Reply

Abstract

I read the article by Hamandi and colleagues 1 with great interest. The authors are to be congratulated for their outstanding contribution to our current knowledge. I have several concerns about the article.In patients undergoing isolated tricuspid valve (TV) surgery, it is essential to separate the patients with endocarditis or congenital TV disease from those with functional tricuspid insufficiency (TI), as progressive dilatation and dysfunction of the right ventricle (RV) develops concomitantly in patients with functional TI. It is given that RV function and the status of end organs are two important preoperative factors dictating early and late outcome after TV surgery. 2 Moreover, the RV tolerates the high-volume state in functional TI by remaining well adapted to maintain the contractility and cardiac output for prolonged periods before progressive RV dilatation, dysfunction, and failure. 3 Therefore, timing of TV surgery is critical, and it relies heavily on the status of the RV, especially in patients with functional TI. Because of the asymptomatic nature of the disease for a long period, serial evaluation of RV function and timely diagnosis of RV dysfunction in its early stage carries the utmost significance in the management of these patients. In the present study, the TV pathology was reported as functional in almost 44% of patients, and almost 62% of patients were in good functional status (New York Heart Association class I and II). The authors had not performed any test to evaluate the RV function; therefore, it is not clear from the article how they judged the exact timing of TV surgery. To my knowledge, for the evaluation of preoperative RV function, in addition to ejection fraction and pulmonary artery pressure, the detection of deterioration in RV function in an early stage with the myocardial performance index and tricuspid annular plane systolic excursion on echocardiography would have helped with the determination of the exact timing of TV surgery, especially in asymptomatic patients with functional TI. 3 In this regard, the estimation of RV volume on cardiac magnetic resonance imaging could also help with determining which patients would benefit from early TV surgery. 3