We read with great interest the article of Arıtürk et al.[1] published in your Journal’s second issue of the year 2015. We congratulate Arıtürk et al.[1] for this study. We believe that their study has contributed significantly to the literature. However, we believe a few points need to be emphasized regarding the article.

Firstly, the fact that this article, which was designed as a prospective observational study and planned well, was indicated as a retrospective study in the third paragraph of the method section creates confusion for the reader. In the study, of which data were conducted between 2000 and 2012, not limiting the prospective-based approach with a follow-up of 30 days may increase the quality of the study even more. Of the current valvular diseases treatment guidelines, American College of Cardiology (ACC)/ American Heart Association (AHA) guidelines have emphasized the issue of severe ischemic mitral regurgitation.[2] In this guidelines, it is indicated that one of the issues is between mitral valve repair and replacement. Sharing data of patients who were performed replacement may contribute significantly to the article since patients who were performed mitral valve repair were selected in the study. Patient group with moderate level mitral regurgitation constitutes a challenging subject in decision-making in ischemic mitral diseases. We believe that the exclusion of moderate level mitral regurgitation group in the study weakens the effect of the study.

We think that left ventricular dysfunction and remodelling process are two significant issues in ischemic mitral regurgitation patients. Authors have emphasized the significance of left ventricular dysfunction in the discussion section. However, the fact that left ventricular ejection fraction was specified as <50% in the planning of patients’ demographical and preoperative characteristics in the article hinders a sufficient and detailed analysis of any positive contributions to left ventricular dysfunction. Considering that ischemic mitral regurgitation is characteristically sensitive to exertion-based changes in dynamic and ventricle wall movements, we believe that this detail is vital for the study as well. Smith et al.[3] reported that performing coronary artery bypass (CABG) surgery simultaneously with mitral valve repair does not contribute as expected to the left ventricular remodelling process. The same study shows that mitral valve repair has no clinically beneficial advantage to CABG surgery in one-year follow-up.

We conclude that this successful study will become an article with stronger effect with the above-mentioned details.

Declaration of conflicting interests
The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding
The authors received no financial support for the research and/or authorship of this article.

REFERENCES
1. Arıtürk C, Ökten M, Gülllü Ü, Şenay Ş, Buturak A,Görmez S, et al. Mitral valve repair for ischemic mitral insufficiency: an increased early postoperative risk for the elderly. Turk Gogus Kalp Dama 2015;23:239-44.

2. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Guyton RA, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:e57-185. [Erratum: J Am Coll Cardiol 2014;63:2489].

3. Smith PK, Puskas JD, Ascheim DD, Voisine P, Gelijns AC, Moskowitz AJ, et al. Surgical treatment of moderate ischemic mitral regurgitation. N Engl J Med 2014;371:2178-88.

Author’s Reply
Dear editor,

I would like to thank the authors for their contributions in our article.

As it was mentioned in the article, the lack of mid- and long-term results are the limitations of our study and such results of ongoing studies will soon be shared. Also, it was clearly stated that the study aimed to evaluate the risk factors for mortality and morbidity regarding “mitral valve repair” for ischemic mitral regurgitation. Moreover, in our clinical practice, we aim to preserve mitral valve unless there is any disease other than ischemic regurgitation. Besides, patients with any degenerative, rheumatic disease in mitral valve were excluded. However, mitral valve repair and mitral valve replacement results may be compared in another study.

In the materials and methods section, mitral insufficiency evaluation from 1+ to 4+ was explained and it was stated that patients with 3+ mitral regurgitation -which was also mentioned as “moderate”- were included in the study.

Fifty percent ejection fraction (EF) was not a patient selection criterion for us; however, as it can easily be understood from the table, most of the patients had EF lower than 50%. It is obvious that the patients with ischemic mitral regurgitation in our study had multivessel disease which may cause ischemia resulting in a significantly decreased EF, deteriorated left ventricular systolic function, and hence mitral regurgitation.

Correspondence: Cem Arıtürk, M.D. Acıbadem Üniversitesi Kalp ve Damar Cerrahisi Anabilim Dalı, 34742 Ataşehir, İstanbul, Turkey.
Tel: +90 216 - 533 50 77 e-mail: cemariturk.kvc@gmail.com