This letter was referred to Prof. Kumar, who replies in this manner:
The decision to replace a thickened, mildly regurgitant mitral valve was made because of previous open commissurotomy in this patient and to avoid a 3rd, possibly more hazardous, open-heart operation, in consideration of the young age of the patient.
We routinely mobilize the entire heart in redo surgery to provide good exposure, better topical cooling, and complete de-airing. In this patient, the small left atrium would not have enabled adequate exposure of the mitral valve without mobilizing the heart. The decision to replace the mitral valve through the aorta was made only after excising the aortic cusps.
Retaining the entire mitral valve during replacement produces significant left ventricular outflow gradients postoperatively. We therefore prefer Miki's technique of chordal preservation.
None of these patients had atrial fibrillation. Moreover, the interior of both the left atrium and the appendage can be fully and clearly viewed through this approach, by inverting the appendage after excising the anterior leaflet.
Finally, we are glad to have had this opportunity to reflect on these comments. I believe that these doubts concerning technique are not real issues and are best resolved with the acquisition of additional knowledge and experience. Only a prepared mind is capable of using an approach that provides many advantages to both the surgeon and the patient.