First of all, we would like to thank the authors for their interest in our article,1 given their experience in this field.2

Although endomyocardial fibrosis is clearly an idiopathic restrictive cardiomyopathy typically occurring in tropical and subtropical regions, it has also been previously reported in European citizens with no history of travelling to tropical countries.3 Some of these reports have communicated severely calcified forms of this disease.4 We would like to state that an exhaustive evaluation was performed to complete the diagnostic workup and exclude possible causes of our patient's massive cardiac calcification. In fact, calcium metabolism was found to be normal. Diastolic function assessment by transthoracic echocardiogram was hampered by the presence of atrial fibrillation and no invasive evaluation was conducted. In our opinion, cardiac calcification is almost transmural, not only myocardial, as shown by computed tomography. Left ventriculography, which was not included in the original article, revealed a marked distortion of the left ventricular cavity with involvement of the apex (Video).

We should recognize, as the authors state, that endomyocardial biopsy lacks consistency, but we would like to underscore that it is technically challenging to obtain good quality tissue samples in such a calcified heart, which may represent the end stage of this entity. Histopathological examination after surgery could have been definitive for diagnosis; unfortunately, the patient was deemed a poor surgical candidate because of the considerable extent of the process.