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Eur J Cardiothorac Surg 2006;29:634-635
© 2006 Elsevier Science NL

Letter to the Editor

‘Trivial tricuspid regurgitation’ — is the impact really trivial?

Glasgow Royal Infirmary, 16 Alexandra Parade, Glasgow G31 2ER, UK

Received 18 November 2005; accepted 29 December 2005.

^_* Corresponding author. Address: 2/2 6 McAslin Court, Glasgow G4 0PQ, UK. Tel.: +44 141 5645206/2114731; fax: +44 141 2114845. (Email: mishrapk_25{at}yahoo.com).

Key Words: Information • Consent • Cardiac • Questionnaire

I read with interest the recent article by Koch et al. [1] where they have discussed the influence of different implantation techniques on AV valve competence after orthotopic heart transplantation. It is an excellent article minus some glaring spelling mistakes (e.g. first line of abstract where ‘pulmonary’ and first line on page 722 where ‘imminent’ are wrongly spelled). The presentation of Section 4.7 on Surgical Technique makes reading and interpretation a bit difficult. I would like to add a few comments.

The impact of tricuspid valve regurgitation (TR) on right ventricular function (RV) has been grossly underestimated since the advent of cardiac transplantation. A poorly functioning RV leads to further aggravation of tricuspid regurgitation leading to a vicious cycle [2]. Repeated endomyocardial biopsies lead to further chordal and valvular trauma with increasing tricuspid regurgitation [2,3]. Endomyocardial biopsy continues to be the gold standard for postoperative surveillance for rejection. The various non-invasive investigations recommended lack the sensitivity and specificity and hence are poor surveillance tools. It should be noted that the frequency of endomyocardial biopsies varies from centre to centre and efforts should be made to decrease its frequency [3].

The impact of TR and a poor RV function on patients’ quality of life is enormous. The situation becomes more challenging in patients with pulmonary hypertension. Therefore, one must be cautious in interpreting ‘mild TR’ or ‘trivial TR’ reported on echocardiography in this subset of patients. Some of these echocardiography results are coming from cardiologists or technicians who more often than not fail to see the larger picture as discussed above. Tricuspid regurgitation is quite often ignored and underreported while mitral incompetence (MR) might set the alarms ringing.

Patients with moderate TR postcardiac transplantation do not necessarily have a benign course [2,4]. Suggestions have been made that the severity of intraoperative tricuspid regurgitation could predict poor late survival following cardiac transplantation [4]. Intraoperative echocardiography could detect TR, and it needs to be evaluated whether there is a role for concomitant TV repair at the time of transplant [4,5]. Whether it will improve the long-term survival is not known [4].

Once tricuspid regurgitation becomes severe enough to affect the quality of life, its management is difficult and controversial. Results of medical management are not gratifying. Though both repair and replacement of the tricuspid valve in cardiac transplant patients have been described, the reported series are small in numbers, mortality is high and the end results poor.

This article clearly shows that incidence of severe TR is much less with total orthotopic technique. In spite of this only 4.5% centres are using this technique worldwide [1]. It's high time that tricuspid incompetence got the ‘respect’ and attention it deserves as far prevention, diagnosis and treatment is concerned. It could not be allowed to play second fiddle to mitral incompetence anymore.

I congratulate the authors for their good work.

Footnotes

The authors of the original paper [1] were invited to reply to this Letter to the Editor but declined.

References

1. Koch A, Remppis A, Dengler TJ, Schnabel PA, Hagl S, Sack FU. Influence of different implantation techniques on AV valve competence after orthotopic heart transplantation. Eur J Cardiothorac Surg 2005;28:717-723.[Abstract/Free Full Text]
2. Chan MC, Giannetti N, Kato T, Kornbluth M, Oyer P, Valantine HA, Robbins RC, Hunt SA. Severe tricuspid regurgitation after heart transplantation. J Heart Lung Transplant 2001;20(7):709-717.[Medline]
3. Nguyen V, Cantarovich M, Cecere R, Giannetti N. Tricuspid regurgitation after cardiac transplantation: how many biopsies are too many?. J Heart Lung Transplant 2005;24(7 Suppl.):S227-S231.[Medline]
4. Anderson CA, Shernan SK, Leacche M, Rawn JD, Paul S, Mihaljevic T, Jarcho JA, Stevenson LW, Fang JC, Lewis EF, Couper GS, Mudge GH, Byrne JG. Severity of intraoperative tricuspid regurgitation predicts poor late survival following cardiac transplantation. Ann Thorac Surg 2004;78(5):1635-1642.[Abstract/Free Full Text]
5. Haverich A, Albes JM, Fahrenkamp G, Schafers HJ, Wahlers T, Heublein B. Intraoperative echocardiography to detect and prevent tricuspid valve regurgitation after heart transplantation. Eur J Cardiothorac Surg 1991;5(1):41-45.[Abstract]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Pankaj Kumar Mishra Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Mishra, P. K. Search for Related Content PubMed PubMed Citation Articles by Mishra, P. K. Related Collections Transplantation - heart Valve disease