We thank Dr Bhargava and colleagues for their interest in our paper, regarding recurrent miscarriages as an indication for percutaneous tricuspid valvuloplasty during pregnancy .
Indeed, cardiac output in our reported case did not substantially increase, but heart rate decreased from 105 to 82 p/min and, consequently, stroke volume increased from 43 to 56 ml/min, demonstrating a substantial hemodynamic improvement. We assume that a further increase in cardiac output would have occurred a few days after the procedure due to the discontinuation of diuretics that the patient was taking before the procedure. Bleeding during the procedure from the puncture site could also explain the lack of substantial increase in cardiac output that is a common observation in our experience of balloon mitral valvuloplasty.
As to the use of the Inoue balloon, we are impressed by the short fluoroscopy time of 110 seconds reported by the authors for combined tricuspid and mitral valvuloplasty, which must be the shortest time ever reported for such a combined procedure . In our experience of balloon mitral valvotomy during pregnancy [3], the fluorocopy time was of 16 ฯฎ 7 minutes, which was similar to the experience of others . The relatively long fluoroscopy time in our case was mostly related to the difficulty in positioning the balloons, which is a common problem reported by others . We used the double balloon technique because the Inoue balloon was not available in our center at the time. However, we do agree that the use of Inoue technique would have shortened the fluoroscopy time.