Assessment of Right Ventricle Function in Patients with Mitral Repair: Case Series

To the Editor, We sincerely appreciate the thoughtful and constructive feedback from the authors on our study, Assessment of Right Ventricular Function in Patients Undergoing Mitral Valve Repair: A Case Series.[1] Their insights contribute valuable perspectives that will help refine future research on right ventricular function assessment in the context of mitral valve repair. The two main observations are the following: PULMONARY ARTERY SYSTOLIC PRESSURE (PASP) AND RV-PA COUPLING We acknowledge the significance of Pulmonary Artery Systolic Pressure (PASP) as a key parameter in patients with tricuspid regurgitation (TR). PASP has been widely used to estimate RV afterload and evaluate RV-PA coupling, particularly when combined with functional parameters like TAPSE/PASP or RVLS/PASP.[2] However, we would like to highlight an alternative parameter that may provide additional prognostic value in this setting. Rather than relying solely on PASP, the Mean Arterial Pressure (MAP) to Mean Pulmonary Artery Pressure (mPAP) ratio has been proposed as a superior predictor of outcomes in cardiac surgery patients, particularly in those undergoing valvular procedures.[3] The MAP/mPAP ratio provides a more comprehensive assessment of ventriculo-arterial coupling, which is an essential determinant of RV function and systemic adaptation postoperatively. While PASP remains relevant, we suggest that future research should also explore MAP/mPAP as a complementary parameter in assessing RV adaptation following MV repair. Furthermore, the provided citations analyzed the PASP and RV-PA coupling preoperative using TTE. Therefore, this displays a difference in our study since all the measurements were acquired after the patient was induced with general anesthesia. VASOACTIVE-INOTROPIC SCORE (VIS) AND HEMODYNAMIC SUPPORT We appreciate the suggestion regarding the quantification of vasoactive and inotropic support using the Vasoactive-Inotropic Score (VIS). As the authors correctly pointed out, VIS has been shown to correlate with postoperative right ventricular dysfunction in pediatric and adult cardiac surgery populations.[4] However, due to the retrospective nature of our study, vasoactive medication doses were not systematically recorded in a manner that would allow for a reliable VIS calculation. We fully agree that incorporating VIS in future prospective studies would provide a more detailed and objective analysis of the hemodynamic impact on RV function. VIS has been associated with postoperative morbidity, mortality, and length of ICU stay, and its inclusion would strengthen our understanding of the relationship between RV function and vasopressor support in MV surgery patients.[5] We appreciate this suggestion and will consider it for future research. STRENGTHS OF OUR STUDY DESPITE LIMITATIONS We acknowledge the retrospective nature of our study and its inherent limitations, including the absence of PASP and VIS data. However, we would like to emphasize several key strengths: Echocardiographic Assessment: Our study focused on Intraoperative Right Ventricular Longitudinal Strain (RVLS), which has higher diagnostic accuracy for detecting subclinical RV dysfunction compared to traditional measures like TAPSE and S’.[6] We identified distinct RV strain patterns in response to MV repair, which could guide perioperative RV assessment in clinical practice. Clinical Dynamic Relevance of RV Dysfunction in MV Surgery: Our findings reinforce that RV dysfunction is a common but variable outcome following MV repair. The study underscores the importance of assessing RV function dynamically, as changes in RVLS, TAPSE, and FAC may not always correlate with immediate clinical outcomes, but could indicate long-term RV remodeling.[7] Standardized Surgical and Echocardiographic Protocol: All surgeries were performed by the same lead surgeon, ensuring procedural consistency. Advanced echocardiographic software (EchoInsight) was used to obtain high-precision RV functional measures, enhancing data reliability. CONCLUSION We sincerely appreciate the valuable feedback provided by the Letter to the Editor. Their insightful suggestions regarding PASP and VIS highlight important considerations for future prospective research on RV function in cardiac surgical patients. We particularly agree that incorporating VIS and a more detailed RV-PA coupling assessment could further enhance the predictive value of echocardiographic parameters in this setting, especially when gathered after the general anesthetic (intraoperatively). While our study was retrospective and had inherent limitations, we believe it provides a meaningful contribution by demonstrating the clinical utility of RVLS in perioperative RV assessment. We hope this study will serve as a foundation for further prospective investigations that integrate VIS, PASP, and MAP/mPAP to refine risk stratification and improve RV function monitoring in patients undergoing MV repair. Thank you once again for this constructive discussion, which we believe will strengthen future research in perioperative RV assessment. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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