In a similar study by Farooq and colleagues on TA plus
mitral valve replacement there was no progression of TR reported at
three years (11). Recently reported randomized controlled trial by
Gammie and colleagues showed much lesser progression of moderate TR at
two years (0.6% vs. 6.1% control group, relative risk, 0.09; 95% CI,
0.01 to 0.69) (3). Bernal and colleagues reported progression of TR
during their 15,8 years mean follow up in 23,5% of the RHD population
caused by recurrent rheumatic disease (12). Progression of TR in
rheumatic endemic region is recognized as an important clinical event
which is a sequelae of rheumatic fever caused by streptococcal infection
of the throat (Strept-Throat). Consequently, long-term penicillin
prophylactic therapy against recurrent RHD as recommended by the World
Health Organization (WHO) should be included in the protocol for optimal
medical therapy (OMT) for TA-MV Repair.
The authors should be congratulated for their laudable clinical
studies and for sharing the results with the global cardiovascular
community. Although it is a single centre observational trial like
others, which they admit, their data provide valuable information that
stimulates discussions in the clinical practice, which encourages early
aggressive approach for concomitant tricuspid annuloplasty (TA) plus
mitral valve surgery (MVS) in rheumatic populations (11,12 ). A
multi-centre randomized controlled trial to provide predictive power of
the resultant data is required for developing a surgical strategy for TA
and MVS in rheumatic patients (10-12). Pacemaker implantation was not an
issue in their series as well as Farooq and Bernal and their
colleagues, but it is a global concern as indicated by a recent
multicenter trial that TA carries an additional risk of pacemaker (PM)
implantation at a rate of up to 14% as compared to 2.5% for mitral
valve surgery alone (rate ratio, 5.75; 95% CI, 2.27 - 14.60) (3,11,12).
The risk for procedural related PM implantation needs to be
addressed (4-13). It can be reduced or eliminated by refined TA
techniques (2,3, 5-8,10-12).