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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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Pizarro C, Bhat MA, Davis DA, Duncan D, Pelletier GJ, Baffa G. Tailored strategy to match anatomy and physiology with intervention can improve outcomes of symptomatic neonates with Ebstein anomaly. JTCVS OPEN 2022; 12:344-354. [PMID: 36590729 PMCID: PMC9801273 DOI: 10.1016/j.xjon.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 09/14/2022] [Accepted: 09/21/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE Neonatal presentation of Ebstein anomaly (EA) represents the most severe form of this condition. Despite significant advances, operative mortality remains high and management decisions represent a formidable challenge. We used a strategy aimed to match anatomy and physiology with type and time of intervention to increase survival. METHODS We performed a review of all patients with fetal or neonatal diagnosis of EA managed at a single center between 2007 and 2020. RESULTS Among 18 patients with EA, 8 underwent neonatal intervention. The most common indication included cyanosis and heart failure (8/8), end organ dysfunction (6/8), and maldistribution of cardiac output (6/8). Only 2/8 had antegrade pulmonary blood flow. Associated conditions included pulmonary regurgitation in 4/8, atrial tachyarrhythmia in 4, and a ventricular septal defect in 3. Three patients underwent initial stabilization with main pulmonary artery occlusion including bilateral pulmonary artery banding in 2. Five patients underwent biventricular repair with conversion to right ventricle exclusion in 2 cases. Three others underwent the Starnes procedure as initially planned. The median age at surgery was 10 days (range, 1-30) and median weight 2.6 kg (range, 1.9-4.0). The median duration of mechanical ventilation and intensive care unit stay were 9 days (range, 5-34) and 30 days (range, 15-100), respectively. Operative mortality was 1/8. At a median follow-up of 130 months (range, 5-146), there were no late deaths, and all survivors remain in functional class I and free of valvular reintervention. CONCLUSIONS Symptomatic neonates with EA can be effectively managed with good outcomes. Preoperative stabilization and choice of management pathway on the basis of anatomy and physiology can help reduce morbidity and mortality.
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Affiliation(s)
- Christian Pizarro
- Address for reprints: Christian Pizarro, MD, Nemours Cardiac Center, Alfred I. duPont Hospital for Children, 1600 Rockland Rd, Wilmington, DE 19803.
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Corno AF, Adebo DA, LaPar DJ, Salazar JD. Modern advances regarding interatrial communication in congenital heart defects. J Card Surg 2021; 37:350-360. [PMID: 34842296 DOI: 10.1111/jocs.16166] [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: 11/05/2021] [Revised: 11/12/2021] [Accepted: 11/19/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The interatrial communication, one of the most frequent congenital heart defects, represents an important intracardiac shunt between systemic and pulmonary circulations. Direction and magnitude of the interatrial shunting depends upon several features, including defect size, shape and location, pressure difference between right and left atrium, and difference in right and left ventricular compliance. METHODS In this review article, the presence or absence of interatrial communication, and its role, have been analyzed, as they can have a critical impact on the cardiovascular physiopathology, and the interatrial communication can prove to be either clinically harmful, useful or indispensable. Accordingly, the utility and role of the interatrial communication in modern congenital, pediatric and adult, disease has evolved, with modification of the indications to close, maintain patency, or create an interatrial communication. RESULTS The interatrial communication and shunting can be manipulated to maximize the oxygen delivery to the tissues, accordingly with the underlying congenital heart defect. While not always relevant to patients with bi-ventricular circulations, this becomes extremely important in children and adults with complex congenital heart defects. CONCLUSIONS With improving long-term survival for the vast majority of congenital heart patients, an advanced understanding of the role and utility of the interatrial communication, and of all the possibilities of its manipulation, is essential to improve the patient outcomes.
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Affiliation(s)
- Antonio F Corno
- Department of Pediatric and Congenital Heart Surgery, Houston Children's Heart Institute, Memorial Hermann Children's Hospital, University of Texas Health, McGovern Medical School, Houston, Texas, USA
| | - Dilachew A Adebo
- Department of Pediatric and Congenital Cardiology, Houston Children's Heart Institute, Memorial Hermann Children's Hospital, University of Texas Health, McGovern Medical School, Houston, Texas, USA
| | - Damien J LaPar
- Department of Pediatric and Congenital Heart Surgery, Houston Children's Heart Institute, Memorial Hermann Children's Hospital, University of Texas Health, McGovern Medical School, Houston, Texas, USA
| | - Jorge D Salazar
- Department of Pediatric and Congenital Heart Surgery, Houston Children's Heart Institute, Memorial Hermann Children's Hospital, University of Texas Health, McGovern Medical School, Houston, Texas, USA
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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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Freud LR, McElhinney DB, Kalish BT, Escobar-Diaz MC, Komarlu R, Puchalski MD, Jaeggi ET, Szwast AL, Freire G, Levasseur SM, Kavanaugh-McHugh A, Michelfelder EC, Moon-Grady AJ, Donofrio MT, Howley LW, Selamet Tierney ES, Cuneo BF, Morris SA, Pruetz JD, van der Velde ME, Kovalchin JP, Ikemba CM, Vernon MM, Samai C, Satou GM, Gotteiner NL, Phoon CK, Silverman NH, Tworetzky W. Risk Factors for Mortality and Circulatory Outcome Among Neonates Prenatally Diagnosed With Ebstein Anomaly or Tricuspid Valve Dysplasia: A Multicenter Study. J Am Heart Assoc 2020; 9:e016684. [PMID: 33076749 PMCID: PMC7763426 DOI: 10.1161/jaha.120.016684] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background In a recent multicenter study of perinatal outcome in fetuses with Ebstein anomaly or tricuspid valve dysplasia, we found that one third of live‐born patients died before hospital discharge. We sought to further describe postnatal management strategies and to define risk factors for neonatal mortality and circulatory outcome at discharge. Methods and Results This 23‐center, retrospective study from 2005 to 2011 included 243 fetuses with Ebstein anomaly or tricuspid valve dysplasia. Among live‐born patients, clinical and echocardiographic factors were evaluated for association with neonatal mortality and palliated versus biventricular circulation at discharge. Of 176 live‐born patients, 7 received comfort care, 11 died <24 hours after birth, and 4 had insufficient data. Among 154 remaining patients, 38 (25%) did not survive to discharge. Nearly half (46%) underwent intervention. Mortality differed by procedure; no deaths occurred in patients who underwent right ventricular exclusion. At discharge, 56% of the cohort had a biventricular circulation (13% following intervention) and 19% were palliated. Lower tricuspid regurgitation jet velocity (odds ratio [OR], 2.3 [1.1–5.0], 95% CI, per m/s; P=0.025) and lack of antegrade flow across the pulmonary valve (OR, 4.5 [1.3–14.2]; P=0.015) were associated with neonatal mortality by multivariable logistic regression. These variables, along with smaller pulmonary valve dimension, were also associated with a palliated outcome. Conclusions Among neonates with Ebstein anomaly or tricuspid valve dysplasia diagnosed in utero, a variety of management strategies were used across centers, with poor outcomes overall. High‐risk patients with low tricuspid regurgitation jet velocity and no antegrade pulmonary blood flow should be considered for right ventricular exclusion to optimize their chance of survival.
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Affiliation(s)
- Lindsay R Freud
- Division of Cardiology Department of Pediatrics NewYork-Presbyterian Morgan Stanley Children's Hospital Columbia University Medical Center New York NY
| | - Doff B McElhinney
- Division of Cardiology Department of Pediatrics Lucile Packard Children's Hospital Stanford School of Medicine Palo Alto CA
| | - Brian T Kalish
- Division of Newborn Medicine Department of Pediatrics Boston Children's Hospital Harvard Medical School Boston MA
| | - Maria C Escobar-Diaz
- Department of Pediatric Cardiology Hospital Sant Joan de Déu Universitat de Barcelona Spain
| | - Rukmini Komarlu
- Division of Pediatric Cardiology Department of Pediatrics Cleveland Clinic Children's Hospital Lerner College of Medicine at Case Western Reserve University Cleveland OH
| | - Michael D Puchalski
- Division of Cardiology Department of Pediatrics Primary Children's Hospital University of Utah School of Medicine Salt Lake City UT
| | - Edgar T Jaeggi
- Division of Cardiology Department of Paediatrics Hospital for Sick Children University of Toronto Toronto Ontario Canada
| | - Anita L Szwast
- Division of Cardiology Department of Pediatrics Children's Hospital of Philadelphia Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Grace Freire
- Division of Cardiology Department of Pediatrics Johns Hopkins All Children's Hospital St. Petersburg FL
| | - Stéphanie M Levasseur
- Division of Cardiology Department of Pediatrics NewYork-Presbyterian Morgan Stanley Children's Hospital Columbia University Medical Center New York NY
| | - Ann Kavanaugh-McHugh
- Division of Cardiology Department of Pediatrics Monroe Carell Jr. Children's Hospital Vanderbilt University School of Medicine Nashville TN
| | - Erik C Michelfelder
- Division of Cardiology Department of Pediatrics Children's Healthcare of Atlanta Sibley Heart Center Emory University School of Medicine Atlanta GA
| | - Anita J Moon-Grady
- Division of Cardiology Department of Pediatrics UCSF Benioff Children's Hospital University of California-San Francisco School of Medicine San Francisco CA
| | - Mary T Donofrio
- Division of Cardiology Department of Pediatrics Children's National Medical Center George Washington University School of Medicine and Health Sciences Washington DC
| | - Lisa W Howley
- Division of Cardiology Department of Pediatrics Children's Hospital Colorado University of Colorado School of Medicine Aurora CO
| | - Elif Seda Selamet Tierney
- Division of Cardiology Department of Pediatrics Lucile Packard Children's Hospital Stanford School of Medicine Palo Alto CA
| | - Bettina F Cuneo
- Division of Cardiology Department of Pediatrics Children's Hospital Colorado University of Colorado School of Medicine Aurora CO
| | - Shaine A Morris
- Division of Cardiology Department of Pediatrics Texas Children's Hospital Baylor College of Medicine Houston TX
| | - Jay D Pruetz
- Division of Cardiology Department of Pediatrics Children's Hospital Los Angeles University of Southern California Keck School of Medicine Los Angeles CA
| | - Mary E van der Velde
- Division of Cardiology Department of Pediatrics University of Michigan Congenital Heart Center C.S. Mott Children's Hospital University of Michigan Medical School Ann Arbor MI
| | - John P Kovalchin
- Division of Cardiology Department of Pediatrics Nationwide Children's Hospital Ohio State University College of Medicine Columbus OH
| | - Catherine M Ikemba
- Division of Cardiology Department of Pediatrics Children's Medical Center University of Texas Southwestern Medical School Dallas TX
| | - Margaret M Vernon
- Division of Cardiology Department of Pediatrics Seattle Children's Hospital University of Washington School of Medicine Seattle WA
| | - Cyrus Samai
- Division of Cardiology Department of Pediatrics Children's Healthcare of Atlanta Emory University School of Medicine Atlanta GA
| | - Gary M Satou
- Division of Cardiology Department of Pediatrics Mattel Children's Hospital University of California-Los Angeles David Geffen School of Medicine Los Angeles CA
| | - Nina L Gotteiner
- Division of Cardiology Department of Pediatrics Ann & Robert H. Lurie Children's Hospital of Chicago Northwestern University Feinberg School of Medicine Chicago IL
| | - Colin K Phoon
- Division of Cardiology Department of Pediatrics Hassenfeld Children's Hospital at NYU Langone New York University School of Medicine New York NY
| | - Norman H Silverman
- Division of Cardiology Department of Pediatrics Lucile Packard Children's Hospital Stanford School of Medicine Palo Alto CA.,Division of Cardiology Department of Pediatrics UCSF Benioff Children's Hospital University of California-San Francisco School of Medicine San Francisco CA
| | - Wayne Tworetzky
- Department of Cardiology Boston Children's Hospital Harvard Medical School Boston MA
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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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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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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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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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