to Tomšič et al.

Reply to Tomšič et al. European Journal of Cardio-Thoracic Surgery 0 (2018) 1 LETTER TO THE EDITOR RESPONSE reported by ‘centres of excellence’. It is important to state that conventional Reply to Tomsic et al. surgery also required many years to reach the current level of quality and improved significantly mostly in the last decades when imaging technologies Andrea Colli* †,Eleonora Bizzotto,Laura Besola† and Gino Gerosa have been widely adopted as well as when new and more physiological surgi- Cardiac Surgery Unit, Department of Cardiac, Thoracic, and Vascular Sciences, cal techniques have been standardized. University of Padua, Italy Finally, we would like to stress that in our experience all patients who pre- sented with recurrence of moderate MR during follow-up were not symptomat- Received 22 May 2018; accepted 31 May 2018 ic, and in case of symptoms they all had preserved left ventricle function and low left ventricle volumes often with a significant reduction after the procedure Keywords: Mitral valve regurgitation � Mitral valve insufficiency � Mitral valve [6]. So, regarding this specific issue, we take this opportunity to ask the entire car- diovascular community, how often in your clinical practice have you ever reop- prolapse � Mitral valve flail � Mitral valve repair � Neochord erated an asymptomatic patient with moderate residual MR, preserved left ventricle ejection fraction and preserved left ventricle volumes, only for the pres- We thank Tomsic et al. [1] for their interesting comments on our article ence of moderate MR? We guess that the answer is most likely: not often. regarding the early results of the European experience with the Neochord off- pump mitral valve (MV) repair system, which included the first 213 consecu- Conflict of interest: All authors received travel grants from Neochord, Inc. tive patients [2]. Andrea Colli is a proctor for Neochord, Inc. The authors underline a higher early mortality rate and an inferior proced- ural success with longer hospital stay when compared to traditional on-pump surgery. We agree that the current results of this newly-adopted technology REFERENCES have not been as good as conventional MV surgery in terms of residual mitral regurgitation, but absolutely comparable in terms of mortality. Patients who [1] Tomsic A,Klautz RJM,PalmenM.Off-pump mitral valve repair:is expired were considered inoperable with conventional MV surgery. Please less really more? Eur J Cardiothorac Surg 2018; doi:10.1093/ejcts/ remember that MV surgery has been performed since the late 1970s, based ezy229. on the same surgical dogmas we are following without hesitation. [2] Colli A, Manzan E, Aidietis A, Rucinskas K, Bizzotto E, Besola L et al.An We have already published data [3] confirming that the learning curve of a early European experience with transapical off-pump mitral valve repair single-centre experience, as well as for all surgical procedures – Neochord re- with NeoChord implantation. Eur J Cardiothorac Surg 2018; doi: pair has its specific learning curve-depends mostly on the standardization of 10.1093/ejcts/ezy064. the surgical technique and on the definition of the specific patient selection [3] Colli A, Manzan E, Zucchetta F, Bizzotto E, Besola L, Bagozzi L et al. criteria [4]. With this aim, a specific training programme with a biosimulator Transapical off-pump mitral valve repair with Neochord implantation: (ex vivo pulsatile heart model) and a pneumatic simulator has been established early clinical results. Int J Cardiol 2016;204:23–8. to allow the surgeon to gain confidence with the device and with a completely [4] Colli A, Bagozzi L, Banchelli F, Besola L, Bizzotto E, Pradegan N et al. different and innovative surgical concept. Learning curve analysis of transapical NeoChord mitral valve repair. Eur Recently, to continue on the track of self-critics, we also reviewed our ex- J Cardiothorac Surg 2018; doi:10.1093/ejcts/ezy046. perience to analyse the mechanisms of recurrence of MR by identifying tech- [5] Zekry SB, Freeman J, Jajoo A, He J, Little SH, Lawrie GM et al. Patient- nical pitfalls and new physiopathological mechanisms that have never been specific quantitation of mitral valve strain by computer analysis of three- described before with conventional MV surgery. In particular, the paradoxical dimensional echocardiography a pilot study. Circ Cardiovasc Imaging movement of the posterobasal ventricle (curling) seems to play a role in MR 2016;9:e003254. recurrence because it is part of a complex pathology that involves the mitral [6] Colli A, Besola L, Montagner M, Soriani N, Manzan E, Bizzotto E et al. leaflet, the mitral annulus and also the left ventricle [5]. Patients with curling Acute intraoperative echocardiographic changes after transapical off- require an additional annuloplasty procedure to stabilize the result in the long pump mitral valve repair with NeoChord implantation. Int J Cardiol term. These findings have been submitted to the 2018 EACTS annual meeting. 2018;257:230–4. The reported mortality of 1.6% was due to the death of 2 elderly patients with a very high risk profile, for whom Neochord off-pump procedure was chosen as a compassionate use due to their extreme frailty as described previ- *Corresponding author. Department of Cardiology, Thoracic and Vascular ously [3]. Moreover, length of hospital stay is affected by the specific local en- Sciences, University of Padua, via Giustiniani, 2, 35128 Padova, Italy. vironment (delay in transfer to postoperative rehabilitation because of lack of Tel: +39-049-8212410; e-mail: colli.andrea.bcn@gmail.com (A. Colli). bed supply, minimum hospital stay length for public reimbursement, etc.) and †These authors contributed equally to this work. therefore is extremely variable. In their letter, a very high rate of on-pump MV repair success is reported; doi:10.1093/ejcts/ezy231 nevertheless, we should consider the real world results that are far from those The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. Downloaded from https://academic.oup.com/ejcts/advance-article-abstract/doi/10.1093/ejcts/ezy231/5045546 by Ed 'DeepDyve' Gillespie user on 12 July 2018 LETTER TO THE EDITOR http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Journal of Cardio-Thoracic Surgery Oxford University Press

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
ISSN
1010-7940
eISSN
1873-734X
DOI
10.1093/ejcts/ezy231
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Abstract

European Journal of Cardio-Thoracic Surgery 0 (2018) 1 LETTER TO THE EDITOR RESPONSE reported by ‘centres of excellence’. It is important to state that conventional Reply to Tomsic et al. surgery also required many years to reach the current level of quality and improved significantly mostly in the last decades when imaging technologies Andrea Colli* †,Eleonora Bizzotto,Laura Besola† and Gino Gerosa have been widely adopted as well as when new and more physiological surgi- Cardiac Surgery Unit, Department of Cardiac, Thoracic, and Vascular Sciences, cal techniques have been standardized. University of Padua, Italy Finally, we would like to stress that in our experience all patients who pre- sented with recurrence of moderate MR during follow-up were not symptomat- Received 22 May 2018; accepted 31 May 2018 ic, and in case of symptoms they all had preserved left ventricle function and low left ventricle volumes often with a significant reduction after the procedure Keywords: Mitral valve regurgitation � Mitral valve insufficiency � Mitral valve [6]. So, regarding this specific issue, we take this opportunity to ask the entire car- diovascular community, how often in your clinical practice have you ever reop- prolapse � Mitral valve flail � Mitral valve repair � Neochord erated an asymptomatic patient with moderate residual MR, preserved left ventricle ejection fraction and preserved left ventricle volumes, only for the pres- We thank Tomsic et al. [1] for their interesting comments on our article ence of moderate MR? We guess that the answer is most likely: not often. regarding the early results of the European experience with the Neochord off- pump mitral valve (MV) repair system, which included the first 213 consecu- Conflict of interest: All authors received travel grants from Neochord, Inc. tive patients [2]. Andrea Colli is a proctor for Neochord, Inc. The authors underline a higher early mortality rate and an inferior proced- ural success with longer hospital stay when compared to traditional on-pump surgery. We agree that the current results of this newly-adopted technology REFERENCES have not been as good as conventional MV surgery in terms of residual mitral regurgitation, but absolutely comparable in terms of mortality. Patients who [1] Tomsic A,Klautz RJM,PalmenM.Off-pump mitral valve repair:is expired were considered inoperable with conventional MV surgery. Please less really more? Eur J Cardiothorac Surg 2018; doi:10.1093/ejcts/ remember that MV surgery has been performed since the late 1970s, based ezy229. on the same surgical dogmas we are following without hesitation. [2] Colli A, Manzan E, Aidietis A, Rucinskas K, Bizzotto E, Besola L et al.An We have already published data [3] confirming that the learning curve of a early European experience with transapical off-pump mitral valve repair single-centre experience, as well as for all surgical procedures – Neochord re- with NeoChord implantation. Eur J Cardiothorac Surg 2018; doi: pair has its specific learning curve-depends mostly on the standardization of 10.1093/ejcts/ezy064. the surgical technique and on the definition of the specific patient selection [3] Colli A, Manzan E, Zucchetta F, Bizzotto E, Besola L, Bagozzi L et al. criteria [4]. With this aim, a specific training programme with a biosimulator Transapical off-pump mitral valve repair with Neochord implantation: (ex vivo pulsatile heart model) and a pneumatic simulator has been established early clinical results. Int J Cardiol 2016;204:23–8. to allow the surgeon to gain confidence with the device and with a completely [4] Colli A, Bagozzi L, Banchelli F, Besola L, Bizzotto E, Pradegan N et al. different and innovative surgical concept. Learning curve analysis of transapical NeoChord mitral valve repair. Eur Recently, to continue on the track of self-critics, we also reviewed our ex- J Cardiothorac Surg 2018; doi:10.1093/ejcts/ezy046. perience to analyse the mechanisms of recurrence of MR by identifying tech- [5] Zekry SB, Freeman J, Jajoo A, He J, Little SH, Lawrie GM et al. Patient- nical pitfalls and new physiopathological mechanisms that have never been specific quantitation of mitral valve strain by computer analysis of three- described before with conventional MV surgery. In particular, the paradoxical dimensional echocardiography a pilot study. Circ Cardiovasc Imaging movement of the posterobasal ventricle (curling) seems to play a role in MR 2016;9:e003254. recurrence because it is part of a complex pathology that involves the mitral [6] Colli A, Besola L, Montagner M, Soriani N, Manzan E, Bizzotto E et al. leaflet, the mitral annulus and also the left ventricle [5]. Patients with curling Acute intraoperative echocardiographic changes after transapical off- require an additional annuloplasty procedure to stabilize the result in the long pump mitral valve repair with NeoChord implantation. Int J Cardiol term. These findings have been submitted to the 2018 EACTS annual meeting. 2018;257:230–4. The reported mortality of 1.6% was due to the death of 2 elderly patients with a very high risk profile, for whom Neochord off-pump procedure was chosen as a compassionate use due to their extreme frailty as described previ- *Corresponding author. Department of Cardiology, Thoracic and Vascular ously [3]. Moreover, length of hospital stay is affected by the specific local en- Sciences, University of Padua, via Giustiniani, 2, 35128 Padova, Italy. vironment (delay in transfer to postoperative rehabilitation because of lack of Tel: +39-049-8212410; e-mail: colli.andrea.bcn@gmail.com (A. Colli). bed supply, minimum hospital stay length for public reimbursement, etc.) and †These authors contributed equally to this work. therefore is extremely variable. In their letter, a very high rate of on-pump MV repair success is reported; doi:10.1093/ejcts/ezy231 nevertheless, we should consider the real world results that are far from those The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. Downloaded from https://academic.oup.com/ejcts/advance-article-abstract/doi/10.1093/ejcts/ezy231/5045546 by Ed 'DeepDyve' Gillespie user on 12 July 2018 LETTER TO THE EDITOR

Journal

European Journal of Cardio-Thoracic SurgeryOxford University Press

Published: Jun 26, 2018

References