Concerns about tricuspid leaflet augmentation for severe tricuspid regurgitation

We read with great interest the article describing clinical outcomes after leaflet augmentation using a fresh autologous pericardium for severe functional tricuspid regurgitation (FTR) with a tethering height of at least 8 mm [1]. At 4 years, 84% of survivors were in New York Heart Association functional Class I or II and only two patients had persistent moderate tricuspid regurgitation. First, authors used fresh autologous pericardiums to augment tricuspid leaflet. We were concerned about its durability without any treatment because of retraction and thickening fibrosis of the pericardium. Glutaraldehyde-treated autologous pericardiums have been applied to valve repairs because glutaraldehyde provides pericardiums with greater resistance to retraction and tissue degeneration. We have used glutaraldehyde-treated pericardiums in mitral valve repair and calcification on them has not been recognized in this study [2]. We also reported a case of tricuspid leaflet augmentation using a glutaraldehyde-treated pericardium for recurrent severe FTR in redo operation [3]. Authors should need to follow-up these patients for a long period to investigate changes of fresh autologous pericardiums. Second, Dreyfus et al. [4] recommended systemic approaches including tricuspid annular size, mode of leaflet coaptation and the extent of leaflet tethering when assessing FTR. Authors performed tricuspid valve repair based on the same indication [1]. However, leaflet coaptation is easily affected by changes in right ventricular size, shape and function. Hence, depending on tethering height to determine requirement of leaflet augmentation is unreliable. Additionally, tenting volume has been an independent predictor of residual FTR after tricuspid annuloplasty [5]. Preoperative tenting volume should also be considered when choosing surgical techniques for FTR. These are our concerns about tricuspid leaflet augmentation for FTR.