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\begin{document}

\title{Response to Letter to Editor Regarding: Equivalent outcomes with
minimally invasive and sternotomy mitral valve repair for degenerative
mitral valve disease. J Card Surg. 2021; 36:2636-43.}



\author[1]{Ramsey Elsayed}%
\author[1]{Brittany Abt}%
\author[1]{Michael Bowdish}%
\affil[1]{University of Southern California}%


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  \date{May 26, 2024}


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Response to Letter to Editor Regarding: Equivalent outcomes with
minimally invasive and sternotomy mitral valve repair for degenerative
mitral valve disease. J Card Surg. 2021; 36:2636-43.

\emph{Authors:} Ramsey S. Elsayed, MD MS\textsuperscript{1}, Brittany
Abt, MD\textsuperscript{1}, and Michael E. Bowdish, MD
MS\textsuperscript{1,2}

\emph{Institutions and Affiliations:} \textsuperscript{1}Division of
Cardiac Surgery, Department of Surgery, Keck School of Medicine of USC,
University of Southern California, Los Angeles, CA, USA

\textsuperscript{2}Department of Preventive Medicine, Keck School of
Medicine of USC, University of Southern California, Los Angeles, CA, USA

\emph{Address for Correspondence:} Dr. Michael E. Bowdish, Associate
Professor of Surgery and Preventive Medicine; Department of Surgery,
Keck School of Medicine of USC; University of Southern California; 1520
San Pablo Street, HCC II Suite 4300; Los Angeles, CA 90033; Phone:
(323)-442-5849; Email: Michael.Bowdish@med.usc.edu

\emph{Conflicts of Interest/Competing Interests:} None

\emph{Funding:} Research reported in this publication was supported by
the Department of Surgery of the Keck School of Medicine of USC. MEB is
partially supported by UM1-HL11794 from the National Heart Lung and
Blood Institute of the National Institutes of Health.

To the editor,

We would like to thank Song et. al. for their letter regarding our
recent publication in the Journal of Cardiac Surgery titled ``Equivalent
outcomes with minimally invasive and sternotomy mitral valve repair for
degenerative mitral valve disease''\textsuperscript{1}. They asked some
important questions and brought up valuable points that are worthy of
discussion.

Regarding the selection criteria we use for operative approach for
mitral valve repair operations, it is primarily based on collective
surgeon-patient decision making. However, patients with a previous
history of cardiac surgery or peripheral vascular disease (which would
render peripheral cannulation difficult), and those in need of
concomitant cardiac procedures such as coronary artery bypass grafting,
aortic replacement, or biatrial ablation, are not offered a minimally
invasive approach. Regarding the role of artificial chordae (neochordae)
in mitral valvuloplasty, we use elongated polytetrafluorethylene made of
interrupted GoreTex (Gore-Tex, WL Gore and Associates, Inc., Flagstaff,
AZ) sutures placed in a horizontal mattress fashion. These neochordae
are routinely used to repair elongated or ruptured chordae causing
mitral valve prolapse or regurgitation.\textsuperscript{2} Typically,
the neochordae are used in the anterior leaflet of the mitral valve. The
etiologies of degenerative mitral valve disease are comprised of
myxomatous degeneration of the MV, fibroelastic deficiency including so
called Barlow's valves, and dystrophic calcification of the mitral
annulus.\textsuperscript{3} While the etiologies are not mutually
exclusive and may overlap, myxomatous degeneration and fibroelastic
deficiencies resulting in severe, symptomatic MR were the most common
indications for operation in our patient population. As mentioned by
Song and colleagues, the success and durability of MVr can vary
depending on etiology, particularly on how much of the valve apparatus
is affected by pathology. While not examined in this paper specifically,
previous papers (including Tatum et al. conducted at our institution),
have demonstrated that anterior leaflet repair is significantly
associated with recurrence and progression of MR after surgery, whereas
isolated posterior repair is protective.\textsuperscript{3,4}

The operative team was similar in all cases, whereas the senior author
(VAS) performed over 85\% of the total procedures and nearly 100\% of
the minimally invasive procedures. The success rate of the minimally
invasive cohort was 100\% (as defined by the Society of Thoracic
Surgeons). There was one conversion to conventional sternotomy in the
minimally invasive cohort (.003\%) for bleeding control.

Finally, Song and colleagues are to be congratulated on their robotic
and thoracoscopic mitral valvuloplasty results. Their 10-year total
robotic mitral valve valvuloplasty results showing excellent cardiac
function with 93\% of patients in NYHA classes I and
II.\textsuperscript{5} Furthermore, their early thoracoscopic results
were very good with one operative mortality and only two reoperations
demonstrating thoracoscopic mitral valvuloplasty is a technically
feasible, safe, effective, and reproducible
technique.\textsuperscript{6}

References:

\begin{enumerate}
\tightlist
\item
  Bowdish ME, Elsayed RS, Tatum JM, Cohen RG, Mack WJ, Abt B, Yin V,
  Barr ML, Starnes VA. Equivalent outcomes with minimally invasive and
  sternotomy mitral valve repair for degenerative mitral valve disease.
  J Card Surg. 2021 Aug;36(8):2636-2643. PMID: 33908645.
\item
  Bortolotti U, Milano AD, Frater RW. Mitral valve repair with
  artificial chordae: a review of its history, technical details,
  long-term results, and pathology. Ann Thorac Surg. 2012
  Feb;93(2):684-91. PMID: 22153050.
\item
  David, Tirone E. ''Durability of mitral valve repair for mitral
  regurgitation due to degenerative mitral valve disease.'' \emph{Annals
  of cardiothoracic surgery} 4.5 (2015): 417.
\item
  Tatum, James M., et al. ''Outcomes after mitral valve repair: a
  single-center 16-year experience.'' \emph{The Journal of thoracic and
  cardiovascular surgery} 154.3 (2017): 822-830.
\item
  Zhao H, Gao C, Yang M, Wang Y, Kang W, Wang R, Zhang H. Surgical
  effect and long-term clinical outcomes of robotic mitral valve
  replacement: 10-year follow-up study. J Cardiovasc Surg (Torino). 2021
  Apr;62(2):162-168. PMID: 33302613.
\item
  Cui H, Zhang L, Wei S, Li L, Ren T, Wang Y, Jiang S. Early clinical
  outcomes of thoracoscopic mitral valvuloplasty: a clinical experience
  of 100 consecutive cases. Cardiovasc Diagn Ther. 2020
  Aug;10(4):841-848. PMCID: PMC7487400.
\end{enumerate}

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