Letter by Raikhelkar and Scurlock Regarding Article, “Determinants of Surgical Outcome in Patients With Isolated Tricuspid Regurgitation”
To the Editor:
We applaud Kim et al1 for addressing the importance of determining the preoperative risk factors of clinical outcomes in patients after isolated tricuspid valve surgery. The authors concluded that the preoperative hemoglobin level and right-ventricular end-diastolic area were independent determinants of clinical outcomes.
This study enrolled 61 consecutive patients with isolated tricuspid regurgitation, of which 57 patients (93%) had a previous history of left-sided valve surgery. Only 4 patients in the study had other types of tricuspid valve disease, making the study population rather homogenous in that regard. Is this an accurate representation of the complete spectrum of tricuspid pathology? Rogers et al reported that primary causes of tricuspid regurgitation (rheumatic, endocarditis, carcinoid disease, trauma, and iatrogenic) comprise ≈25% of all tricuspid regurgitation.2 Filsoufi et al reported an organic pathogenesis in 64% of patients undergoing tricuspid valve replacement.3 In this study, the primary causes of tricuspid regurgitation are present in a minority of patients.
In the present study, all patients underwent comprehensive 2-dimensional echocardiographic examinations at intermittent intervals in which right-ventricular end-diastolic and end-systolic areas were measured. Apical views obtained during 2-dimensional echo scanning are often foreshortened and may result in an underestimation of right-ventricular length used in area-length formulas.4 Although it is a well-validated marker of right-ventricular systolic function, measurement of right-ventricular end-systolic area requires experienced personnel for image acquisition and may not be so easily attainable with accuracy with 2-dimensional echocardiography.
Kim YJ, Kwon DA, Kim HK, Park JS, Hahn S, Kim KH, Kim KB, Sohn DW, Ahn H, Oh BH, Park YB. Determinants of surgical outcome in patients with isolated tricuspid regurgitation. Circulation. 2009; 120: 1672–1678.
Rogers JH, Bolling SF. The tricuspid valve: current perspective and evolving management of tricuspid regurgitation. Circulation. 2009; 119: 2718–2725.