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).