of fresh nonpreserved autologous pericardium needs to be confirmed. In 1980, Carpentier and colleagues [2], demonstrated that the anterior leaflet has restricted motion, which is a major factor in tricuspid incompetence [3]. In our practice, the reduced motion of the anterior leaflet has to be treated to obtain a competent tricuspid valve. I would be interested to know how the authors solve the problem of reduced mobility of the anterior leaflet. The right ventricular wall resection is a major contribution. It appears to be safe and to produce excellent results. Sylvain Marc Chauvaud, MD Department of Cardiovascular Surgery Hôpital Européan Georges Pompidou 20, Rue Leblanc 75015 Paris, France e-mail: sylvain.chauvaud@egp.ap-hop-paris.fr References 1. Wu Q, Huang Z. A new procedure for Ebstein’s anomaly. Ann Thorac Surg 2004;77:470 – 6. 2. Carpentier A, Chauvaud S, Mace L, et al. A new reconstruc- tive operation for Ebstein’s anomaly of the tricuspid valve. J Thorac Cardiovasc Surg 1988;96:92–101. 3. Chauvaud S, Berrebi A, d’Attellis N, Mousseaux E, Hernigou A, Carpentier A. Ebstein’s anomaly: repair based on func- tional analysis. Eur J Cardio-thorac Surg 2003;23:525–31. Reply To the Editor: Thank you very much for your very kind comments and interest in my article [1]. I wish to clarify some details in response to your letter. I agree with your description about the anatomy of the septal and posterior leaflets; we see the same in our patients. There is a mistake in my article: “Half of the septal leaflet near to the antero-septal commissure was severely hypoplastic, which made this area without valve tissue. The remainder of the septal leaflet was displaced 1.5 cm from the annulus” should be changed to: “Half of the septal leaflet near the postseptal commissure was severely hypoplastic, which made this area without valve tissue. The remainder of the septal leaflet was displaced 1.5 cm from the annulus.” As you said mobilization of the septal leaflet appears to be an impossible challenge; therefore, we detached the base of the septal leaflet to use that as some chordae tendinea or as part of the leaflet extension. As you know, there is no material better than fresh autologous pericardium. Glutaraldehyde-treated pericardium is too in- flexible to preserve function of the rebuilt leaflet. What is more, we have experience that fresh autologous pericardium produced good results in mitral valve repair; therefore we believe that fresh autologous pericardium should be satisfac- tory for leaflet function in the tricuspid valve, which is under lower stress than the mitral valve. Furthermore, the septal leaflet is not as important as the anterior leaflet. In my article, we did not discuss the hypoplastic anterior leaflet, but we do think the anterior leaflet is the most important part to maintain normal function of the tricuspid valve. For anterior leaflet adhesion, we usually detached the free edge of the adherent leaflet, using the posterior or septal leaflet tissue to form “new chordae tendinea.” We transferred this to the free edge of the anterior leaflet, to rebuild the anterior leaflet, or we freed some parts of the muscle, which connected to the anterior papillary muscle to lengthen the muscle. We suggest that Ebstein’s anomaly may be better divided into three pathologic types, which has some advantage in the surgi- cal treatment for the anomaly. Type A (no downward displace- ment of anterior leaflet with septal and post leaflets anomaly) and type B (less than 1/3 of the anterior leaflet displaced downward, with septal and post leaflets anomaly) are both eligible for the new procedure to avoid the valve replacement. Type C (more than 1/3 of the anterior leaflet displaced down- ward and is severe hypoplasty, with septal and post leaflets anomaly, and right outflow tract stenosis often can be seen in this type) may need a Glenn procedure, 1 1 / 2 ventricle correction, total cave-pulmonary vein connection (TCPC), or heart trans- plantation. The anterior leaflet situation usually correlates to the size of the atrialized ventricle, the degree of the tricuspid regurgitation, and function of the right ventricle. Thanks again for your interest. I hope my team and I can meet you in the near future to share your experience. Qing-yu Wu, MD Department of Cardiovascular Surgery 1st Hospital affiliated to Tsinghua University No. 6 Jiuxianqiao 1st Road, Chaoyang District Beijing, China 100016 e-mail: wuqingyu@public.bta.net.cn Reference 1. Wu Q, Huang Z. A new procedure for Ebstein’s anomaly. Ann Thorac Surg 2004;77:470 – 6. Patent Ductus Arteriosus in Neonates and New Approaches To the Editor: The publication by Vicente and colleagues [1] describes an original approach to patent ductus arteriosus (PDA) closure in premature neonates. Although PDA treatment has historically been a field in which pediatric surgery and cardiology have pioneered new techniques, we believe that the reported surgical procedure does not offer clear advantages. Very low birth weight ( 1,500 g) infants are an extremely fragile group of patients, and concerns about morbidity of our therapeutic acts are particularly important [2]. A thoracotomy is always an invasive act, even if performed with a minimally invasive intent. Muscle cutting, rib spreading, and lung manip- ulation are components of the dorsal approach; besides, it is performed close to the spine, the hinge of the thoracic cage. We fear that posterior incision can augment the risk of complica- tions such as scoliosis, rib deformities, and shoulder dysfunction [2]. Blunt dissection by q-tips does not warrant pleural integrity: actually “parietal pleural lacerations” were said to be “common” in the article [1]. Thus it is logical to suppose the occurrence of pneumothorax, but incidence and techniques of drainage are not reported. Another drawback is the prone position of the patient with potential problems of airway control, endotracheal tube displacement, management of perfusion, and monitoring lines. It was not reported where the operation was performed, but transfer to the operating room of such patients who are frequently unstable, in addition to temperature management can be very demanding. Last year The Annals of Thoracic Surgery published a consistent experience of a video-assisted thoracoscopic clipping of the PDA 1827 Ann Thorac Surg CORRESPONDENCE 2005;79:1824 –30 © 2005 by The Society of Thoracic Surgeons 0003-4975/05/$30.00 Published by Elsevier Inc MISCELLANEOUS