An effective balance is based on many pillars

we thank dr tomsic and colleagues from Leiden for their comments about our recently published study. annular stabilization is the main concern of cardiac surgeons for long-term durability of transapical neochords implantation (NC) due to our well-established surgical technique. transcatheter edge-toedge mitral repair is always done with no annular stabilization but apparently, this is not seen as a major concern among interventional cardiologists who have demonstrated to be perseverant and keep on expanding indications and performing trials (REPAIR MR clinical trials.gov Identifier: NCT04198870 and PRIMARY clinical trials.gov Identifier: NCT05051033). as a matter of fact, so far data do not support the lack of mitral annulus stabilization as a potential cause of NC failure. In our entire experience with transapical-NC [1], failure has never been related to mitral annular enlargement. furthermore, it has already been demonstrated that annular remodelling (reduction of annular diameter) occurs in patients undergoing this procedure [2]. early referral and consequently early treatment of patients with degenerative mitral regurgitation (DMR) is likely going to reduce the need for annular stabilization. It is true that conventional surgery for DMR provides optimal results in terms of mortality and complications as well as of freedom from recurrent mitral regurgitation (MR) in centres of excellence that are dedicated and highly committed to this procedure [3] but the real world is a different thing [3, 4].