We have read with interest the response of Uribarri et al. to our report.1 The patient had severe left ventricular dysfunction. This patient was evaluated and not considered a good candidate for septal myectomy, which would not improve his severe systolic impairment and adverse remodeling. Severe systolic impairment is a rare complication in patients with hypertrophic cardiomyopathy that has a poor prognosis2; this situation would not be improved by performing an isolated myectomy.

All surgical considerations described by Uribarri et al. were also evaluated by our team, as well as the opinion of international surgeons with hundreds of implants. As reported, we performed an intraoperative examination of the left ventricle, when the patient was on pump, which included visual and digital examination of the cavity, in addition to the preoperative analysis of transthoratic and transesophageal echocardiograms. There was enough space after the coring without any possibility that the inflow caused any suction of the trabecules, if the pump was correctly positioned. We considered performing a myectomy during the implantation and decided that the risks outweighed the potential benefits. Although inotropes could theoretically increase the outflow tract gradient, this would be a minor complication at short term, because the effects would be the same as those of a closed aortic valve. We did not see any midventricular gradient; probably as the result of the good selection of a patient with enough cavity. We would like to point out that adding more procedures to device implantation leads to a longer time on cardiopulmonary bypass, which is a well-known independent risk factor for postoperative mortality, morbidity, and right heart failure in cardiac surgery3; therefore, additional procedures in this case would have increased surgical risk with an unclear clinical benefit. The anatomical variability of these patients makes an individual case evaluation mandatory and general messages not useful.

We agree that ventricular assist devices in patients with restrictive physiology should be performed in high-volume centers; at this moment in Spain there are no hospitals that meet these criteria but we have patients who need treatment. The rarity and complexity of a patient like the one we present make “safe options” difficult to find. What this patient needed was an option and now he is on the transplant list after normalization of pulmonary pressures.