The au ho epo ed no con lic s o in e es .
The Jou nal policy equi es edi o s and e iewe s
o disclose con lic s o in e es and o decline
handling o e iewing manusc ip s o which hey
may ha e a con lic o in e es . The edi o s and e-
iewe s o his a icle ha e no con lic s o in e es .
REPLY FROM AUTHOR:
ATRIAL FIBRILLATION
AND FUNCTIONAL
TRICUSPID OR MITRAL
REGURGITATION:
WHICH COMES FIRST,
THE EGG OR THE CHICKEN?
Reply o he Edi o :
We ead wi h in e es he Le e o he Edi o om Ba-
bokin and colleagues.
1
Pulmona y a e y dene a ion has
been ecen ly desc ibed as an al e na i e me hod o ea
pulmona y hype ension in pa ien s wi h le hea ailu e,
2
bu despi e he e icacy and sa e y o such p ocedu es, i
emains o be es ablished in he long e m and i is also
deba able whe he hese p ocedu es a e supe io o he
s anda d o ca e pha macologic he apies o pulmona y
hype ension.
A ial ib illa ion (AF) is a silen disease wi h ca a-
s ophic consequences, om hea ailu e, s oke, o sudden
dea h. I s associa ion wi h al ula disease, igh - o le -
sided, has long been demons a ed as well as he nega i e
impac e en a e su gical co ec ion o he al ula p ob-
lem. Mo eo e , he la es Ame ican and Eu opean guide-
lines ha e conside ed i bene icial o pe o m AF abla ion
o symp oma ic pa ien s wi h pa oxysmal o pe sis en
AF who a e unde going al ula /ca diac su ge y.
3,4
The causal e ec o AF in he genesis o icuspid (TFR)
o mi al (MFR) unc ional egu gi a ion has been dispu ed,
and o a long ime AF was me ely conside ed as a na u al
consequence o he al ula disease. Howe e , in ecen
imes, he concep o “a ial”MFR and TFR has gained
e ain in opposi ion o he well-es ablished “ en icula ”
unc ional egu gi a ion, whe e he dila a ion o he le o
igh en icle was seen as he p ecu so o he al ula
egu gi a ion, espec i ely. In e es ingly, he common
g ound o his nosological en i y is he p esence o AF. In
ega d o a ial MFR, which has been epo ed o be be ween
3%and 15%in pa ien s wi h AF, MFR can occu among
pa ien s wi h signi ican dila a ion o mi al annulus and
le a ium.
5
Ne e heless, o he impo an igge s o
MFR, in he p esence o he la e ana omical changes,
ha e been iden i ied, such as educed annula con ac ili y,
inc eased al e s ess by la ened saddle shape o he
annulus, and le a ial dys unc ion. In addi ion, “a io-
genic”lea le e he ing and imbalance o annulus a ea o
lea le a ea can esul om insu icien lea le emodeling.
The e is li le e idence hus a on he apeu ic op ions o
he managemen o a ial FMR, wi h hy hm-con ol s a e-
gies om pha macologic he apies o ca he e o su gical
abla ion being plausible solu ions. In espec o a ial
TFR, long-s anding AF has been associa ed wi h he exis-
ence o icuspid egu gi a ion despi e no mal igh en ic-
ula geome y and unc ion. The pa hophysiology in ol es
he in e ac ion among icuspid annulus emodeling, igh
a ium dila a ion, and loss o unc ion. Ne e heless, he
empo al ela ionship be ween icuspid egu gi a ion and
AF emains o be cla i ied.
6
Hence, one can say ha he e is su icien e idence o
belie e ha AF comes i s , and al ula egu gi a ion is
he na u al nega i e e olu ion o his disease. No wi h-
s anding, he he apeu ic challenge can be di e en om
he “ en icula ” unc ional egu gi a ion. In a ial unc-
ional egu gi a ion, hy hm con ol (pha macologic,
ca he e o su gical AF abla ion) and o su gical co ec-
ion should be ailo ed o he speci ic pa hophysiology
ound in each pa ien . Isola ed annuloplas y may no be
app op ia e when he e is se e e a iogenic e he ing o
inadequa e lea le emodeling causing annulus a ea-
lea le a ea imbalance, and lea le pa ch augmen a ion
could be necessa y along wi h he implan a ion o an
annuloplas y ing.
Gonc¸alo F. Cou inho, MD, PhD
Facul y o Medicine
Ca dio ho acic Su ge y Depa men
Uni e si y Hospi al and Cen e o Coimb a
Uni e si y o Coimb a
Coimb a, Po ugal
Re e ences
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ion and dene a ion o pulmona y unk and pulmona y a e ies. J Tho ac Ca di-
o asc Su g Open. No embe 5, 2021 [Epub ahead o p in ].
2. Zhang H, Zhang J, Chen M, Xie DJ, Kan J, Yu W, e al. Pulmona y a e y dene -
a ion signi ican ly inc eases 6-min walk dis ance o pa ien s wi h combined p e-
and pos -capilla y pulmona y hype ension associa ed wi h le hea ailu e: he
PADN-5 s udy. JACC Ca dio asc In e . 2019;12:274-84.
3. O o CM, Nishimu a RA, Bonow RO, Ca abello BA, E win JP III, Gen ile F, e al.
2020 ACC/AHA guideline o he managemen o pa ien s wi h al ula hea dis-
ease: a epo o he Ame ican College o Ca diology/Ame ican Hea Associa ion
join commi ee on clinical p ac ice guidelines. Ci cula ion. 2021;143:e72-227.
4. Vahanian A, Beye sdo F, P az F, Miloje ic M, Baldus S, Baue sachs J, e al. 2021
ESC/EACTS guidelines o he managemen o al ula hea disease de eloped
by he ask o ce o he managemen o al ula hea disease o he Eu opean So-
cie y o Ca diology (ESC) and he Eu opean Associa ion o Ca dio-Tho acic Su -
ge y (EACTS). Eu Hea J. Augus 26, 2021 [Epub ahead o p in ].
Copy igh Ó2022 The Au ho (s). Published by Else ie Inc. on behal o The Ame -
ican Associa ion o Tho acic Su ge y. This is an open access a icle unde he CC
BY-NC-ND license (h p://c ea i ecommons.o g/licenses/by-nc-nd/4.0/).
JTCVS Open cVolume 9, Numbe C 95
Adul : Mi al Val e: Le e s o he Edi o
5. Kagiyama N, Mondillo S, Yoshida K, Mandoli GE, Cameli M. Sub ypes o a ial
unc ional mi al egu gi a ion imaging insigh s in o hei mechanisms and he a-
peu ic implica ions. JACC Ca dio asc Imaging. 2020;13:820-35.
6. Mu a u D, Gu a AC, Ochoa-Jimenez RC, Ba os D, A u a P, Mihaila S, e al. Func-
ional egu gi a ion o a io en icula al es and a ial ib illa ion: an elusi e
pa hophysiological link dese ing u he a en ion. J Am Soc Echoca diog .
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h ps://doi.o g/10.1016/j.xjon.2022.01.014
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