Reply to Papazisi et al.

Dear Editor,

We greatly appreciate the insightful comments from Dr Papazisi et al. [1] regarding our study, ‘Optimizing ring selection for secondary tricuspid regurgitation: the role of body size’ [2]. Their constructive feedback highlights important methodological considerations and provides an opportunity to clarify further and contextualize our findings.

We acknowledge that our study has certain limitations. As stated in the original manuscript, our study was based on a limited sample size and a short follow-up period. We reported 3-year outcomes, which included more patients. Although longer follow-up data exists, they include an increasing proportion of censored cases, which could introduce bias (see the risk analysis curves).

We appreciate the discussion regarding additional factors influencing tricuspid regurgitation (TR) recurrence, such as leaflet tenting height, atrial fibrillation, pulmonary pressures and mitral aetiologies. Nonetheless, the multivariate analysis showed that the tricuspid annuloplasty ring index (TARI) and right ventricular dimension were independent predictors of TR recurrence, among other previously reported risk factors. Propensity score matching was performed with potentially influential factors; as shown in the supplementary file, those values are balanced after matching. In addition, mitral valve replacement or plasty was not a risk factor for TR recurrence in our study.

Indications for tricuspid annuloplasty (TAP) followed the current guidelines [3, 4]. Patients with annular dilation underwent TAP even if TR was not significant. Our cohort only included patients with TR secondary to mitral valve disease. Patients having tricuspid valve abnormalities were excluded.

The mean body size in our cohort was 1.53 m², smaller than that of the Western European cohort. This limits direct extrapolation to Western populations, but would it be appropriate to apply the same ring in patients with body surface area of 1.5 and 1.9 m² if the valve measurement is the same? Annular dilation compared to the body size has been reported to be the risk for late significant TR in unrepaired patients [5, 6]. Thus, considering the target annular dimension after TAP according to an individual’s body size may be helpful. Future studies are needed to validate our findings in broader demographic settings.

We adopted the cutoff point of TARI at 19.0 mm/m² and divided the cohort into 2 groups for subsequent prognostic study. In our study, the large TARI group showed worse survival and adverse event-free rates, although they did not reach statistical significance. However, as stated in the limitation, there is no question that external validation of the cutoff point is necessary. Further research is needed to determine how large is too large.

Despite its limitations, our study underscores the importance of considering body size when selecting ring size. The association between TARI and TR recurrence highlights the need for a more individualized approach to ring sizing. Further research with extended follow-up and broader population cohorts is essential to refine surgical strategies for tricuspid valve repair.

We are grateful to Dr Papazisi et al. for their valuable input. We hope our clarifications contribute to an ongoing dialogue to optimize patient outcomes in tricuspid valve surgery.

FUNDING

Institutional funding was provided for this research. There is no external source of funding to report.

Conflict of interest: none declared.

ACKNOWLEDGEMENTS

We thank Editage (https://www.editage.com/) for the English editing.

REFERENCES