Reply to Buratto et al. Meena Nathan a,b, *, Sitaram Emani a,b and Pedro J. del Nido a,b a Department of Cardiac Surgery, Boston Children’s Hospital, Boston, MA, USA b Department of Surgery, Harvard Medical School, Boston, MA, USA Received 15 December 2017; accepted 18 December 2017 Keywords: Unbalanced atrioventricular septal defects • Biventricular conver- sion • Outcomes We thank you for the opportunity to respond to the letter by Buratto et al. [1] regarding our article on the mid-term outcomes in unbalanced complete atrioventricular septal defect [2]. They raised the concern of survivor bias in our biventricular conversion/re- cruitment (BiVC/BiVR) cohort. We would like to point out that the reason we chose the date of BiVR or BiVC as the timing of entry into the study was be- cause these patients, particularly BiVC patients, had their initial surgery at out- side institutions. Therefore, obtaining accurate survival data for all unbalanced complete atrioventricular septal defect cases from these institutions was not feasible. Furthermore, for patients who were cared for from the neonatal period at our centre, we were careful to include all patients in whom an ultim- ate BiV circulation was planned in the BiVR group to avoid this bias. The premise of our article was to show that BiVC with or without BiVR could be achieved with a reasonably low mortality and morbidity, but with increased rates of reintervention. This is particularly important in certain high- risk groups such as trisomy 21 and heterotaxy, which poorly tolerate single- ventricle palliation. As depicted in our supplementary material, fig. S2, 13 of 57 (23%) patients with heterotaxy in the single-ventricle group died when compared with 3 of 32 (9%) in the BiVC/BiVR group and 4 of 101 (4%) patients in the primary BiV repair group. As we accrue more patients, we will be able to perform a matched analysis of the three cohorts in the future. As decision making in this complex cohort continues to evolve [ 3–6 ], longitu- dinal data on this cohort would provide valuable information to further eluci- date therapy that is designed to meet the individual patient needs based on anatomical and physiological parameters. We agree that atrioventricular re- gurgitation remains the primary driver of reinterventions in unbalanced com- plete atrioventricular septal defect, whether it is single-ventricle palliation, primary BiV repair or BiVC/BiVR, as presented in table 6 of our article. Abnormalities in both valve morphology and ventricular morphology contrib- uted to atrioventricular valve regurgitation in this patient population and therefore necessitate an individualized approach to repair. REFERENCES [1] Buratto E, Khoo B, Ye XT, Konstantinov IE. Does biventricular conversion bring survival benefits to patients with an unbalanced atrioventricular sep- tal defect. Eur J Cardiothorac Surg 2018;53:1295. [2] Nathan M, Emani S, IJsselhof R, Liu H, Gauvreau K, del Nido P. Midterm outcomes in unbalanced atrio ventricular septal defect: successful biven- tricular conversion from single ventricle palliation. Eur J Cardiothorac Surg 2017;52:565–72. [3] Nathan M, Liu H, Pigula FA, Fynn-Thompson F, Emani S, Baird CA et al. Biventricular conversion after single-ventricle palliation in unbalanced atrioventricular canal defects. Ann Thorac Surg 2013;95:2086–95. [4] Herrin MA, Zurakowski D, Baird CW, Banka P, Esch JJ, del Nido PJ et al. Hemodynamic parameters predict adverse outcomes following biventricu- lar conversion with single-ventricle palliation takedown. J Thorac Cardiovasc Surg 2017;154:572–82. [5] Bacha E. Borderline left ventricle: trying to see the forest for the trees. J Thorac Cardiovasc Surg 2017;154:570–1. [6] Delius RE. 2-V or not 2-V: that is the question...plus some musings on thinking out of the box. J Thorac Cardiovasc Surg 2017;154:583–4. *Corresponding author. Department of Cardiac Surgery, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA. Tel: +1-617- 3557932; fax: +1-617-7300214; e-mail: meena.nathan@cardio.chboston.org (M. Nathan). doi:10.1093/ejcts/ezx500 Advance Access publication 19 January 2018 Predictors of right ventricular failure after implantation of left ventricular assist devices Orhan Gokalp a, *, Hasan Iner b , Yuksel Besir a and Gamze Gokalp c a Department of Cardiovascular Surgery, Faculty of Medicine, Izmir Katip Celebi University, Izmir, Turkey b Department of Cardiovascular Surgery, Adıyaman Education and Research Hospital, Adiyaman, Turkey c Department of Paediatrics Emergency, Izmir Tepecik Education and Research Hospital, Izmir, Turkey Received 30 November 2017; accepted 29 December 2017 Keywords: Right ventricular failure • Mechanical circulatory support • Ventricular assist device • Risk factors Congratulations to Boegershausen et al. [1] on their study. As the authors have noted, the incidence of right ventricular failure (RVF) development after im- plantation of left ventricular assist devices (LVADs), which is the most import- ant treatment option for advanced stage heart failure, is not very low. In various series, this ratio is up to 50% [ 2–4 ]. As can be seen, RVF development rates are extremely high. Even more important subject is the increased mortal- ity rates when RVF develops after LVAD. Therefore, determining the RVF pre- dictors after LVAD is frequently discussed as an important topic today. But, in the literature, many different parameters have been emphasized with regard to the predictive factors for the development of RVF after LVAD. For example, in this study, Boegershausen et al. report that only the basal longitudinal sys- tolic strain of the right ventricular (RV) free wall (PSLSbasal) and the central venous pressure are predictive factors for RVF. Similarly, another study of 4428 patients reported that high central venous pressure and low right ven- tricular stroke work index were predictive factors for RVF after LVAD [4]. But, in the same study, unlike the study by Boegershausen et al., they reported that international normalized ratio, N-terminal pro-b-type natriuretic peptide, moderate-to-severe right ventricular dysfunction, increased right ventricular/ left ventricular ratio and preprocedural ventilator dependence were also pre- dictive factors for RVF after LVAD implantation. Another study [5] reported that parameters such as increased pulmonary artery pressure, increased right atrial pressure, decreased stroke volume, preoperative severe tricuspid regur- gitation and renal replacement therapy were risk factors for RFV, unlike the study by Boegershausen et al. It is, of course, it is possible to increase these examples. However, it is clear that there is no single predictive factor for the development of RVF after LVAD. Another issue that we want to mention is that the main treatments applied by Boegershausen et al. for RVF after LVAD implantation are vasodilator inhalation, prolongation of inotropic treatment and right-sided extracorporeal membrane oxygenation. However, other ven- tricular support systems, such as a Levitronix CentriMag ventricular assist de- vice for the right side, have never been used. How do authors explain the reason for this? We believe that sharing the authors’ ideas on this subject will add value to their study. REFERENCES [1] Boegershausen N, Zayat R, Aljalloud A, Musetti G, Goetzenich A, Tewarie L et al. Risk factors for the development of right ventricular failure after left ven- tricular assist device implantation-a single-centre retrospective with focus on deformation imaging. Eur J Cardiothorac Surg 2017;52:1069–76. [2] McIlvennan CK, Magid KH, Ambardekar AV, Thompson JS, Matlock DD, Allen LA. Clinical outcomes after continuous-flow left ventricular assist de- vice: a systematic review. Circ Heart Fail 2014;7:1003–13. [3] Lampert BC, Teuteberg JJ. Right ventricular failure after left ventricular as- sist devices. J Heart Lung Transplant 2015;34:1123–30. [4] Bellavia D, Iacovoni A, Scardulla C, Moja L, Pilato M, Kushwaha SS et al. Prediction of right ventricular failure after ventricular assist device implant: systematic review and meta-analysis of observational studies. Eur J Heart Fail 2017;19:926–46. [5] Kiernan MS, Grandin EW, Brinkley M Jr, Kapur NK, Pham DT, Ruthazer R et al. Early right ventricular assist device use in patients undergoing continuous-flow left ventricular assist device implantation: incidence and risk factors from the interagency registry for mechanically assisted circula- tory support. Circ Heart Fail 2017;10:e003863. 1296 Letters to the Editor / European Journal of Cardio-Thoracic Surgery