Reply to Chatzis et al

Thank you for your Letter to the Editor [1] regarding our report ‘Tricuspid valve repair in a case with congenital absence of left thoracic pericardium’. We appreciate your comments and agree that congenital elements in partial and complete absence of pericardum must be considered. Associated anomalies including mitral stenosis, atrial septal defect, patent ductus arteriosus and tetralogy of Fallot can be found in about 30% of the cases reported with congenital pericardial defect [2–4]. A case of congenital tricuspid valve insufficiency or Ebstein anomaly associated with a pericardial defect was not reported yet. You presented recently the first case of congenital tricuspid insufficiency associated with partial absence of the right-sides pericardium.

In our case we reported the tricuspid annulus was widely dilated due to heart displacement and stretching of the right ventricular anterior wall. The tricuspid valve leaflets appeared of normal structure. The anterior tricuspid leaflet had a normal size and shape but was disrupted from the tricuspid annulus. There existed no further congenital anomalies in this case beside the absence of left thoracic pericardium.

It is to emphasize that any larger pericardial defect including right sided absence of pericardium has an impact on the geometry of the heart and may alter the integrity and function of the atrioventricular valves although a major cardiac displacement is not apparent. In addition we have to be aware that the risk for valvular endocarditis is increased in valvular heart disease and observed valvular thickening or attenuation can be caused by endocarditis [5].

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