Our series of patients with ASD by transcatheter occlusion shows that the procedure is safe and effective in the vast majority of cases. To further reduce the complications rate, the criteria of device selection according to ASD morphology and some technical tips during implantation are discussed.

In the current era and in experienced hands, pmVSD closure can be performed safely and successfully. The major concern is the occurrence of cAVB; therefore, very careful monitoring of rhythm is mandatory during follow-up.

Although the surgical mortality significantly increased with increased age, surgical management was still associated with significantly lower in-hospital mortality rates compared with medical management until the age of 80 years. Surgery may decrease the in-hospital mortality rate for octogenarians with type A aortic dissection and might be considered in all patients with type A aortic dissection regardless of age.

The International Registry of Acute Aortic Dissection experience confirms that patient selection plays an important role in determining surgical outcomes in patients with acute type A aortic dissection. Knowledge of significant risk factors for operative mortality can contribute to better management and a more defined risk assessment in patients affected by acute type A aortic dissection.

We thank Dr Lown et al and Dr Miceli et al for their comments about our article. 1 They raise several different and interesting points.It is of course possible that the selection of a limited number of variables for the risk model may better benefit from other more sophisticated statistical approaches. However, even if our model is apparently simplistic, it seems to work better than other complex models. We agree that an area under curve value of 0.744 is probably inadequate for clinical purposes, but this is the value reached by the widely used EuroSCORE in many clinical settings. 2 Actually, in the validation series, the area under curve value of the ACEF score (age, creatinine, ejection fraction) was higher than 0.8. 2 As stated in our article, it is a matter of terminology. We could say that the ACEF and the EuroSCORE are equally good or equally bad models. To answer the authors' question, we did sensitivity analyses in a subgroup of patients at low, medium, and high risk, and the worst accuracy was achieved in the high-risk patients (EuroSCORE Ͼ5). However, it should be considered that the ACEF is built for elective patients. When addressing the whole range of cardiac surgery population, more variables are needed to improve the accuracy of the model, up to 5 for medium-risk patients and even 12 in high-risk patients. 2 Dichotomization of continuous variables is always arbitrary in statistics but is a common practice in the development of risk scores. The important point is to dichotomise according to a method that may guarantee the best specificity and sensitivity of the identified cutoff value. We did dichotomise the serum creatinine value (as in the great majority of the existing scores) using the sensitivity and specificity values of the receiver operating characteristics curve coordinates and the Youden index. We agree that every kind of preoperative renal function impairment may strongly affect the operative mortality, and we cannot exclude that using serum creatinine as a continuous variable (as we did for age and ejection fraction) may improve the accuracy of the model, however at the expenses of more complex calculations.We agree with Lown et al about the limitations of area under curve-based systems and the risk of overfitted models, availability of data, and subjectivity, and these last reasons led us to propose a parsimonious model. Conversely, we are not sure that simple models may be more adequate for acute settings and complex models for elective settings. Actually, our experience is that when acute risk conditions intervene, more factors are needed to stratify the risk. 2 It was demonstrated that when severe acute conditions are present, the current scores are inadequate to stratify mortality risk. 3 When developing this model, we considered many potential factors that could be independently associated with operative mortality after cardiac surgery. Among these factors are those mentioned by Miceli et al (gender, chronic obstructive pulmonary disease, operations other than isolated coronary a...