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Monaldi Hospital, University of Naples II, Via G. Gigante No. 7, Naples 80136, Italy
(Email: pasquale.sante{at}fastwebnet.it).
We are pleased to answer the letter to the editor [1] concerning our article [2], first of all because it gives us the chance to emphasize some points of our technique dealing with complex reconstructions of the posterior mitral leaflet.
When it is said: "quite a few of us ... have been using this technique for years" and: "I ... consider this an adaptation of a posterior folding plasty ... and of the double-breasted mitral valve repair technique," we think being "an adaption" means something new not previously used. The "Z-plasty suture" is in our opinion a satisfactory technique when a complex posterior mitral leaflet lesion is to be dealt with and the aim is to achieve as much as possible of an anatomic reconstruction. According to our data in patients where the posterior mitral annulus is not enlarged and the inter-papillary muscles distance (both in diastole and in systole) has to be kept within the normal range, together with a good posterior mitral leaflet motion, the described technique has shown encouraging results. Furthermore there were no findings of left ventricle inflow tract obstruction in any of the patients as well as systolic anterior motion of the anterior leaflet.
The "folding plasty" consists of a rectangular excision of the prolapsing leaflet, the annulus of the excised leaflet is nonplicated (same as the "Z-plasty"), and the margins of the two remaining leaflets are both sutured to the annulus and then each other (not as in the "Z-plasty"). In the technique we described, the most redundant residual scallop is the only one to be sutured to the annulus in such a way to become the basal portion of the new scallop, while the other not prolapsing residual scallop is sutured to the free edge of the previous one with its normal primary chordae in such a way to become the free edge of the new scallop, thus avoiding a stretching whatsoever on chordal apparatus and the consequent variation of inter-papillary muscles distance and posterior mitral leaflet lack of motility.
Furthermore, our postoperative echo data were good as far as the residual mitral regurgitation, the mitral valve area, and the ejection fraction were concerned.
The "double-breasted repair" consists of a triangular or quadrilateral excision of the prolapsing leaflet, the annulus of the excised leaflet is nonplicated (same as the "Z-plasty"), and the two leaflet edges are double-breasted in such a way that the smaller remnant (opposite to the "Z-plasty") is sutured to the annulus while the larger is sutured to the annulus overlapping the previous one. In our opinion, such a technique is even more at risk to create stretching or distortion of the involved chordae.
In conclusion, we think the "Z-plasty suture" technique is to be kept in mind when dealing with complex reconstructions of the posterior mitral leaflet and is to some extent to be preferred to a simple posterior folding plasty or double-breasted repair.
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