Letter to the Editor Letter to the Editor Clinical Treatment for Pulmonary Artery Sarcoma

I read with interest the article by Sung and colleagues about tricuspid valve replacement [1]. I agree with the authors that their reported results, although better than others, are still unsatisfactory. I think tricuspid valve replacement is an unfavourable surgery rather than catastrophic. The most important question in these operations is when to replace and not to repair the tricuspid valve. The surgeon has to decide intra-operatively, based on the valve pathology, that the best tricuspid repair technique will produce worse results than replacement. This is applicable in a very small sector of those patients where the tricuspid valve is heavily diseased and the anterior leaflet with its chordae are fibrosed and retracted to the degree that cannot fill an acceptable or adequate valve area. In the old days, severe tricuspid endocarditis with large multiple vegetations were treated with valvectomy, which was well tolerated by patients with mild to moderate pulmonary hypertension. Sung and colleagues clearly demonstrated that cardiopulmonary bypass is a major risk factor in those patients. Most of their procedures were done on an arrested heart and they preferred mechanical prostheses. Cardiac surgeons in the Third World countries are faced with a large number of patients with severe and symptomatic tricuspid regurgitation; most of those patients are usually poor and live in remote areas. Cost containment is now an important issue everywhere and valve replacement implies a major increase in the cost of the procedure and the added cost of complications. Chang and colleagues [2] reported excellent results using autologous pericardial strip repair, which is the most suitable for our patients. The technique is quite feasible and effective in producing excellent intraand postoperative results. Among its several advantages, it is ready, available without cost, resists infection and is flexible, allowing growth in the paediatric age group. Our surgical technique is different from that of Sung and colleagues in that we perform the repair, or even tricuspid replacements, on a beating heart, which give us a better assessment of the tricuspid valve before and after the repair as well as early detection of heart block or arrhythmias. This also helps in shortening the aortic cross-clamp and bypass times, which will reflect positively on the morbidity and mortality results of those critical patients as shown by Sung and colleagues and others [1,3]. The choice of the prostheses is of a major concern. Although there is no survival benefit of either type, in general, bioprostheses are more favourable as it has shown good results in freedom from re-operation and structural deterioration [4].