We read with interest the recently-published scientific letter by Caneiro-Queija et al.,1 in which they showed the possibility of combined treatment of mitral regurgitation (MR) and tricuspid regurgitation (TR) in a single procedure using MitraClip devices. It does indeed demonstrate the high levels at which operators and structural intervention are currently working, but we would like to raise some points regarding the indication for performing the 2 repairs in a single procedure.
First, while it is quite normal in surgical procedures to repair several valves in a single operation, in interventional cardiology this aspect may generate some controversy. Longer duration of the procedure is associated with an increased risk of complications associated with vascular access,2 the need for a longer anesthetic,3 increased use of ionizing radiation, and more transesophageal ultrasound time.4
Second, with currently-available medical treatment, the short-term mortality from TR, even in its most severe forms, is low, especially in patients who maintain good functional status.5
Third, the 2 valvulopathies are closely dependent. It has been demonstrated that correction of MR, independently of the technique, significantly reduces left ventricular filling pressures and pulmonary hypertension.6 In the case of the MitraClip, between a third and a half of patients have a significant reduction in TR grade following MR repair.7,8 It is therefore more than reasonable to wait and see the results before planning a second procedure, especially in cases with little dilatation of the tricuspid annulus and a structurally normal valve.
Fourth, the use of several devices in a single procedure implies a higher financial burden, which means rigorous selection of appropriate candidates is essential, especially since a high percentage of cases of TR improve after MR repair.
Last, there is little experience of the benefit of performing both repair procedures in combination. Only one study has indicated that a certain survival benefit could be obtained, but there were many limitations to its design, and it compared mitral repair alone against simultaneous repair of both valves, but not against staged repair.9
The percutaneous repair of TR represents a major advance and hope, particularly for patients who are not candidates for surgery.10–14 Although nobody would question combined repair in a surgical procedure, in percutaneous procedures this is more controversial. A randomized study is needed to compare simultaneous repair of both valves against a staged approach based on the results on TR.
CONFLICTS OF INTERESTÁ. Sánchez-Recalde is associate editor of Revista Española de Cardiología; the journal's established editorial procedure to ensure impartial management of the manuscript has been followed.