One, no one, and one hundred thousand: the Barlow’s disease, not only a matter of ring

Dear Editor, We read with interest the manuscript by Pölzl et al. [1], which analyses the 5-year outcomes of minimally invasive mitral valve repair in Barlow’s disease. Among 246 patients, they did not find any significant difference between 3 surgical techniques (annuloplasty, annuloplasty + artificial chordae and annuloplasty + resection) with regard to operative safety and a combined end-point of mortality, reoperation due to repair failure or recurrence of severe mitral regurgitation within the follow-up period. We congratulate the authors, highlighting the concept that Barlow’s disease is an extremely chameleonic disease, in which both anterior and/or posterior leaflets can be preferentially involved [2]. Unfortunately, authors do not show any additional preoperative echocardiographic characteristics (e.g. annular and left ventricle diameters, leaflet prolapse/flail, leaflet-to-annulus index), a point that would be essential to better understand the operative and postoperative outcomes, in particular in those who underwent an isolated annuloplasty (who suffered the highest rate of replacement valve conversion—26.6%). Besides, when discussing the different technical strategies to address Barlow’s disease, authors forget to cite transapical neochord implantation as an alternative option. This off-pump beating-heart approach has been used since 2014 and even if it has shown better 5-year results in favourable anatomies (e.g. posterior leaflet flail/prolapse) [3], it has been successfully applied also in more complex Barlow’s disease [4]. This microinvasive neochord implantation implies mitral valve competence restoration, preserving nature structures without interfering with native mitral annulus physiology. This is a new emerging concept, which must be taken into account while cardiac surgery turns into a new miniaturized therapy; in fact, thanks to the transapical neochord implantation technique, we can offer to a specific subgroup of patients a viable microinvasive alternative, which has the ultimate target of lowering hospital mortality, recovery time and fasting the return to the highest quality of life [5, 6]. However, the preoperative planning and the anatomical evaluation of the disease become the imperative point to embrace the best therapeutical option, which is not only and always directed towards annular management. In conclusion, we acknowledge the authors for their important contribution to the topic; however, it is important to properly evaluate mitral valve anatomy before repair in order to offer patients the most precise treatment option (resect, respect or restore) [5]. Once again, in accordance with the Italian ancient writer Pirandello, we can conclude that Barlow is one disease, with no one unique anatomical definition and one hundred thousand potential surgical solutions. Conflict of interest: none declared.