The Longitudinal Trajectory of FTR is Associated with RVD
At present, studies on the relationship between the severity of FTR and
the incidence of RVD are still controversial[15].
In this study, different longitudinal trajectory of FTR changes in
patients after MVR was combined with RVD outcome events, reflecting the
internal relationship between the two to some extent. This study found
that the severity of preoperative FTR increased the risk of
postoperative RVD, which was consistent with the results of previous
studies[14]. The severity of traditional single
FTR measurement could not explain whether the risk of future RVD would
change with the change of FTR. In this study, GBLM fitting was used to
find that the cumulative incidence of RVD was different in the groups
with different FTR trajectory 5-year after MVR, and the cumulative
incidence of RVD was the highest in the increasing group. Furthermore,
logistic regression model and adjustment for multiple potential
confounding factors confirmed that the upward trend of FTR longitudinal
trajectory was an independent risk factor for RVD after MVR. Continuous
FTR deterioration leads to irreversible remodeling of RV, further
dilation of TA, increased diastolic pressure of the RV, ventricular
septum shift to the left ventricle(LV), limitation of filling of the LV
due to it was compressed, of the LV further increase of diastolic
pressure and PASP, and ultimately RVD[15]. FTR may
influence central venous pressure through RV after load and trigger the
Frank-Starling compensation mechanism of RV cardiomyocytes, thereby
promoting RV compensatory remodeling. However, although the degree of
FTR in some patients is relatively mild, the pulmonary vascular
structure and RV myocardial tissue have undergone irreversible
changes[16]. The decision to perform isolated
tricuspid valve surgery remains challenging due to the limited data
available to guide preoperative evaluation and the lack of preoperative
optimization strategies. Patients undergoing MVR were denied second
surgical intervention for tricuspid valve due to contraindications such
as ventricular dysfunction and pulmonary vascular disease caused by
worsening FTR, resulting in delayed FTR treatment and high
intraoperative mortality[17-19]. Therefore,
preoperative FTR severity cannot be used as the only indication for
simultaneous tricuspid valve surgery. The results of this study further
suggest that clinicians should pay attention not only to the severity of
a single FTR, but also to the longitudinal trajectory of postoperative
FTR. At the same time, questions are also raised about existing
guidelines and clinical practice: The worsening of FTR after MVR
increases the risk of RVD. Should intervention be taken for these
patients in clinical work? How to detect patients with rapidly
increasing FTR trajectory and what intervention measures should be
taken? In the future, further prospective big data studies,
postoperative follow-up and exploration of etiology will contribute to
accurate discussion. Based on high-quality observational scientific
paper, the guidelines note that tricuspid valve repair(TVr) during MVR
does not increase surgical risk and may reverse RV
remodeling[20, 21]. Taken together, we believe
that no matter whether patients have normal TV function and anatomical
structure before MVR, clinicians should pay attention to the existence
of FTR, especially for patients with an increasing trend of FTR change.
In order to avoid RVD in these patients, it is better to perform MVR
while preventing tricuspid valve surgery.
Limitations of this study: 1.The retrospective observational design and
were from the same research center, which was slightly less
representative, and it was a northern population of China with strong
regional characteristics. In the future, large sample and multi-center
studies can be carried out to explore the evolutionary characteristics
of FTR in MVR patients and the influencing mechanism of RVD; 2.In the
evaluation of the relationship between FTR longitudinal trajectory group
and RVD, although possible confounding factors were corrected as far as
possible, other confounding factors, such as right heart function, were
not corrected. At the same time, values cannot be compared across
different ultrasound platforms; 3.Follow-up of 5 years, this study was
to build FTR longitudinal trajectory group only based on the five times
when the follow-up results, may not be able to fully reflect the change
of each individual, and thus underestimated FTR longitudinal trajectory
levels influence on RVD; 4.The comprehensive assessment of RV function
requires the combination of multiple parameters. The definition of RVD
only depended on TAPSE in our study.
This paper has used a novel statistical approach to report complex
longitudinal data, and supports the notion that the long-term
trajectories of worsening FTR in patients with regular follow-up after
MVR were generally associated with increased risk of RVD outcomes. It is
of great clinical significance for clinicians to identify high-risk
patients as soon as possible and execute personalized intervention,
avoid RHF, decrease patient re-hospitalization rate and allocate medical
resources rationally. Future studies should address the underlying
mechanisms and examine whether findings of our study can be translated
into prevention and intervention measures.