Response:
- We agree that our cohort is heterogeneous in terms of the etiology of
mitral pathology. However, our cohort is one of the least
heterogeneous in the literature addressing VAs ablation in patients
MVS as most prior studies evaluated arrhythmias in patients with heart
surgery or valve surgery in general as discussed in the introduction
section in our manuscript.(1) Although mitral regurgitation is
classified into primary and secondary as proposed by the American
College of Cardiology and the American Heart Association (ACC/AHA)
guidelines, different classifications and subgroups exist based on
causes, mechanisms, and leaflet motion, which might cause confusion
due to overlapping terminologies.(2, 3) We concur that the study of VA
outcomes based on the specific mechanism of mitral disease would be a
welcome addition to the literature.
- We did compare patients with coronary artery disease (CAD) to patients
without CAD. As discussed in our manuscript, MVS patients with a
history of CAD showed a trend of better VA recurrence-free survival
compared with those without CAD history.(1)
- Cardiac MRI was not routinely obtained before ablation in our cohort.
We agree that MRI would have provided additional information on our
cohort - indeed our current practice is to incorporate imaging studies
in our preprocedural planning.
- We found that most VAs were not related to the perimitral area. We
agree with Dural et. al that comprehensive evaluation of these
patients and careful review of echocardiography, cardiac MRI, and
prior ablation findings is very important.
In summary, while our manuscript adds insight into the mechanisms and
outcomes of ventricular arrhythmias in patients with prior MVS, further
(ideally prospective) studies utilizing preprocedural imaging including
echocardiography, advanced cardiac imaging etc. coupled with
comprehensive 3D electroanatomical mapping are required. Direct
comparison of those with primary versus secondary mitral valve pathology
would be intriguing given that secondary valve disease is a result of a
diseased ventricle and may yield differing outcomes.