When not to perform isolated tricuspid valve surgery? Our long-term experience in tricuspid valve replacement in highly symptomatic patients

Tricuspid regurgitation and its management remain a controversial issue in cardiology and cardiovascular surgery. As reflected in the article [1], moderate tricuspid regurgitation should be addressed early, in the setting of left valve cardiac surgery. Although the latest guideline recommendations [2] insist on the fact that neither right ventricular function nor tricuspid regurgitation might improve after left heart valve surgery, and annuloplasty is highly recommended even in asymptomatic patients [3], the scenario of isolated tricuspid valve surgery is still an issue that remains to be resolved. Right ventricular function and pulmonary hypertension are directly related to prognosis of these patients. According to the European Society of Cardiology (ESC) Working Groups of Cardiovascular Surgery and Valvular Heart Disease recommendations, both parameters should be adequately and closely monitored on a routine basis in a patient with tricuspid valve disease. If tricuspid surgery is performed once the damage is done and the right ventricle is too enlarged, or the pulmonary pressure is too high, surgery may not provide any kind of clinical or survival benefit [4]. Not only can these measures affect the prognosis of a patient with tricuspid valve disease, highly symptomatic patients may also not be offered any relief of their symptoms if surgery is done too late [5], especially when the right ventricle and the morphology of the tricuspid valve are too disrupted to perform a valve repair and tricuspid valve replacement (TVR) is the only option (excessive annular dilatation, distortion of the right ventricle and advanced rheumatic heart disease). Indeed, we conducted a retrospective, observational and descriptive study with all patients receiving a tricuspid valve prosthesis between 2000 and 2015 in our department [6]. Among the isolated TVR group (40 patients), the factors associated with a poor survival were: (i) logistic EuroSCORE I [hazard ratio (HR) 1.06, 95% confidence interval (CI) 1.02–1.09; P = 0.001]; (ii) low preoperative haemoglobin levels (HR 0.66, 95% CI 0.49–0.89; P = 0.007); (iii) renal failure (HR 3.09, 95% CI 1.09–8.80; P = 0.0035) and (iv) surgery performed in patients who were in New York Heart Association (NYHA) Class IV (HR 4.12, 95% CI 1.46–12.19; P = 0.008). In fact, patients who were in NYHA Class IV had a poor 1-year survival (only 12.5%). We also analysed the functional class of all the patients during the follow-up. Only 1 patient undergoing isolated TVR remained in NYHA Class IV, while most of them, who were preoperatively in NYHA Class II–III, were in Class II in the follow-up, therefore, they experienced no significant relief in their clinical status after undergoing isolated TVR. What we would like to highlight is the fact that surgery in a NYHA Class IV situation may not provide any benefit in terms of clinical improvement and mortality. Therefore, and according to what our colleagues stated, tricuspid valve disease must be addressed early, before right ventricular and clinical deterioration, either surgically or with any other percutaneous techniques.