Reply to Kuralay and Karaca Free

We have read with great interest the comments by Dr Kuralay and Dr Karaca [1] on our manuscript [2], and we thank them for their comments. They have suggested that there might be an error with Fig. 1(c), which is an intra-operative picture of the valve after the placement of the modified Alfieri stitch. We have carefully reviewed the figure, and we think it is correct as published. However, we acknowledge the limitations of our picture in terms of clarity, and we think the confusion probably arose from the fact that the mitral valve is not shown completely in the picture, in part due to the significant annulus dilatation and the limited exposure achieved for the photographer. We regret not having been able to show a better view of the valve, but we have to consider that this picture was taken near the end of the third cross-clamp period needed to repair the valve and, at that moment, we did not know if the result would be satisfactory or the valve would need to be replaced.

We would like to clarify this image for the readers; the picture shows the mitral valve as seen by the surgeon from a subseptal approach, and there are several aspects that we deliberately left in the picture to facilitate orientation: first, one can see the ascending aorta on the top-left corner of the picture with the cardioplegia delivery cannula in place; second, the two hand-held retractors on the superior aspect of the image delineate the left atriotomy through Sondergaard’s groove; finally, the cardiotomy sucker shows the posterior wall of the left atrium near the left-atrial appendage and the left-sided pulmonary veins.

Regarding the valve repair and the modified Alfieri stitch, after initial repair, we obtained a competent valve and also severe outflow obstruction due to systolic anterior motion (SAM) that we unsuccessfully tried to address with a conventional A2–P2 Alfieri repair. SAM persisted; hence, we removed the midline A2–P2 Alfieri stitch and placed a new edge-to-edge stitch now between the A1–P1 segments as shown in the picture. Actually, in the picture, we can see the most anterolateral of the two sets of GoreTex^® neochordae (in the A2 scallop close to A1) used to correct the prolapse of A2. We can also see the green pledgeted Ti-Cron^® sutures used for the posterior annulus plication after the quadrangular resection that mark the midline of the mitral valve. With these two references, it is clear that the newly placed Alfieri stitch was moved, as explained in the text, towards the anterolateral commissure and now holds the A1–P1 scallops together. We hope this helps clarify this technique that allowed us to preserve the mitral valve in this case of complex repair for myxomatous bileaflet prolapse.

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