Combined endoscopic repair of the mitral and tricuspid valve

J Thorac Dis 2021;13(8):4626-4628 | https://dx.doi. org/10.21037/jtd-2021-16 The great artist Michelangelo once said, “The greater danger for most of us lies not in setting our aim too high and falling short, but in setting our aim too low, and achieving our mark. ” Aiming high is risk-taking yet a reflection of thinking big. Aiming higher than the current status empowers us to perform more creatively and potentially effectively, overcoming challenges while creating opportunities. It builds resilience and acknowledges weaknesses in the operator and the team while recognizing what could be further achieved. Relentless practice in addition to talent allows high aims to be achieved. It produces positive energy outweighing negativity and confinement. The journey of cardiac surgery has been full of innovation, and the story continues in this article. Huang et al. are to be congratulated on achieving excellent outcomes by endoscopic repair of the tricuspid and mitral valve (1). The tricuspid valve was ignored more than the mitral valve yet now more recognized as a vital heart valve and surgically accessible right-sided valve endoscopically. Functional tricuspid regurgitation is the most common form of the disease. In the absence of severe tricuspid valve insufficiency, separating tricuspid—related symptoms from mitral valve-related symptoms is difficult. Echocardiography can gauge the severity of the tricuspid valve in relation to predicted pulmonary artery pressures and heart function, and in conjunction with patient clinical assessment can be quite comprehensive. Suppose suspicion is high that tricuspid valve insufficiency is significant, in that case, there is nothing wrong with addressing the tricuspid valve at the time of mitral valve surgery by opening the right atrium. The authors did just that using a transseptal approach, gauging the annulus dilation using a rigid annuloplasty sizer after closing the septum and repairing the mitral valve. While this approach is often performed less than direct atrial chamber opening with excellent echocardiography imaging and interpretation, the surgeon made the final determination as to repair the tricuspid valve. Tricuspid valve repair was performed without excluding the vena cava and yet with careful adjustment of the single femoral venous two-stage cannula, which can be unreliable and time-consuming to optimize venous return. Tricuspid annuloplasty was done using both a suture or ring. Cumulative evidence portends that ring prosthesis is durably more superior to suture annuloplasty by optimizing tricuspid leaflet coaptation (2). Furthermore, rigid ring is superior to flexible ring (2). This is important since mortality and morbidity have been linked to tricuspid valve severity and residual regurgitation after mitral valve surgery (2). Their procedure time, outcomes, and follow-up are excellent. Interestingly, a recent meta-analysis of secondary tricuspid valve insufficiency showed that mortality was similar for both suture and ring annulopasty (2). There have been several guidelines published regularly from both North American and European policies. The overarching consensus about as to when to intervene on the tricuspid valve at the time of mitral valve surgery is based on symptoms, annulus dilation (40 mm or 21/mm), grade right ventricular dysfunction with associated pulmonary artery pressures (3). The authors followed these guidelines. Furthermore, the authors used a 1:1 matching propensity score to achieve 40 matched pairs to attain similar pathophysiological variables for fair comparison of Editorial