eComment. Right ventricular dysfunction in functional tricuspid regurgitation: a word of caution

N. Umehara et al. / Interactive CardioVascular and Thoracic Surgery APPENDIX. CONFERENCE DISCUSSION Dr M. Antunes (Coimbra, Portugal): The Tokyo group reviewed the experience of tricuspid reoperation for severe tricuspid regurgitation from the national database. These were not necessarily reoperations on the tricuspid valve but just valve reoperations, the majority of the patients having had only left side valve surgery before. Two subgroups were analysed, patients who required tricuspid valve replacement (fortunately a minority from the results we saw), and those who were treated by valvuloplasty, which is not specified, and I suppose that that means annuloplasty, whether with a ring or with a suture. Patients who had TVR were much sicker and had far more risk factors, hence, not surprisingly, they had much worse outcome. This is not the result of the type of procedure, and I don’t think that the conclusion is correct. You needed to do further statistical analysis to see whether the type of operation itself really was a risk factor. I have doubts about that, except, of course, for AV block, but that requires just careful attention to the technique. So this is a problem of the patients, not a problem of the type of operation, and for that reason I totally support your conclusion that these patients need to be improved before surgery and, in my experience, that can be done in the vast majority of cases with a significant improvement in the results. So my question here, and again, it didn’t become clear from the abstract or from your presentation, is what triggered reoperation for tricuspid regurgitation, the degree of regurgitation or the symptoms of the patients? And that’s important, because not all the patients with severe tricuspid regurgitation get severely symptomatic, and if they are allowed to go too long, the reoperation becomes far more difficult. And, with regard to all the previous presentations, I am not entirely convinced that the so-called remodelling of the right ventricle will happen necessarily and that it cannot be altered or greatly modified by persistence of intense anti-failure therapy, which means diuretics and vasodilators. We operate on these patients’ left valves, they become totally asymptomatic and medical therapy is usually discontinued. In our practice, we keep these patients on vasodilators and diuretics, irrespective of the absence or presence of symptoms, and we do not have a high prevalence of patients requiring reoperation for tricuspid regurgitation. My question is, what makes Japanese surgeons decide to go for a tricuspid valve procedure as a reoperation? Was it symptoms or was it the presence of tricuspid regurgitation, because that makes a difference? Dr S. Saito (Tokyo, Japan): I am a co-author and will answer. The answer to the question is, basically it’s the symptoms, rather than the presence of regurgitation. As you have pointed out, reoperative tricuspid surgery for symptomatic patients can be eventually too late. We Japanese surgeons and cardiologists frequently follow-up the patient who had left side surgery, and sometimes a very small amount of tricuspid regurgitation is found during the follow-up echocardiogram. The patients are looked at, together with liver enzyme elevation or symptoms. Basically, when the patient’s symptoms become evident, such as oedema or right-sided failure, and are combined with a total bilirubin and liver enzyme elevation, that would be the perfect timing for the reoperation. Nevertheless, the cardiologists are following up the patients for too long, and when we are putting the patient on the operating table, sometimes it is quite difficult to repair. Would that be the answer to your question? Dr Antunes: More or less. I understand that there are some language problems, but I think I left the message I wanted to give. Author: Ovidio A. Garcia-Villarreal Department of Cardiac Surgery, Hospital of Cardiology, UMAE 34, IMSS, Monterrey, Mexico doi: 10.1093/icvts/ivu149 © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. I have read the article by Umehara et al. [1] with great interest. The results shown in this paper are not unexpected. I think the decision of whether or not to operate on these patients depends on the state of right ventricular (RV) function. In severe RV dysfunction, functional tricuspid regurgitation (TR) provides the RV with an additional “escape”. The choice facing the surgeon is clear. The greater the RV dysfunction, the greater the TR. This emphasis is fully understandable and focused on what occurs beyond the procedure. Mild or moderate functional TR left uncorrected at the time of left-sided valvular surgery can become severe in approximately 34% of cases, with a poor outcome and reduced survival [2]. Quality of life and survival are directly related to residual RV function rather than the type of procedure on the tricuspid valve. The presence of severe pulmonary hypertension and/or significant RV dysfunction can be a relative contraindication to reoperation [3]. Therefore, the risks and benefits of tricuspid valve reoperation should be carefully considered when severe RV systolic dysfunction and/or irreversible pulmonary hypertension are present, due to the possibility of RV failure following the procedure. I strongly recommend the assessment of RV systolic function by echocardiography (tricuspid annular plane systolic excursion >16 mm, tricuspid valve annular velocity >10 cm/s, and RV end-systolic area <20 cm2) as a very important tool in the decision-making process. These observations address the option that these patients might be considered as inoperable [4]. Conflict of interest: none declared. References [1] Umehara N, Miyata H, Motomura N, Saito S, Yamazaki K. Surgical results of reoperative tricuspid surgery: analysis from the Japan Cardiovascular Surgery Database. Interact CardioVasc Thorac Surg 2014;19:82–87. [2] Dreyfus GD, Corbi PJ, Chan KM, Bahrami T. Secondary tricuspid regurgitation or dilatation: Which should be the criteria for surgical repair? Ann Thorac Surg 2005;79:127–32. [3] Fukuda S, Gillinov AM, McCarthy PM, Stewart WJ, Song JM, Kihara T et al. Determinants of recurrent or residual functional tricuspid regurgitation after tricuspid annuloplasty. Circulation 2006;114(Suppl I):I582–7. [4] Garcia-Villarreal OA, Cepeda-Ayala GA. Beyond the tricuspid annuloplasty techniques. Interact CardioVasc Thorac Surg 2013;17:738. ORIGINAL ARTICLE eComment. Right ventricular dysfunction in functional tricuspid regurgitation: a word of caution [7] Motomura N, Miyata H, Tsukihara H, Takamoto S. Risk model of valve surgery in Japan using the Japan Adult Cardiovascular Surgery Database. Japan Cardiovascular Surgery Database Organization. J Heart Valve Dis 2010;19:684–91. [8] Motomura N, Miyata H, Tsukihara H, Takamoto S. Japan Cardiovascular Surgery Database Organization. Risk model (...truncated)