Independently from mitral regurgitation, Barlow disease may cause left ventricular enlargement and thereby anticipation of surgery.

Sir: We read the article ‘Anatomic characteristics of bileaflet mitral valve prolapse – Barlow disease – in patients undergoing mitral valve repair’ by Rostagno et al. (2014) with great interest. In this article, they shared their surgical observations about bileaflet mitral valve prolapse (MVP) in terms of mitral valve repair. We appreciated their experiences on mitral valve repair in patients having MVP. However, we have some doubts about the timing of surgery. They reported that almost half of the patients were in New York Heart Association functional class (NYHA) I or II and that the left ventricular (LV) end-diastolic and end-systolic diameters of the patients were 58.02±6.14 and 34.81±6.88 mm, respectively. Moreover, LV ejection fraction of the patients were 62.32±7.11%. All of the above mentioned findings suggest the possibility that surgical intervention was premature in some patients according to guidelines (Vahanian et al., 2012). This may result from the good experience of the surgical team in the repair procedures for MVP. They may desire that mitral regurgitation (MR) disappears before impairment in systolic function of LV. This may have logical reasons. Instead of replacement, they repair mitral valves, thereby i) patients take not so much surgical risk, and ii) they are protected the patients from the negative effects of long-term mechanical valve. It is well known that capabilities may sometimes influence decision-making process. However, there is no randomized clinical trial investigating the optimal timing for surgical intervention in patients with MR who are candidate for mitral valve repair. In this context, new studies investigating the optimal timing for surgery are needed for patients with MR having high probability to undergo mitral valve repair. Furthermore, we previously conducted a research on patients with classic MVP (Yiginer et al., 2012) and demonstrated that patients with classic bileaflet MVP have