Rethinking tricuspid ring size: one size does not fit all?

European Journal of Cardio-Thoracic Surgery, vol. 67

Abstract

Dear Editor, With great interest, we read the article by Ono et al. [1] entitled ‘Optimizing ring selection for secondary tricuspid regurgitation: the role of body size’. It addresses an interesting and rather understudied topic in cardiothoracic surgery. The tricuspid valve has long been referred to as the ‘forgotten valve’; however, it has recently gained more attention with more studies being performed to further understand its epidemiology of disease and to get insight into treatment possibilities. Herewith, we would like to address several points of concern related to the methodology and generalizability of this study. Besides the limitations already mentioned by the authors, we would like to highlight some methodological concerns. The mean body surface area (BSA) in this study was 1.53 m2, which raises concerns regarding its representativeness for the European population where the average BSA is markedly higher (i.e. 1.86 m2 from a German study [2]). In addition, despite the propensity score matching, more patients in the small tricuspid annuloplasty ring index (TARI) group underwent a mitral valve replacement than the large TARI group (72.9% versus 58.3%, respectively) and, accordingly, less patients underwent a mitral valve repair. Both the severity and mechanism of disease might be substantially different behind these 2 procedures, which might have skewed the results towards 1 end. Last, the preoperative tricuspid regurgitation (TR) grade was moderate in 43.1% and severe in 14.6% of the patients; however, no information is provided regarding the indication for a concomitant tricuspid annuloplasty in the other 42.3%.

Authors 3

1. Olga Papazisi corresponding Aachen Department of Cardiothoracic Surgery

   University Medical Center Utrecht · Leiden University Medical Center

   Affiliation as printed

   Department of Cardiothoracic Surgery, Leiden University Medical Center , Leiden,

   Department of Cardiothoracic Surgery, University Medical Center Utrecht , Utrecht,

   Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands

   Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, Netherlands

2. Amir H. Sadeghi

   University Medical Center Utrecht

   Affiliation as printed

   Department of Cardiothoracic Surgery, University Medical Center Utrecht , Utrecht,

   Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, Netherlands

3. Mostafa M. Mokhles

   University Medical Center Utrecht

   Affiliation as printed

   Department of Cardiothoracic Surgery, University Medical Center Utrecht , Utrecht,

   Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, Netherlands