CORRESPONDENCE Exclusion of Mitral Valvuloplasty From Predictors of Mortality for Patients Undergoing Cardiac Valve Replacements in New York State To the Editor: We read with great interest the recent article by Hannan and associates [1], which represented studies at an academic medical center in New York State with an extremely large experience with valvular heart surgery. Although the model created for predicting mortality in valvular surgery was validated, we were concerned by the incomplete treatment of mitral valve recon- struction in this report. In their analysis the authors create logistic regression models for all major groups of cardiac valve operations with the exception of isolated mitral valvuloplasty. Indeed, even within the isolated mitral replacement model the effect of various valve types is independently tested. Meanwhile, in Table 1 of their article, the authors separately identify 742 cases of mitral valvuloplasty that are not included in the logistic modeling, while performing such a logistic analysis on the fewer than 600 patients with mitral valve replacement and/or valvulo- plasty and concomitant coronary artery bypass grafting. Assum- ing that the mitral valvuloplasty category in Table 1 refers to isolated mitral reconstruction, the crude mortality of 2.56% makes the unadjusted mortality for mitral replacement 2.4-fold that of mitral valvuloplasty. It is, therefore, very unclear as to why no analysis was performed to test the effect of mitral valuloplasty compared with mitral valve replacement, as it seems intuitive that risk-adjusted modeling of such large patient groups would be very instructive in determining whether there is an independent hospital survival benefit from mitral valvulo- plasty. Similarly, excluding these patients from the analysis may skew the results significantly or perhaps even invalidate the results of predictive mortality risk in all patients requiring isolated mitral valve surgery. In summary, we congratulate the authors on an excellent analysis on predictors of mortality after valvular surgery, but strongly suggest that they include mitral valvuloplasty patients in any future analysis. The relevant data are readily available, and inclusion of these patients would enhance the validity of their results and strengthen any conclusions that are ultimately based on their data. Stephen B. Colvin, MD Aubrey C. Galloway, MD Eugene A. Grossi, MD Department of Surgery New York University School of Medicine 530 First Ave, Suite 9V New York, NY 10016 Reference 1. Hannan EL, Racz MJ, Jones RH, Gold JP, Ryan TJ, Hafner J-P, Isom OW. Predictors of mortality for patients undergoing cardiac valve replacements in New York State. Ann Thorac Surg 2000;70:1212– 8. Reply To the Editor: The authors of our manuscript [1] sincerely appreciate the comments of Colvin and associates and their many contribu- tions to the field of valvular heart disease. The analysis presented in the manuscript under discussion was modeled on the STS National Database reports with regard to choosing valve procedures for presentation. Although inde- pendent risk factors were identified for mitral valve repair during our analyses, they were not reported for this reason. However, even if mitral valve repairs had been reported, the direct comparison of mitral valve replacement and mitral valve repair outcomes is problematic. The patient populations differ significantly, and therefore the significant risk factors and out- comes differ as well. The authors’ suggestions for future investigation are appreci- ated, and we agree with them that mitral valve repair is a sufficiently important part of the modern surgical armentarium to be considered for inclusion in future valve surgery reports. Jeffrey P. Gold, MD Edward L. Hannan, PhD Michael J. Racz, MA Robert H. Jones, MD Thomas J. Ryan, MD Jean-Paul Hafner, MD O. Wayne Isom, MD Department of Cardiothoracic Surgery Montefiore Medical Center Albert Einstein School of Medicine 111 E 210th St Bronx, NY 10467 e-mail: elh03@health.state.ny.us. Reference 1. Hannan EL, Racz MJ, Jones RH, Gold JP, Ryan TJ, Hafner J-P, Isom OW. Predictors of mortality for patients undergoing cardiac valve replacements in New York State. Ann Thorac Surg 2000;70:1212– 8. Combined Transseptal Superior Approach to Mitral Valve: Management of Left Superior Vena Cava To the Editor: Of the various approaches for mitral valve operations, we have been using the combined transseptal and superior approach more often, and it is the approach of choice during minimally invasive mitral valve operation as described by Cosgrove and Gillinov [1]. The indications and efficacy of this approach have been described previously [2, 3]. A persistent left superior vena Fig 1. Direct left superior vena cava (LSVC) cannulation does not interfere with exposure of the mitral valve. © 2001 by The Society of Thoracic Surgeons Ann Thorac Surg 2001;72:663–9 • 0003-4975/01/$20.00 Published by Elsevier Science Inc PII S0003-4975(01)02754-0