Reply: Alfred Kocher technique—A eulogy for patient-prosthesis mismatch

Reply to the EditorThe exact research by the author on the history of aortic root enlargement, which brings to light names previously unknown to the broader cardiac surgical community, is appreciated but the conclusion is not. 1 In analogy, young people were in love long before the publication of Romeo and Juliet by the famous playwright William Shakespeare 2 elements of the plot trace back to Ovid's Metamorphoses in 8 AD 3 -and even the feud and the Verona setting had been popularized before.However, it took a masterstroke to epitomize tragic romance.The Alfred Kocher technique is the latest iteration of a number of aortic root enlargement procedures, all aiming at solving one profound problem in surgical aortic valve replacement that has been there right from the beginning in 1960: patient-prosthesis mismatch (PPM).4 PPM is very common, with up to 70% occurrence in a recent meta-analysis, and carries the risk of premature death regardless of its degree.Nicks was the first surgeon to tackle this issue back in 1965 by extending the aortotomy next to the posterior commissure toward the anterior mitral leaflet.Surgeons then veered away from axial blood flow to the posterior commissure, left sinus, anterior commissure, and right sinus, requiring a more extended aortotomy, involving numerous anatomical structures for one single procedure, ie, the proximal aorta, mitral valve annulus and anterior leaflet, left atrial roof, interventricular septum and right ventricular outflow tract, leading to increasing complexity with greater perioperative mortality.Only a handful of those colleagues and their eponyms have become household names in cardiac surgery.The novelty of the Alfred Kocher technique lies in its eclectic approach, sophistication through simplicity, and conceptual unimprovability.It is worth noting that both the comments by Soquet and Piehler's surgical procedure are solely based on the location of the incision.The Alfred Kocher technique is not merely an incision.It begins with a standard hockey stick aortotomy, allowing the decision to enlarge to be made after sizing.The inverted asymmetric T-incision-a configuration neither named nor illustrated in