since the use of a prosthetic ring seems to greatly enhance the durability of the mitral homograft. 2 Using the wall of the aortic homograft and a low insertion of the valve so as to exclude the aorto-mitral abscess when present made unnecessary any recon- struction of the left atrial roof. The mean bypass time was 192  11 minutes, which is comparable with the monobloc aorto- mitral technique according to Obadia and suggests that the preservation of an intact aorto-mitral continuity did not spare any significant ischemic time. Among our 6 pa- tients, there was no in-hospital death. One patient died at 47 months of cerebral hem- orrhage, and there was one reoperation for recurrence of endocarditis at 69 months. Af- ter a mean follow-up of 59  6 months, the remaining 4 patients were asymptomatic and 1 patient had had from a normal preg- nancy. In conclusion, although technically challenging, a combined aortic and mitral valve replacement with two separate ho- mografts can also be a valid option in highly selected cases. Christophe Acar, MD Department of Cardiovascular Surgery Hôpital Pitié-Salpétrière Paris, France References 1. Obadia JF, Hénaine R, Bergerot C, Ginon I, Nataf P, Chavanis N, et al. Monobloc aorto- mitral homograft or mechanichal valve re- placement: a new surgical option for extensive bivalvular endocarditis. J Thorac Cardiovasc Surg. 2006;131:243-5. 2. Ali M, Iung B, Lansac E, Bruneval P, Acar C. Homograft replacement of the mitral valve: eight year results. J Thorac Cardiovasc Surg. 2004;128:529-34. doi:10.1016/j.jtcvs.2006.02.054 Reply to the Editor: The comment by Christophe Acar discusses the alternative between monobloc aorto- mitral homograft, as my colleagues and I have proposed, or separate aortic homograft plus mitral homograft, which he appears to prefer. In our opinion, the indications are not strictly the same. 1 The patients reported in Acar’s series were very different from ours. Our patients had much more severe disease and always had a history of multi- ple reoperations with at least one if not two prostheses in place. The justification for a monobloc procedure is related to the pres- ence of a large abscess in the aorto-mitral curtain, and the main value of monobloc reconstruction is to allow complete resec- tion of the aorto-mitral curtain and there- fore all of the infected tissues. This is im- possible with a separate aortic replacement plus mitral replacement, which obviously leaves all or part of the subaortic curtain in place. In contrast with Acar’s claim, the tech- nique that we propose is not necessarily more difficult to perform. Access to the papillary muscle is largely facilitated by a very large aorto-mitral orifice obtained af- ter resection of all of the subaortic curtain, providing excellent exposure of the papil- lary muscles, which facilitates suture of the mitral homograft. Christophe Acar has an extensive experi- ence with mitral homografts, and his studies inspired us to systematically insert a mitral ring onto the mitral homograft to limit, as rightly suggested by Acar, the risks of mis- match, which are effectively a risk factor for secondary homograft dysfunction. In conclusion, as suggested by Christo- phe Acar, separate homografts could be reserved for patients with distinct aortic and mitral lesions. In contrast, we think it is logical to maintain the principle of a mono- bloc procedure, which is the only technique allowing resection of aorto-mitral abscesses. I believe that the most important point is the quality of the resection phase. Ho- mograft reconstruction has not been dem- onstrated to be superior to monobloc me- chanical prosthesis, which can therefore be preferred in the absence of an available monobloc homograft in the tissue bank. Jean-François Obadia, MD, PhD INSERM, E 0226 Lyon, France Hôpital Louis Pradel Cardiothoracic Surgery and Transplantation Lyon-Bron, France Reference 1. Obadia JF, Hénaine R, Bergerot C, Ginon I, Nataf P, Chavanis N, et al. Monobloc aorto- mitral homograft or mechanichal valve replace- ment: a new surgical option for extensive bi- valvular endocarditis. J Thorac Cardiovasc Surg. 2006;131:243-5. doi:10.1016/j.jtcvs.2006.04.004 What patients want: A new biological era in valvular prostheses To the Editor: We read with great interest the article by Smedira and associates. 1 It deals with the important issue of valvular disease and gives further data to help surgeons to choose the right prosthesis. One of the points that attracted our at- tention was the aim of the study. As the authors clearly expressed, the renewed in- terest in biologic prostheses reflects in- creased attention given by patients to the biologic valve. We are experiencing a similar trend. An increasing number of patients are well in- formed about the benefits and risks of all types of prostheses when they are admitted to the hospital for valve replacement. Con- trary to guidelines, a growing number of patients prefer to choose a biologic pros- thesis, even if they are young and will require a prosthesis replacement. The rea- sons for this trend vary. First, a patient who must undergo valve replacement is inter- ested not only in life expectancy but also in quality of life. Anticoagulant therapy is considered a major limitation to quality of life, especially in those young patients who have an active lifestyle and do not want to change their habits. Moreover, they are more concerned by the risk of thromboem- bolism linked to mechanical prostheses and to anticoagulation than by reoperation. Pa- tients actually know that mortality and morbidity risks after reoperation are de- creasing. Another important topic that is leading more patients to choose a biologic prosthe- sis is the strong belief in technology and technologic advances. Starting with the consideration that the mean life expect- ancy of biologic prostheses is calculated on valves implanted 15 to 20 years ago, newer prostheses probably will last longer because they are constructed with new techniques and treated with new anticalci- fication treatments. Moreover, those pa- tients strongly believe that future replace- ment prostheses probably will have an even longer life expectancy. The surgeon must take note of this new trend. In our institute we are implanting an increased number of biologic prostheses even in younger patients. Even the number of Bentall operations performed with bio- logic valves is increasing, as is the number of valve repairs. Moreover, we have started Letters to the Editor The Journal of Thoracic and Cardiovascular Surgery ● Volume 132, Number 2 443