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We thank Dr Gualis and colleagues [1Gualis J. Castaño M. Gómez-Plana J. et al.Mitral valve replacement in heavily calcified annulus (letter).Ann Thorac Surg. 2010; 90: 2090Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar] for their interest regarding our article [2Di Stefano S. López J. Flórez S. Rey J. Arevalo A. San Román A. Building a new annulus: a technique for mitral valve replacement in heavily calcified annulus.Ann Thorac Surg. 2009; 87: 1625-1627Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar] and we appreciate the editor for giving us the opportunity to reply.They performed a complete resection of both calcified leaflets, and no native annular or leaflet tissue was included in the new annulus [1Gualis J. Castaño M. Gómez-Plana J. et al.Mitral valve replacement in heavily calcified annulus (letter).Ann Thorac Surg. 2010; 90: 2090Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar]. Interrupted pledgetted mattress sutures were applied only in the left atrial wall.We have to remember that the aim of our technique is to give more consistence to the new annulus, to avoid complications like atrial wall rupture and development of a paravalvular leak and possible dehiscence. In this sense, we consider it very important to fix the atrium wall with mitral leaflet, obtaining more hemodynamic resistance and an intra-annular placement of the prosthesis.We agree with the authors that sometimes severe calcification involves both leaflet and papillary muscles. In fact, in this case they describe a total resection of mitral leaflets, so they could not perform our technique.We believe that this modification could be a useful tool when massive leaflet calcification is observed, and it is impossible to use subvalvular tissue to support the atrial wall. We thank Dr Gualis and colleagues [1Gualis J. Castaño M. Gómez-Plana J. et al.Mitral valve replacement in heavily calcified annulus (letter).Ann Thorac Surg. 2010; 90: 2090Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar] for their interest regarding our article [2Di Stefano S. López J. Flórez S. Rey J. Arevalo A. San Román A. Building a new annulus: a technique for mitral valve replacement in heavily calcified annulus.Ann Thorac Surg. 2009; 87: 1625-1627Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar] and we appreciate the editor for giving us the opportunity to reply. They performed a complete resection of both calcified leaflets, and no native annular or leaflet tissue was included in the new annulus [1Gualis J. Castaño M. Gómez-Plana J. et al.Mitral valve replacement in heavily calcified annulus (letter).Ann Thorac Surg. 2010; 90: 2090Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar]. Interrupted pledgetted mattress sutures were applied only in the left atrial wall. We have to remember that the aim of our technique is to give more consistence to the new annulus, to avoid complications like atrial wall rupture and development of a paravalvular leak and possible dehiscence. In this sense, we consider it very important to fix the atrium wall with mitral leaflet, obtaining more hemodynamic resistance and an intra-annular placement of the prosthesis. We agree with the authors that sometimes severe calcification involves both leaflet and papillary muscles. In fact, in this case they describe a total resection of mitral leaflets, so they could not perform our technique. We believe that this modification could be a useful tool when massive leaflet calcification is observed, and it is impossible to use subvalvular tissue to support the atrial wall. Mitral Valve Replacement in Heavily Calcified AnnulusThe Annals of Thoracic SurgeryVol. 90Issue 6PreviewWe recently read with interest the case report “Building a New Annulus: A Technique for Mitral Valve Replacement in Heavily Calcified Annulus” published in the “How to Do It” section in May 2009 in The Annals of Thoracic Surgery by Di Stefano and colleagues [1]. Full-Text PDF