Letter to the Editor Percutaneous Valvuloplasty for Mitral Valve Restenosis TO THE EDITOR With great interest, we read the article ‘‘Percutane- ous valvuloplasty for mitral valve restenosis: Postbal- loon valvotomy patients fare better than postsurgical closed valvotomy patients’’ by Nair et al. [1]. Indeed, the authors are to be congratulated for their intriguing work that presented the long-term (mean 3.47 6 2.07 years) follow-up data following redo percutaneous bal- loon mitral valvuloplasty (PBMV) comparing patients with prior initial PBMV versus those with prior initial surgical closed mitral valvotomy (CMV). Actually, some prior studies also demonstrated long-term out- come data following redo PBMV in patients with rheu- matic mitral restenosis [2–4]. To the best of our knowledge, this article was the first to present such a comparison based on the type of the original procedure. The salient point underscored by the authors was the significantly better long-term event-free survival fol- lowing redo PMBV in patients with prior initial PBMV (92.8%) as compared to those with prior initial CMV (69%) [1]. However, I was quite overwhelmed by the low rate of immediate procedural success of redo PBMV (59%)—being even lower in patients with prior initial PBMV (57.1%)—which is far lower than the figures reported in literature for redo PBMV in patients with mitral restenosis (75–92.5%) [2–4]. The early echocardiographic score for assessment of eligibility for PBMV (which is the one adopted by the authors) employed semi-quantitative evaluation of leaf- let thickness, mobility, calcification, and subvalvular involvement. Yet, it is widely accepted now that clini- cal and procedural outcome can be predicted from pru- dent evaluation of commissural morphology (particu- larly commissural calcification) in addition to other clinical and procedural variables. Several studies emphasized the significance of commissural calcifica- tion and subvalvular involvement for predicting the occurrence of severe mitral regurgitation following PMV [5,6]. More recently, a novel mitral valve scoring system has been suggested, based only on these two later pa- rameters and better predicted outcome after PBMV, in comparison with the earlier score [7]. Excluding other parameters (namely, leaflet thickness and mobility) not closely related to the outcome of PBMV, would improve patient selection and, therefore, improve the immediate procedural success rate of redo PBMV and subsequently the long-term outcome. Wail Nammas, MD Department of Cardiology Faculty of Medicine Ain Shams University Cairo, Egypt REFERENCES 1. Nair K, Sivadasanpillai H, Sivasubramonium P, Ramachandran P, Tharakan JA, Titus T, Ajit Kumar VK, Sivasubramonian S, Krishnamoorthy KM, Dora S. Percutaneous valvuloplasty for mi- tral valve restenosis: Postballoon valvotomy patients fare better than postsurgical closed valvotomy patients. Catheter Cardiovasc Interv 2010;76:174–180. 2. Iung B, Garbarz E, Michaud P, Fondard O, Helou S, Kamblock J, Berdah P, Michel PL, Lionet P, Cormier B, Papouin G, Vaha- nian A. Immediate and mid-term results of repeat percutaneous mitral commissurotomy for restenosis following earlier percutane- ous mitral commissurotomy. Eur Heart J 2000;21:1683–1690. 3. Pathan AZ, Mahdi NA, Leon MN, Lopez-Cuellar J, Simosa H, Block PC, Harrell L, Palacios IF. Is redo percutaneous mitral bal- loon valvuloplasty (PMV) indicated in patients with post-PMV mitral restenosis? J Am Coll Cardiol 1999;34:49–54. 4. Rifaie O, Ismail M, Nammas W. Immediate and long-term out- come of redo percutaneous mitral valvuloplasty: Comparison with initial procedure in patients with rheumatic mitral restenosis. J Interv Cardiol 2010;23:1–6. 5. Padial LR, Freitas N, Sagie A, Newell JB, Weyman AE, Levine RA, Palacios IF. Echocardiography can predict which patients will develop severe mitral regurgitation after percutaneous mitral valvotomy. J Am Coll Cardiol 1996;27:1225–1231. 6. Hernandez R, Macaya C, Ban ˜uelos C, et al. Predictors, mecha- nisms and outcome of severe mitral regurgitation complicating percutaneous mitral valvotomy with the Inoue balloon. Am J Car- diol 1992;70:1169–1174. 7. Rifaie O, Esmat I, Abdel-Rahman M, Nammas W. Can a novel echocardiographic score better predict outcome after percutane- ous balloon mitral valvuloplasty? Echocardiography 2009;26: 119–127. Conflict of interest: Nothing to report. Received 23 August 2010; Revision accepted 4 September 2010 DOI 10.1002/ccd.22822 Published online 15 February 2011 in Wiley Online Library (wileyonlinelibrary.com). ' 2011 Wiley-Liss, Inc. Catheterization and Cardiovascular Interventions 77:596 (2011)