eReply to eComment: Is flexible band or rigid ring the best choice for functional tricuspid regurgitation?

I sincerely thank Tourmousoglou and colleagues for their interest and for the constructive and complementary comments [1] to our article [2] where early and late outcomes of tricuspid valve annuloplasty with a flexible band (B-TVA) or a rigid ring (R-TVA) were compared. The most important conclusion of our analysis was that, although flexible band and rigid ring annuloplasty seem to be equally effective in the long-term treatment of functional tricuspid regurgitation, there are two different patterns of right heart reverse remodelling, which is more complete (see RV involvement) when a ring has been used - at least that is what we think.

As stated in the Discussion section of our paper, annuloplasty bands could offer specific benefits (over rings) due to the inherent flexibility and the simpler design and technique of implantation, at least on a speculative basis. There is a lower risk of device dehiscence or fracture and tricuspid stenosis, even after undersized annuloplasty. There is virtually no risk of injuring the conduction tissue and the right coronary artery, or the aortic box during implantation within a beating heart. Finally, flexible bands could best preserve RV function and help RV functional recovery after surgery. Nevertheless, despite all these benefits, there is no evidence of the superiority of B-TVA over R-TVA. If anything, the opposite is true. However, we did not explore the specific mechanisms of late failure of TVA. As we performed no comparison between two- and three-dimensional rings. In effect, in the reported experience, the two types of rigid rings were used during two very different periods: the Carpentier-Edwards classic (Edwards Lifesciences, Irvine, CA, USA) two-dimensional ring has been used until 2003 whilst both the Edwards MC3 and the Carpentier-Edwards Physio rings have been adopted since 2010. Thus, any interpretation of the results could be very difficult and not conclusive. I absolutely agree with Tourmousoglou et al. that prospective studies involving a large number of patients and new ring designs are needed for confirming the best annuloplasty device that has to be used to repair functional tricuspid regurgitation. In the meantime, we would stress the concept that the right heart reverse remodelling should be considered in every future study.

Conflict of interest: none declared.