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Rebuttal: Percutaneous valvuloplasty for mitral valve restenosis

We thank Nammas et al. [1] for his interest in our report [2], and we could not agree more with many of his statements. Nammas et al. states that ‘‘actually, some prior studies also demonstrated long-term outcome data following redo PBMV in patients with rheumatic mitral restenosis [3–5].’’ We are aware of these prior studies and in fact reference 2 [3] in the letter by Nammas et al. is actually quoted as reference 19 in our manuscript. None of these quoted studies [3–5] are however similar in design to ours and we re-emphasize Nammas’s point that probably our article was the first to present a comparison of outcomes of reballoon mitral valvotomy based on the type of the original procedure. Nammas et al. is concerned over the low rate of immediate procedural success of redo PBMV (59%), being even lower in patients with prior initial PBMV (57.1%), which is far lower than the figures reported in literature for redo PBMV in patients with mitral restenosis (75–92.5%) [3–5]. In our manuscript, procedural success of balloon valvuloplasty was defined as mitral valve area >1.5 cm in the absence of more than mild mitral regurgitation as had been defined earlier [1,6–8]. Our centre is a tertiary level high volume teaching centre doing balloon mitral valvuloplasty, with multiple peer reviewed publications in this field [9–11]. Probably, a referral bias was there so that we saw patients with worse valves than the other studies though this is not reflected in the Wilkins score. We are aware of the multiple scoring systems for the mitral valve in Refs. 12–14. We opted for the Wilkins score for morphological assessment because it is the commonest score used in multiple studies. The initial echocardiograms were scored using this system, so we had to continue with it. Simple scoring systems like, as proposed by Rifaie et al. [14] are easier to use than the Wilkins system. We are now evaluating this novel scoring system in our patients. We do not agree that better selection of valves would have improved the outcome. The major exclusion criteria in our study were consistent with standard of care in the field namely significant mitral regurgitation and bi-commissural calcium. We did not use a specific cut-off value of the Wilkins Score as an exclusion criterion for balloon mitral valvotomy. It is also intuitive that if we had used such a cut off value, more valves would have been excluded than would have been excluded with simpler scoring systems. In addition, the central point in our article was not the procedural outcome following re-balloon mitral valvotomy which has been studied earlier. The focal point in our manuscript was that following balloon valvuloplasty for mitral restenosis, patients with post balloon valvuloplasty are found to have lesser event rates on follow-up compared to patients with post-CMV, though procedural success rates are similar for both groups.