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Konstantinov IE, Chai P, Bacha E, Caldarone CA, Da Silva JP, Da Fonseca Da Silva L, Dearani J, Hornberger L, Knott-Craig C, Del Nido P, Qureshi M, Sarris G, Starnes V, Tsang V. The American Association for Thoracic Surgery (AATS) 2024 expert consensus document: Management of neonates and infants with Ebstein anomaly. J Thorac Cardiovasc Surg 2024; 168:311-324. [PMID: 38685467 DOI: 10.1016/j.jtcvs.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 03/27/2024] [Accepted: 04/03/2024] [Indexed: 05/02/2024]
Abstract
OBJECTIVES Symptomatic neonates and infants with Ebstein anomaly (EA) require complex management. A group of experts was commissioned by the American Association for Thoracic Surgery to provide a framework on this topic focusing on risk stratification and management. METHODS The EA Clinical Congenital Practice Standards Committee is a multinational and multidisciplinary group of surgeons and cardiologists with expertise in EA. A citation search in PubMed, Embase, Scopus, and Web of Science was performed using key words related to EA. The search was restricted to the English language and the year 2000 or later and yielded 455 results, of which 71 were related to neonates and infants. Expert consensus statements with class of recommendation and level of evidence were developed using a modified Delphi method, requiring 80% of members votes with at least 75% agreement on each statement. RESULTS When evaluating fetuses with EA, those with severe cardiomegaly, retrograde or bidirectional shunt at the ductal level, pulmonary valve atresia, circular shunt, left ventricular dysfunction, or fetal hydrops should be considered high risk for intrauterine demise and postnatal morbidity and mortality. Neonates with EA and severe cardiomegaly, prematurity (<32 weeks), intrauterine growth restriction, pulmonary valve atresia, circular shunt, left ventricular dysfunction, or cardiogenic shock should be considered high risk for morbidity and mortality. Hemodynamically unstable neonates with a circular shunt should have emergent interruption of the circular shunt. Neonates in refractory cardiogenic shock may be palliated with the Starnes procedure. Children may be assessed for later biventricular repair after the Starnes procedure. Neonates without high-risk features of EA may be monitored for spontaneous closure of the patent ductus arteriosus (PDA). Hemodynamically stable neonates with significant pulmonary regurgitation at risk for circular shunt with normal right ventricular systolic pressure should have an attempt at medical closure of the PDA. A medical trial of PDA closure in neonates with functional pulmonary atresia and normal right ventricular systolic pressure (>20-25 mm Hg) should be performed. Neonates who are hemodynamically stable without pulmonary regurgitation but inadequate antegrade pulmonary blood flow may be considered for a PDA stent or systemic to pulmonary artery shunt. CONCLUSIONS Risk stratification is essential in neonates and infants with EA. Palliative comfort care may be reasonable in neonates with associated risk factors that may include prematurity, genetic syndromes, other major medical comorbidities, ventricular dysfunction, or sepsis. Neonates who are unstable with a circular shunt should have emergent interruption of the circular shunt. Neonates who are unstable are most commonly palliated with the Starnes procedure. Neonates who are stable should undergo ductal closure. Neonates who are stable with inadequate pulmonary flow may have ductal stenting or a systemic-to-pulmonary artery shunt. Subsequent procedures after Starnes palliation include either single-ventricle palliation or biventricular repair strategies.
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Affiliation(s)
- Igor E Konstantinov
- Department of Cardiothoracic Surgery, Royal Children's Hospital, Parkville, Australia; Department of Paediatrics, University of Melbourne, Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia.
| | - Paul Chai
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Emory University, Atlanta, Ga
| | - Emile Bacha
- Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, NY
| | | | - Jose Pedro Da Silva
- Division of Cardiothoracic Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa
| | | | - Joseph Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Lisa Hornberger
- Department of Pediatrics, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Christopher Knott-Craig
- Division of Cardiothoracic Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tenn
| | - Pedro Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | | | - George Sarris
- Department of Pediatric Heart Surgery, Mitera Children's Hospital, Athens, Greece
| | - Vaughn Starnes
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Victor Tsang
- Cardiothoracic Unit, Great Ormond Street Hospital, London, United Kingdom
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Park I, Jun TG, Yang JH, Kang IS, Huh J, Song J, Lee OJ. Long-Term Outcomes of Modified Cone Reconstruction for Ebstein's Anomaly in Pediatric Patients in a Single Center. Korean Circ J 2024; 54:78-90. [PMID: 38196117 PMCID: PMC10864249 DOI: 10.4070/kcj.2023.0200] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/23/2023] [Accepted: 11/24/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND AND OBJECTIVE We aimed to investigate long-term clinical and echocardiographic outcomes, including tricuspid valve durability, annular growth, and left ventricular reverse remodeling, after modified cone reconstruction in patients with Ebstein's anomaly. METHODS This was a retrospective analysis of all pediatric patients who underwent modified cone reconstruction for Ebstein's anomaly at a single tertiary center between January 2005 and June 2021. RESULTS A total of 14 pediatric patients underwent modified cone reconstruction for Ebstein's anomaly; the median age was 5.8 years (range, 0.01-16.6). There were three patients (21.4%) with Carpentier type B, ten patients with Carpentier type C (71.4%), and one patient with Carpentier type D (7.1%). There was no early or late mortality, arrhythmia, or readmission for heart failure at a 10-year follow-up. There were no cases of more than mild tricuspid stenosis or more than moderate tricuspid regurgitation during the study period, except for one patient with severe tricuspid regurgitation who underwent reoperation. The z value for tricuspid valve annular size significantly decreased immediately after the operation (2.46 vs. -1.15, p<0.001). However, from 1 year to 7 years after surgery, the z values were maintained between -1 and +1. Left ventricular end-systolic volume, end-diastolic volume, and stroke volume increased after surgery and remained elevated until seven years postoperatively. CONCLUSIONS Ebstein's anomaly in children can be repaired by modified cone reconstruction with low mortality and morbidity, good tricuspid valve durability, and annular growth relative to somatic growth.
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Affiliation(s)
- Ilkun Park
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae-Gook Jun
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Ji-Hyuk Yang
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - I-Seok Kang
- Department of Pediatrics, Cardiovascular Imaging Center, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - June Huh
- Department of Pediatrics, Cardiovascular Imaging Center, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jinyoung Song
- Department of Pediatrics, Cardiovascular Imaging Center, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ok Jeong Lee
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Park HK. Cone Reconstruction for Ebstein's Anomaly: Is It Durable in Pediatric Patients? Korean Circ J 2024; 54:91-92. [PMID: 38346696 PMCID: PMC10864250 DOI: 10.4070/kcj.2024.0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 01/11/2024] [Indexed: 02/16/2024] Open
Affiliation(s)
- Han Ki Park
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
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LaSala VR, Buratto E, Beqaj H, Aguirre I, Maldonado J, Goldshtrom N, Goldstone A, Setton M, Krishnamurthy G, Bacha E, Kalfa DM. Outcomes of surgical management of Ebstein anomaly and tricuspid valve dysplasia in critically ill neonates and infants. JTCVS OPEN 2023; 16:629-638. [PMID: 38204669 PMCID: PMC10774978 DOI: 10.1016/j.xjon.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/22/2023] [Accepted: 08/02/2023] [Indexed: 01/12/2024]
Abstract
Objective To describe the surgical outcomes in neonates and infants who had surgery for Ebstein anomaly (EA) and tricuspid valve dysplasia (TVD). Methods Retrospective chart review for all patients who underwent surgery for EA or TVD during the index hospitalization after birth at our institution from January 2005 to February 2023. Results Fifteen symptomatic neonates and infants who had surgery for EA or TVD were included, 8 with EA and 7 with TVD. Eleven patients (73%) and 3 patients (20%) required preoperative inotropes and extracorporeal membrane oxygenation, respectively. Nine patients (60%) had a Starnes procedure and 6 patients (40%) had tricuspid valve repair (TVr). Mortality at last follow-up was 27% overall (n = 4/15), 22% after Starnes (n = 2/9) and 33% after TVr (n = 2/6), without a significant difference despite a greater-risk profile in the Starnes group. Postoperative day 1 lactate level was associated with mortality on Cox regression (hazard ratio, 1.45; P = .01). Three of 9 patients who had a Starnes procedure were or will be converted to a cone repair (1.5/2-ventricle repair). Conclusions Mortality after surgery for EA or TVD during the index hospitalization after birth is still significant in the current era and is associated with a greater lactate level at postoperative day 1. The Starnes procedure and TVr had comparable outcomes despite a greater-risk profile in the Starnes group. An initial single-ventricle approach does not preclude conversion to biventricular or 1.5-ventricle repair.
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Affiliation(s)
- V. Reed LaSala
- Section of Pediatric and Congenital Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian Morgan Stanley Children’s Hospital, Columbia University Medical Center, New York, NY
| | - Edward Buratto
- Section of Pediatric and Congenital Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian Morgan Stanley Children’s Hospital, Columbia University Medical Center, New York, NY
| | - Halil Beqaj
- College of Physicians and Surgeons, Columbia University, New York, NY
| | - Isabel Aguirre
- College of Physicians and Surgeons, Columbia University, New York, NY
| | - Julian Maldonado
- College of Physicians and Surgeons, Columbia University, New York, NY
| | - Nimrod Goldshtrom
- Division of Neonatology, Department of Pediatrics, New York-Presbyterian Morgan Stanley Children’s Hospital, Columbia University Medical Center, New York, NY
| | - Andrew Goldstone
- Section of Pediatric and Congenital Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian Morgan Stanley Children’s Hospital, Columbia University Medical Center, New York, NY
| | - Matan Setton
- Division of Cardiology, Department of Pediatrics, New York-Presbyterian Morgan Stanley Children’s Hospital, Columbia University Medical Center, New York, NY
| | - Ganga Krishnamurthy
- Division of Neonatology, Department of Pediatrics, New York-Presbyterian Morgan Stanley Children’s Hospital, Columbia University Medical Center, New York, NY
| | - Emile Bacha
- Section of Pediatric and Congenital Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian Morgan Stanley Children’s Hospital, Columbia University Medical Center, New York, NY
| | - David M. Kalfa
- Section of Pediatric and Congenital Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian Morgan Stanley Children’s Hospital, Columbia University Medical Center, New York, NY
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LaSala VR, Nguyen SN, Bouhout IA, Shah A, Kalfa DM. Repair of congenital tricuspid valve dysplasia: The croissant technique. JTCVS Tech 2023; 20:146-149. [PMID: 37555053 PMCID: PMC10405152 DOI: 10.1016/j.xjtc.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/25/2023] [Accepted: 04/11/2023] [Indexed: 08/10/2023] Open
Affiliation(s)
- V. Reed LaSala
- Section of Pediatric and Congenital Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY
| | - Stephanie N. Nguyen
- Section of Pediatric and Congenital Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY
| | - Ismail A. Bouhout
- Section of Pediatric and Congenital Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY
| | - Amee Shah
- Division of Pediatric Cardiology, Department of Pediatrics, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY
| | - David M. Kalfa
- Section of Pediatric and Congenital Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY
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Cantinotti M, McMahon CJ, Marchese P, Köstenberger M, Scalese M, Franchi E, Santoro G, Assanta N, Jacquemyn X, Kutty S, Giordano R. Echocardiographic Parameters for Risk Prediction in Borderline Right Ventricle: Review with Special Emphasis on Pulmonary Atresia with Intact Ventricular Septum and Critical Pulmonary Stenosis. J Clin Med 2023; 12:4599. [PMID: 37510714 PMCID: PMC10380858 DOI: 10.3390/jcm12144599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 05/26/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023] Open
Abstract
The aim of the present review is to highlight the strengths and limitations of echocardiographic parameters and scores employed to predict favorable outcome in complex congenital heart diseases (CHDs) with borderline right ventricle (RV), with a focus on pulmonary atresia with intact ventricular septum and critical pulmonary stenosis (PAIVS/CPS). A systematic search in the National Library of Medicine using Medical Subject Headings and free-text terms including echocardiography, CHD, and scores, was performed. The search was refined by adding keywords "PAIVS/CPS", Ebstein's anomaly, and unbalanced atrioventricular septal defect with left dominance. A total of 22 studies were selected for final analysis; 12 of them were focused on parameters to predict biventricular repair (BVR)/pulmonary blood flow augmentation in PAIVS/CPS. All of these studies presented numerical (the limited sample size) and methodological limitations (retrospective design, poor definition of inclusion/exclusion criteria, variability in the definition of outcomes, differences in adopted surgical and interventional strategies). There was heterogeneity in the echocardiographic parameters employed and cut-off values proposed, with difficultly in establishing which one should be recommended. Easy scores such as TV/MV (tricuspid/mitral valve) and RV/LV (right/left ventricle) ratios were proven to have a good prognostic accuracy; however, the data were very limited (only two studies with <40 subjects). In larger studies, RV end-diastolic area and a higher degree of tricuspid regurgitation were also proven as accurate predictors of successful BVR. These measures, however, may be either operator and/or load/pressure dependent. TV Z-scores have been proposed by several authors, but old and heterogenous nomograms sources have been employed, thus producing discordant results. In summary, we provide a review of the currently available echocardiographic parameters for risk prediction in CHDs with a diminutive RV that may serve as a guide for use in clinical practice.
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Affiliation(s)
- Massimiliano Cantinotti
- Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy
- Institute of Clinical Physiology, 56124 Pisa, Italy
| | - Colin Joseph McMahon
- Department of Pediatric Cardiology, Childrens Health Ireland, D12 N512 Dublin, Ireland
- School of Medicine, University College Dublin, D04 V1W8 Dublin, Ireland
| | - Pietro Marchese
- Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy
- Istituto di Scienze Della Vita (ISV), Scuola Superiore Sant'Anna, 56127 Pisa, Italy
| | - Martin Köstenberger
- Department of Pediatrics, Division of Pediatric Cardiology, Medical University Graz, 8036 Graz, Austria
| | - Marco Scalese
- Istituto di Scienze Della Vita (ISV), Scuola Superiore Sant'Anna, 56127 Pisa, Italy
| | - Eliana Franchi
- Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy
| | | | - Nadia Assanta
- Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy
| | - Xander Jacquemyn
- Helen B. Taussig Heart Center, Department of Pediatrics, Johns Hopkins Hospital, Baltimore, MD 21205, USA
| | - Shelby Kutty
- Helen B. Taussig Heart Center, Department of Pediatrics, Johns Hopkins Hospital, Baltimore, MD 21205, USA
| | - Raffaele Giordano
- Adult and Pediatric Cardiac Surgery, Department Advanced Biomedical Sciences, University of Naples "Federico II", 80131 Naples, Italy
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Mah K, Mertens L. Echocardiographic Assessment of Right Ventricular Function in Paediatric Heart Disease: A Practical Clinical Approach. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2022; 1:136-157. [PMID: 37970496 PMCID: PMC10642122 DOI: 10.1016/j.cjcpc.2022.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 05/05/2022] [Indexed: 11/17/2023]
Abstract
As the right ventricle (RV) plays an integral role in different paediatric heart diseases, the accurate assessment of RV size and function is essential in the diagnosis, management, and prognostication of congenital and acquired cardiac lesions. Yet, echocardiographic evaluation of the RV is challenging because of its complex and variable morphology, its different physiology compared with the left ventricle, and its capability to adapt to different loading conditions associated with congenital and acquired heart diseases within certain ranges. Reliable echocardiographic detection of RV systolic and diastolic dysfunction remains challenging while important for patient management. This review provides an updated, practical approach to assessing RV function in structurally normal hearts and in children with common congenital heart defects and in those with pulmonary hypertension. We also review the impact of tricuspid valve function on RV functional parameters. There is no single functional RV parameter that uniquely describes RV function; instead a combination of different parameters is recommended in clinical practice. Qualitative and quantitative analysis of RV function will be reviewed including more recent techniques such as speckle tracking and 3D echocardiography.
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Affiliation(s)
- Kandice Mah
- Division of Cardiology, BC Children’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Luc Mertens
- Department of Paediatrics, Labatt Family Heart Centre, the Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6562019. [DOI: 10.1093/ejcts/ezac212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/10/2022] [Accepted: 03/18/2022] [Indexed: 11/14/2022] Open
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Nabeshima J, Yamagishi M, Maeda Y, Hongu H, Nakatsuji H, Nagase T, Yaku H. A case of redo tricuspid valve repair after neonatal cone operation for Ebstein's anomaly. Gen Thorac Cardiovasc Surg 2021; 70:289-291. [PMID: 34841447 DOI: 10.1007/s11748-021-01742-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 11/09/2021] [Indexed: 11/29/2022]
Abstract
Cone reconstruction for Ebstein's anomaly, although effective, is challenging in neonatal cases. Very few reports have discussed recurrent regurgitation. Herein, we report a successful redo tricuspid valve repair for recurrent regurgitation 5 years after cone reconstruction. A 5-year-old boy underwent cone reconstruction for Ebstein's anomaly in the neonatal period. Although tricuspid regurgitation reduced initially, it subsequently worsened. The mechanisms of regurgitation are dilatation of the anteroseptal commissure, indentation in the septal leaflet, and foreshortening of the anterior leaflet. Augmentation of the anterior leaflet using an elliptic autologous pericardium and mending of the gaping commissure and indentation markedly reduced the regurgitation.
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Affiliation(s)
- Junya Nabeshima
- Department of Pediatric Cardiovascular Surgery, Children's Medical Center, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan.
| | - Masaaki Yamagishi
- Department of Pediatric Cardiovascular Surgery, Children's Medical Center, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Yoshinobu Maeda
- Department of Pediatric Cardiovascular Surgery, Children's Medical Center, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Hisayuki Hongu
- Department of Pediatric Cardiovascular Surgery, Children's Medical Center, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Hiroki Nakatsuji
- Department of Pediatric Cardiovascular Surgery, Children's Medical Center, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Takashi Nagase
- Department of Pediatric Cardiovascular Surgery, Children's Medical Center, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Knott-Craig CJ, Boston US. Current surgical techniques in the management of the symptomatic neonate with severe Ebstein anomaly: Too much, too little, or just enough? JTCVS Tech 2021; 9:128-134. [PMID: 34647081 PMCID: PMC8501262 DOI: 10.1016/j.xjtc.2021.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 05/11/2021] [Indexed: 12/03/2022] Open
Abstract
The management of severely symptomatic neonates with Ebstein anomaly is challenging during the early neonatal period. Initial management goals should focus on mitigating a central shunt; providing respiratory mechanical support; providing an adequate but not excessive source of pulmonary blood flow; and minimizing pulmonary vascular resistance. For most patients thus stabilized, definitive repair should be prudently deferred until it is safe for a bailout bidirectional Glenn anastomosis to be added, usually at age 3 to 4 months. For those who remain critical, initial ligation of the large ductus and placing a more peripheral aortopulmonary shunt, or ligating the main pulmonary artery, should be weighed against a primary biventricular repair (Knott-Craig repair), or the Starnes' single-ventricle palliation. The Da Silva cone biventricular repair should generally be avoided during the early neonatal period. An initial Starnes' repair can be potentially converted to a biventricular repair in later infancy.
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Affiliation(s)
- Christopher J. Knott-Craig
- Address for reprints: Christopher J. Knott-Craig, MD, FACS, Division of Pediatric Cardiovascular Surgery, Le Bonheur Children's Hospital and the University of Tennessee Health Sciences Center, Suite 332 Physician office Building, 50 N Dunlap, Memphis, TN 38105.
| | - Umar S. Boston
- Division of Pediatric Cardiovascular Surgery, Le Bonheur Children's Hospital, Memphis, Tenn
- University of Tennessee Health Sciences Center, Memphis, Tenn
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11
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LaPar DJ, Moroi MK, Nguyen SN, Bacha EA. Neonatal Cone Valvuloplasty for Pulmonary Atresia/Intact Ventricular Septum and Ebsteinoid Valve. Ann Thorac Surg 2021; 112:e345-e347. [PMID: 33421397 DOI: 10.1016/j.athoracsur.2020.09.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/16/2020] [Accepted: 09/27/2020] [Indexed: 11/18/2022]
Abstract
Pulmonary atresia with intact ventricular septum (PA/IVS) is a rare lesion with wide anatomic variability. A rare variant exists, marked by right-sided dilatation, an Ebsteinoid tricuspid valve (TV), and severe tricuspid regurgitation. Neonatal cone valvuloplasty allows for a biventricular circulation and avoids complications of prosthetic valves; however, this technique inevitably requires reintervention to exchange the RV-PA conduit as the patient grows. We present a successful complete repair cone tricuspid valvuloplasty in a 9-day-old (2.8 kg) neonate with trisomy 21, PA/IVS, and an Ebsteinoid TV.
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Affiliation(s)
- Damien J LaPar
- Section of Congenital and Pediatric Cardiothoracic Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York; Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York.
| | - Morgan K Moroi
- Section of Congenital and Pediatric Cardiothoracic Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York; Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Stephanie N Nguyen
- Section of Congenital and Pediatric Cardiothoracic Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York; Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Emile A Bacha
- Section of Congenital and Pediatric Cardiothoracic Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York; Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
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Abstract
BACKGROUND Isolated congenital tricuspid regurgitation other than Ebstein's anomaly was rare especially for children. The objective of this study was to investigate the clinical characteristics and to assess the results of tricuspid valvuloplasty for children with isolated tricuspid regurgitation. METHODS From January 2010 to June 2019, 10 consecutive patients with isolated tricuspid regurgitation who were unresponsive to drug therapy underwent tricuspid valvuloplasty in our hospital. Patients' clinical data were analysed retrospectively. RESULTS Mean age at operation was 48.5 ± 31.0 (range: 9-106) months and mean weight at operation was 16.1 ± 6.9 (range: 8.6-33.0) kg. All patients presented severe isolated tricuspid regurgitation. According to pathological lesions, the main causes accounted for chordae tendinea rupture (3/10), leaflet cleft (2/10), mal-connected chordal tendinea to leaflets (2/10), elongated chordae (1/10) and chordae absent (1/10), and severe anterior leaflet dysplasia (1/10). Individualised tricuspid valvuloplasty was adapted to all of them successfully. Post-operative echocardiography showed no tricuspid regurgitation in two patients and mild regurgitation in eight patients. The cardiothoracic ratios on their chest roentgenograms decreased from 0.59 ± 0.05 to 0.54 ± 0.05. At the latest follow-up (50.4 ± 47.2 months), echocardiography showed that mild to moderate tricuspid regurgitation in seven patients, moderate tricuspid regurgitation in three patients, and no patient with severe tricuspid regurgitation. All patients were in NYHA functional class I. CONCLUSIONS For patients with isolated tricuspid regurgitation who were not well responsive to drug therapy, individualised tricuspid valve repair can achieve an excellent result.
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Alsoufi B. Commentary: Never let the truth get in the way of a good story. JTCVS Tech 2020; 3:284-285. [PMID: 34317900 PMCID: PMC8302937 DOI: 10.1016/j.xjtc.2020.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 05/24/2020] [Accepted: 05/28/2020] [Indexed: 12/04/2022] Open
Affiliation(s)
- Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Ky
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14
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Davies RR. Commentary: The best of both worlds? Conversion of a neonatal modified Starnes procedure to biventricular circulation. JTCVS Tech 2020; 3:286-287. [PMID: 34317901 PMCID: PMC8302951 DOI: 10.1016/j.xjtc.2020.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 05/15/2020] [Accepted: 05/21/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- Ryan R Davies
- Department of Cardiovascular and Thoracic Surgery, UT Southwestern Medical Center and Children's Health, Dallas, Tex
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15
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Ebstein's anomaly in the neonate. Indian J Thorac Cardiovasc Surg 2020; 37:17-25. [PMID: 33603283 DOI: 10.1007/s12055-020-00942-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 01/26/2020] [Accepted: 02/24/2020] [Indexed: 10/24/2022] Open
Abstract
Ebstein's anomaly is a rare congenital heart defect characterized by apical displacement of the tricuspid valve and reduced volume of the true functional right ventricle. In its most severe form, the disease presents as right heart failure and cyanosis in the neonate. Although many of these neonates can be managed conservatively, surgical intervention may become necessary in the sickest of them. Surgical intervention in this subgroup can be challenging and requires meticulous appreciation of the anatomy and physiology on a case to case basis. Multicenter studies are required to define a uniform algorithm and approach towards these patients.
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Abstract
Ebstein’s anomaly (EA) is a rare congenital cardiac anomaly. It is a disease at a minimum of the tricuspid valve (TV) and the right ventricular myocardium. Presentation varies from a severe symptomatic form during the neonatal period to an incidental detection later in life due to the wide morphological variation of the condition. The neonatal presentation can be severe and every attempt should be made at medical management ideally into infancy and early childhood. Neonates not eligible or failing medical management should be surgically managed either with a single ventricle palliative approach or a more desirable biventricular repair with a neonatal TV valvuloplasty. Some neonates initially committed to a single ventricle pathway may be converted to a biventricular repair by a delayed TV valvuloplasty. The da Silva Cone repair has become the valvuloplasty of choice especially beyond the neonatal period and can be applied to a wide morphological variation of the condition with good long-term durability. If the chance of a successful TV valvuloplasty is high, it should be offered early in childhood to prevent further cardiac dilation. Adding a Bidirectional Glenn to a valvuloplasty may help salvage marginal risk patients or marginally repairable valves. If valve replacement is the only option, a bioprosthetic valve should be used as it is less thrombogenic especially with marginal right ventricular function. Heart transplantation should be considered in patients with associated left ventricular dysfunction.
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Affiliation(s)
- Sandeep Sainathan
- Department of Surgery, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | | | - Jose Pedro da Silva
- Department of Cardio-thoracic surgery, University of Pittsburgh, Pittsburgh, PA, USA
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17
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Li D, Hirata Y, Zhou X, Masuzawa A, Ono M, An Q. Effect of cone reconstruction on right ventricular function in patients with Ebstein's anomaly: a meta-analysis. Interact Cardiovasc Thorac Surg 2018; 26:301-306. [PMID: 29049811 DOI: 10.1093/icvts/ivx312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 08/13/2017] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES Cone reconstruction (CR) is a novel technique for surgically treating the tricuspid valve and right ventricle (RV) in patients with Ebstein's anomaly. However, precise changes in the RV function after CR remain unclear. This study aimed to evaluate the RV size and New York Heart Association (NYHA) functional class by conducting a meta-analysis of reported data. METHODS The MEDLINE, EMBASE, Cochrane Library and China National Knowledge Infrastructure databases were searched for relevant studies. The variables were RV measurements, NYHA functional classes and tricuspid valve regurgitation grades. A fixed/random effects model was used to summarize the estimates of mean difference with standard error. Sensitivity analysis was conducted to ascertain the primary origin of the heterogeneity. RESULTS Nine studies that involved 210 patients were included. The results demonstrated that after CR, the functional RV volume significantly decreased, NYHA functional class improved and tricuspid valve regurgitation grade decreased. CONCLUSIONS Thus, CR appeared to be a positive approach for Ebstein's anomaly, with good results being obtained for the RV size and NYHA functional class. Because some limitations could not be overcome, studies with more data on RV and longer follow-ups are required to confirm our study results.
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Affiliation(s)
- Dongxu Li
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Sichuan, China.,Department of Cardiac Surgery, The University of Tokyo, Tokyo, Japan
| | - Yasutaka Hirata
- Department of Cardiac Surgery, The University of Tokyo, Tokyo, Japan
| | - Xu Zhou
- Evidence-Based Medicine Research Center, School of Basic Medical Sciences, Jiangxi University of Traditional Chinese Medicine, Jiangxi, China
| | - Akihiro Masuzawa
- Department of Cardiac Surgery, The University of Tokyo, Tokyo, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, The University of Tokyo, Tokyo, Japan
| | - Qi An
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Sichuan, China
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18
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Elzein C, Subramanian S, Ilbawi M. Surgical Management of Neonatal Ebstein’s Anomaly Associated With Circular Shunt. World J Pediatr Congenit Heart Surg 2017; 10:116-120. [DOI: 10.1177/2150135117704615] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Ebstein’s anomaly is a rare congenital cardiac malformation that may present in the neonatal period with life-threatening physiologic derangement, especially when it is associated with circular shunt. Urgent surgical intervention is critical for survival because of hemodynamic compromise. We review our experience with surgical management of neonates with Ebstein’s anomaly associated with circular shunt and review the literature for similar reported cases. The underlying pathophysiology and different options of treatment are discussed.
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Affiliation(s)
- Chawki Elzein
- Advocate Children’s Heart Institute, Advocate Children’s Hospital, Oak Lawn, IL, USA
| | - Sujata Subramanian
- Advocate Children’s Heart Institute, Advocate Children’s Hospital, Oak Lawn, IL, USA
| | - Michel Ilbawi
- Advocate Children’s Heart Institute, Advocate Children’s Hospital, Oak Lawn, IL, USA
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19
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Kumar TKS, Boston US, Knott-Craig CJ. Neonatal Ebstein Anomaly. Semin Thorac Cardiovasc Surg 2017; 29:331-337. [PMID: 28958645 DOI: 10.1053/j.semtcvs.2017.09.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2017] [Indexed: 11/11/2022]
Affiliation(s)
- T K Susheel Kumar
- Pediatric Cardiovascular Surgery, University of Tennessee Health Sciences Center and Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Umar S Boston
- Pediatric Cardiovascular Surgery, University of Tennessee Health Sciences Center and Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Christopher J Knott-Craig
- Surgery and Chief of Pediatric Cardiothoracic Surgery, University of Tennessee Health Sciences Center and Le Bonheur Children's Hospital, Memphis, Tennessee.
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20
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Huang SC, Wu ET, Chen SJ, Huang CH, Shih JC, Chou HW, Chang CI, Chiu IS, Chen YS. Surgical Strategy Toward Biventricular Repair for Severe Ebstein Anomaly in Neonates and Infancy. Ann Thorac Surg 2017; 104:917-925. [PMID: 28434546 DOI: 10.1016/j.athoracsur.2017.01.081] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 01/17/2017] [Accepted: 01/18/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Neonates with severe forms of Ebstein anomaly present a surgical challenge, and the Starnes operation as single ventricle palliation is highly advocated. Cone reconstruction for tricuspid valvuloplasty (TVP) has become a widely accepted technique, although very few cases of TVP have been reported in neonates. This report describes a surgical strategy for neonatal Ebstein anomaly, with an aim toward biventricular repair. METHODS Since 2007, 7 neonates or young infants with severe Ebstein anomalies have received TVP at the National Taiwan University Hospital, Taipei, Taiwan. The principle of cone reconstruction was applied with mobilization of all three leaflets and reattachment to the normal tricuspid annulus. The atrialized right ventricle was not plicated. In patients with pulmonary stenosis, the interatrial communication was not totally closed (n = 5), and a systemic-pulmonary shunt was added if needed (n = 3). RESULTS All patients presented with intractable heart failure or severe cyanosis requiring mechanical ventilation, or both. All patients had marked adherence of the anterior leaflet to the right ventricular free wall. Intracardiac anomalies including ventricular septal defect (n = 2) and tetralogy of Fallot (n = 1) were also repaired simultaneously. Six of the 7 patients (86%) survived. There were no late deaths or repeat TVPs for a median follow-up of 4.3 years (range, 0.8 to 9.9 years). CONCLUSIONS Reconstruction of the tricuspid valve is an acceptable surgical strategy in patients with severe neonatal Ebstein anomaly. Fenestrated atrial septal defect and systemic-pulmonary shunt can help overcome anatomic pulmonary stenosis and high pulmonary resistance in the neonatal period. This surgical strategy has a good survival outcome and preserves the possibility of complete biventricular repair.
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Affiliation(s)
- Shu-Chien Huang
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.
| | - En-Ting Wu
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Shyh-Jye Chen
- Department of Medical Imaging, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chi-Hsiang Huang
- Department of Anesthesiology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jin-Chung Shih
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Hen-Wen Chou
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chung-I Chang
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ing-Sh Chiu
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yih-Sharng Chen
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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21
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LI JS, Ma J, Yan ZX, Cheng DM, Chang L, Zhang HC, Liu JY. Acute arterial embolism of left lower extremity caused by paradoxical embolism in Ebstein's anomaly: A case report. Medicine (Baltimore) 2017; 96:e5901. [PMID: 28151866 PMCID: PMC5293429 DOI: 10.1097/md.0000000000005901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Ebstein's anomaly is a benign and stable congenital heart disease for asymptomatic patients. Despite a low incidence of Ebstein's anomaly (EA), patients' quality of life can be badly affected by EA without positive surgical intervention. Especially EA is associated with other congenital heart disease, such as the atrial septal defect, patent foramen ovale, and arterial embolism exclude other reasons, it is often considered to be the consequence of paradoxical embolism, and surgical intervention must be conducted. CASE REPORT An 11-year-old girl falling off the bed suffered pain from left lower extremity. Echocardiographic evaluation revealed an EA, severe tricuspid regurgitation, and secundum atrial septal defect. Both left leg amputation and cardiac surgery were conducted after recovery. Under the condition of anesthesia cardiopulmonary bypass extracorporeal circulation, atrial septal defect repair and Cone reconstruction of the tricuspid valve were performed. Patient recovered well and left hospital smoothly. DISCUSSION EA is a rare and complex congenital cardiac malformation. There are about 80% to 90% of EA patients with combined atrial septal defect and patent foramen ovale. Sudden arterial occlusion is very rare especially in childhood. When thoracic roentgenoscopy, arterial blood gas analysis, coagulation test, and echocardiographic of lower extremity deep venous system are all normal, one should consider the possibility of a paradoxical embolism. If patients have the paradoxical embolism or worsening tricuspid regurgitation, the most suitable therapeutic regimen should be chosen according to patients' condition. With surgical techniques and methods renewed continuously, cone reconstruction of the tricuspid valve has been confirmed in clinical trials, which can use its own tissues to form not only central bloodstream, but also the coaption between leaflet and leaflet.
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Affiliation(s)
| | - Jie Ma
- Department of Cardiothoracic Surgery
| | | | | | | | | | - Jiang-Yan Liu
- Department of Ultrasound, Shanxi Medical University Second Hospital, Taiyuan, Shanxi, P.R. China
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Luxford JC, Arora N, Ayer JG, Verrall CE, Cole AD, Orr Y, d'Udekem Y, Sholler GF, Winlaw DS. Neonatal Ebstein Anomaly: A 30-year Institutional Review. Semin Thorac Cardiovasc Surg 2017; 29:206-212. [DOI: 10.1053/j.semtcvs.2017.01.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2017] [Indexed: 11/11/2022]
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