Reply from author: Atrial fibrillation and functional tricuspid or mitral regurgitation: Which comes first, the egg or the chicken?

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 1. Babokin VV, T o imo NA, Vladimi o ich ED. Co ec ion o icuspid egu gi a- 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 . 2020;33:42-53. h ps://doi.o g/10.1016/j.xjon.2022.01.014 Adul : Mi al Val e: Le e s o he Edi o 96 JTCVS Open cMa ch 2022