EComment. Beyond the tricuspid annuloplasty techniques

Abstract

We have read with great interest the article by Iida et al. [1]. This is a very nice technique and it seems that it works well. However, the core of tricuspid repair continues to be the use of a prosthetic ring. In fact, better long-term outcomes are obtained with prosthetic rings than with suture annuloplasty, with an incidence of residual severe tricuspid regurgitation (TR) of 12% vs 32% at 5 years, respectively [2, 3]. Much attention has been focused on the importance of the guidelines of the managment of valvular heart disease [4]. Nevertheless, at a glance, the surgeon can note that the level of evidence is C for absolutely all kinds of recommendations. That is, these are based exclusively on consensus of opinion of the experts and/or small studies, retrospective studies or registries. There is no data derived from multiple randomized clinical trials or meta-analyses. All the above has particular importance because beyond the tricuspid annuloplasty techniques, we move into the difficult terrain of surgical practice and decision making where there are no easy or 'pure' solutions. Particular attention must be addressed with great care to identify patients with right ventricular (RV) dysfunction. Today, we know that tricuspid annular plane systolic excursion (TAPSE) ( 20 cm2) could be used with this aim [5]. At present, there are no precise statistical data available on irreversible RV dysfunction in patients with severe TR undergoing left-sided valvular surgery. The concept that all TRs can be operated is worthy of further discussion. In this pool of patients with irreversible RV dysfunction, tricuspid annuloplasty could perhaps worsen the postoperative outcome by removing the only natural escape hatch of a deteriorated and poor RV. Moreover, perhaps these patients should be considered as inoperable. Conflict of interest: none declared