CORRESPONDENCE
I read with interest the article by Wang and colleagues [1]. They raise an important issue regarding selective tricuspid annuloplasty in children with obstructed right heart and tricuspid valve regurgitation. This issue needs very careful consideration before accepting it as an intervention of choice. All their patients had moderate or severe tricuspid valve regurgitation in the setting of pressure overload of the right ventricle (RV) (ie, Tetralogy of Fallot, valvar pulmonary stenosis with or without ventricular septal defect). Primary surgical intervention with tricuspid valve (TV) annuloplasty was performed at an average age of 7.6 ⫾ 3.6 years. This resulted in significant reduction in tricuspid valve regurgitation without significant postoperative morbidity or mortality, and they recommended selective annuloplasty as “a useful procedure for young patients with moderate or severe tricuspid regurgitation and right-sided obstructive lesions resulting from functional reconstruction of the tricuspid valve.” As we understand today, functional integrity of any valve is a product of its morphology and not the pressure to which it is subjected. Thus in a systemic right ventricle, those with systemic right heart pressures, such as in neonates, or those with univentricular heart with right ventricular morphology tricuspid valve regurgitation (TR) is absent unless there is ventricular dysfunction resulting from chronic pressure or volume overload, or both. The observed functional class of the patients studied (New York Heart Association functional class I I-IV) suggests that they may have had right heart failure and RV dysfunction. As published in an earlier edition of this journal, none of the infants with repair of Tetralogy of Fallot from our institution required tricuspid valve annuloplasty or had significant tricuspid valve regurgitation preoperatively or postoperatively [2]. Persistent TR is not a feature of post-balloon valvuloplasty of the pulmonary valve. In those with RV dysfunction and TR, complete resolution occurs with time. The authors used the echocardiographic length of TR flow velocity as one of the measures of severity of TR. This directly reflects the RV pressure, and reduction in length explains surgical relief of RV pressure. Measuring the TR jet is difficult in many patients with severe TR and low RV pressures as in Ebstien’s anomaly. It is often difficult to measure the width or length of TR due to the eccentric nature of the jet and orientation of the jet in a three-dimensional plane of the right atrium (RA). In this context it is interesting to note that TR width was measured in all patients. The observed improvement in TV annular dimensions and TR could be entirely attributed to the reduction in RV pressure, improvement in RV function, and RV remodeling. The observed and appropriate reduction of RA pressure after reduction in RV end-diastolic and systolic pressures is independent of the severity of TR. The TR observed following the repair of tetralogy of Fallot by Rochinni and colleagues [3] was reported to be due to distortion of the septal leaflet of the TV resulting from the closure of the ventricular septal defect. The reported need for annuloplasty of the TV in adults [4] cannot be extrapolated to children, as the functional recovery in adults is not comparable with children. Early surgical intervention of neonates and infants with right heart obstruction should alleviate development of functional © 2006 by The Society of Thoracic Surgeons Published by Elsevier Inc
tricuspid valve regurgitation and the need for tricuspid valve annuloplasty. Joseph J. Vettukattil, MD, MRCPCH Department of Pediatric Cardiology Wessex Cardiothoracic Centre Southampton University Hospitals NHS Trust Tremona Rd Southampton SO16 6YD, United Kingdom e-mail:
[email protected]
References 1. Wang J, Liang Y-W, Hayashi J. Selective annuloplasty for tricuspid regurgitation in children. Ann Thorac Surg 2005;79: 937– 41. 2. Alexiou C, Mahmoud H, Al-Khaddour A, Gnanapragasam J, Salmon AP, Keeton BR, Monro JL. Outcome after repair of tetralogy of Fallot in the first year of life. Ann Thorac Surg 2001;71:494 –500. 3. Rocchini AP, Rosenthal A, Freed M, Castaneda AR, Nadas AS. Chronic congestive heart failure after repair of tetralogy of Fallot. Circulation 1977;56:305–10. 4. Rivera R, Duran E, Ajuria M. Carpertier’s flexible ring versus De Vega’s annuloplasty. J Thorac Cardiovasc Surg 1985;89:196 –203.
Skeletonization of the Internal Thoracic Artery: Pros and Cons To the Editor: The article by Raja and Dreyfus [1] discussing the pros and cons of internal thoracic artery (ITA) skeletonization for conduit procurement in myocardial revascularization provides a good review of the subject. They correctly conclude that ITA dissection in a skeletonized fashion demands a very precise, atraumatic surgical technique, and harvesting time may be increased by 15 minutes or so. Also, skeletonization requires a somewhat longer learning curve than the standard pedicle technique. Although there are no reports to suggest decreased short-term or long-term patency rates for skeletonized ITAs, the authors suggest that randomized trials are needed to “conclusively validate the safety and efficacy of [the] skeletonization technique.” The authors express some concern that ITA skeletonization “is a relatively new surgical technique” but Galbut and associates [2] published their 17-year experience with 1,087 patients using bilateral skeletonized ITAs in 1990. Coronary angiography in 53 of the patients done at a mean postoperative interval of 53 months demonstrated a 92% patency rate for the left ITA and an 84% patency rate for the right ITA. One would be hard-pressed to consider a technique that has been used for over 30 years as “new.” Also, in 1992, we [3] published a detailed description of all aspects of the skeletonization dissection to hopefully decrease the learning curve and prevent unnecessary technical misadventures. Our review included more than 1,000 patients with a consensus among the authors that the skeletonization technique was superior to the pedicled technique for the same reasons as detailed in the current article by Raja and Dreyfus [1]. In my opinion, the authors’ extensive inquiries into the pluses and minuses of ITA skeletonization only strengthen the case for skeletonization. The literature supports the concepts of excellent flow, increased conduit length and diameter, less reduction in sternal blood flow, a decrease in sternal wound infection, less chest wall pain, and no reports of problems with an increased Ann Thorac Surg 2006;81:405– 409 • 0003-4975/06/$32.00 doi:10.1016/j.athoracsur.2005.05.045
MISCELLANEOUS
Is Tricuspid Valve Annuloplasty Required in Children With Right Heart Obstruction and Tricuspid Valve Regurgitation? To the Editor:
