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Jensen B, Andelfinger GU, Postma AV. Molecular Pathways and Animal Models of Ebstein's Anomaly. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1441:915-928. [PMID: 38884760 DOI: 10.1007/978-3-031-44087-8_58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
Ebstein's anomaly is a congenital malformation of the tricuspid valve characterized by abnormal attachment of the valve leaflets, resulting in varying degrees of valve dysfunction. The anatomic hallmarks of this entity are the downward displacement of the attachment of the septal and posterior leaflets of the tricuspid valve. Additional intracardiac malformations are common. From an embryological point of view, the cavity of the future right atrium does not have a direct orifice connected to the developing right ventricle. This chapter provides an overview of current insight into how this connection is formed and how malformations of the tricuspid valve arise from dysregulation of molecular and morphological events involved in this process. Furthermore, mouse models that show features of Ebstein's anomaly and the naturally occurring model of canine tricuspid valve malformation are described and compared to the human model. Although Ebstein's anomaly remains one of the least understood cardiac malformations to date, the studies summarized here provide, in aggregate, evidence for monogenic and oligogenic factors driving pathogenesis.
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Affiliation(s)
- Bjarke Jensen
- Department of Medical Biology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Gregor U Andelfinger
- Cardiovascular Genetics, Department of Pediatrics, CHU Sainte Justine, Université de Montréal, Montréal, QC, Canada
| | - Alex V Postma
- Department of Medical Biology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centres, Amsterdam, The Netherlands.
- Department of Human Genetics, Amsterdam University Medical Centres, Amsterdam, The Netherlands.
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Dobson CP, Christopher AB, Castro-Medina M, Viegas ML, Da Silva JP, Da Silva LDF. Using DaSilva Cone Operation to Establish 1.5 or 2 Ventricle Circulation After Initial Single Ventricle Palliation with Starnes Procedure. Pediatr Cardiol 2023:10.1007/s00246-023-03336-1. [PMID: 38038752 DOI: 10.1007/s00246-023-03336-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/21/2023] [Indexed: 12/02/2023]
Abstract
Ebstein anomaly (EA) is a congenital dysplasia of the tricuspid valve resulting in reduced right ventricular (RV) volume and tricuspid regurgitation. Severe EA in the neonatal period is associated with high mortality. The Starnes procedure (fenestrated RV exclusion) is reserved for EA patients with cardiogenic shock and has previously committed patients to single ventricle (SV) palliation. In this report, we present the results of a strategy to redirect patients utilizing the Da Silva Cone operation to achieve a 2 or 1.5 ventricle circulation. Single-center retrospective study including all consecutive cases of Da Silva Cone operation after Starnes procedure. Between 2019 and 2023, six conversions from Starnes procedure to Cone reconstruction were performed. All were critically ill before their Starnes procedure; four on extracorporeal membrane oxygenation. Two patients were successfully rerouted to a two-ventricle repair; the remainder to 1.5 ventricle circulation. RV pressure estimates showed no correlation with success. Post-Cone intensive care and hospital stays were brief, median 5 and 6 days, respectively. All are between 2.5 and 6 years old, without indications for SV palliation. There were no deaths, with follow up ranging 1 month-4 years. No repeat interventions were performed on the tricuspid valves. One subject had a surgical pulmonary valve replacement. Tricuspid regurgitation was mild in all. The Da Silva Cone operation offers successful redirection of EA patients from a SV pathway to a 1.5 or 2 ventricle pathway after Starnes procedure. The approach is feasible and durable in midterm follow-up. The decision to initially proceed with Starnes need not be an irrevocable decision to continue down a SV palliation pathway.
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Affiliation(s)
- Craig P Dobson
- Division of Pediatric Cardiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
| | - Adam B Christopher
- Division of Pediatric Cardiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Mario Castro-Medina
- Department of Cardiothoracic Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Melita L Viegas
- Department of Cardiothoracic Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Jose Pedro Da Silva
- Department of Cardiothoracic Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
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Bishnoi K, Parida GK, Emerson R, Agrawal K. "Ebstein's Anomaly" a Potential Cause of Misinterpretation on Myocardial Perfusion Imaging. Indian J Nucl Med 2022; 37:392-393. [PMID: 36817212 PMCID: PMC9930459 DOI: 10.4103/ijnm.ijnm_43_22] [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: 03/02/2022] [Revised: 05/06/2022] [Accepted: 05/19/2022] [Indexed: 12/03/2022] Open
Abstract
Ebstein's anomaly is a rare congenital heart disease. We present the case of a 47-year-old woman with history of Ebstein's anomaly who was referred to nuclear medicine department for a myocardial perfusion single-photon emission computed tomography (SPECT) imaging during pre-anesthetic check-up. Myocardial SPECT perfusion images with (99mTc)-Sestamibi demonstrated medium sizes fixed perfusion defect in the mid and proximal infero-septal wall adjacent inferior wall. This is a cause of potential misinterpretation on myocardial SPECT perfusion imaging as this perfusion defect was due to fibrosis rather than scarred myocardium.
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Affiliation(s)
- Komal Bishnoi
- Department of Nuclear Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Girish Kumar Parida
- Department of Nuclear Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Ralph Emerson
- Department of Nuclear Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Kanhaiyalal Agrawal
- Department of Nuclear Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
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Van Praagh R. Tricuspid Valve Anomalies. CONGENIT HEART DIS 2022. [DOI: 10.1016/b978-1-56053-368-9.00013-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Neumann S, Rüffer A, Sachweh J, Biermann D, Herrmann J, Jerosch-Herold M, Hazekamp M, Sinning C, Zengin E, Blankenberg S, Girdauskas E, Reichenspurner H, Kehl T, Müller G, Kozlik-Feldmann R, Rickers C. Narrative review of Ebstein's anomaly beyond childhood: Imaging, surgery, and future perspectives. Cardiovasc Diagn Ther 2021; 11:1310-1323. [PMID: 35070800 PMCID: PMC8748487 DOI: 10.21037/cdt-20-771] [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: 09/08/2020] [Accepted: 12/22/2020] [Indexed: 11/29/2023]
Abstract
Ebstein's anomaly is a rare congenital heart disease with malformation of the tricuspid valve and myopathy of the right ventricle. The septal and inferior leaflets adhere to the endocardium due to failure of delamination. This leads to apical displacement of their hinge points with a shift of the functional tricuspid valve annulus towards the right ventricular outflow tract with a possibly restrictive orifice. Frequently, a coaptation gap yields tricuspid valve regurgitation and over time the "atrialized" portion of the right ventricle may dilate. The highly variable anatomy determines the clinical presentation ranging from asymptomatic to very severe with need for early operation. Echocardiography and magnetic resonance imaging are the most important diagnostic modalities to assess the tricuspid valve as well as ventricular morphology and function. While medical management of asymptomatic patients can be effective for many years, surgical intervention is indicated before development of significant right ventricular dilatation or dysfunction. Onset of symptoms and arrhythmias are further indications for surgery. Modified cone reconstruction of the tricuspid valve is the state-of-the-art approach yielding the best results for most patients. Alternative procedures for select cases include tricuspid valve replacement and bidirectional cavopulmonary shunt depending on patient age and other individual characteristics. Long-term survival after surgery is favorable but rehospitalization and reoperation remain significant issues. Further studies are warranted to identify the optimal surgical strategy and timing before adverse right ventricular remodeling occurs. It is this article's objective to provide a comprehensive review of current literature and an overview on the management of Ebstein's Anomaly. It focuses on imaging, cardiac surgery, and outcome. Additionally, a brief insight into arrhythmias and their management is given. The "future perspectives" summarize open questions and fields of future research.
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Affiliation(s)
- Stephan Neumann
- Department of Pediatric Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - André Rüffer
- Surgery for Congenital Heart Disease, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Jörg Sachweh
- Surgery for Congenital Heart Disease, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Daniel Biermann
- Surgery for Congenital Heart Disease, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Jochen Herrmann
- Department of Pediatric Radiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Mark Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Christoph Sinning
- Department of Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Elvin Zengin
- Department of Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Stefan Blankenberg
- Department of Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Evaldas Girdauskas
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Torben Kehl
- Department of Pediatric Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Götz Müller
- Department of Pediatric Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Rainer Kozlik-Feldmann
- Department of Pediatric Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Carsten Rickers
- Adult Congenital Heart Disease Section, University Heart & Vascular Center Hamburg, Hamburg, Germany
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Stephens EH, Dearani JA, Qureshi MY, Ammash N, Maleszewski JJ. The Congenital Tricuspid Valve Spectrum: From Ebstein to Dysplasia. World J Pediatr Congenit Heart Surg 2021; 11:783-791. [PMID: 33164686 DOI: 10.1177/2150135120949235] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Ebstein anomaly has a breadth of presentations, including "typical" and "atypical," and can be confused with congenital tricuspid dysplasia. We summarize how to differentiate within this spectrum of disease. Both typical and atypical Ebstein have an underlying failure of delamination, but atypical Ebstein does not have ≥8mm/m2 apical septal leaflet displacement. In congenital tricuspid dysplasia, delamination is normal, while the leaflets and subvalvar apparatus are abnormal. To summarize, the sine qua non feature of Ebstein anomaly, present in both typical and atypical, is the failure of delamination. These are distinct from congenital tricuspid valve dysplasia in which the pathology is in the leaflet itself.
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Affiliation(s)
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, 4352Mayo Clinic, Rochester, MN, USA
| | | | - Naser Ammash
- Department of Cardiovascular Diseases, 4352Mayo Clinic, Rochester, MN, USA
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Yang Y, Zhang W, Liu Y, Li G, Zhang H, Fan X, Su J, Liu Y, Fan X. Preoperative percutaneous oxygen saturation is a predictor of postoperative adverse events after Ebstein's anomaly reconstruction. J Card Surg 2021; 36:1012-1017. [PMID: 33503687 DOI: 10.1111/jocs.15373] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 12/31/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Ebstein's anomaly (EA) is a kind of congenital heart disease, which is currently widely treated by cone reconstruction. However, the prediction of postoperative recovery is still challenging. METHODS A retrospective analysis was performed on EA cases undergoing cone reconstruction from January 2010 to January 2016. Univariate and multivariate logistic regression analyses were performed, with postoperative adverse events defined as dependent variable and pre- and intraoperative parameters defined as independent variables. The predictive capacity of preoperative percutaneous oxygen saturation (SPO2 ) and Great Ormond Street (GOS) score was evaluated using areas under the curve of the receiver operating characteristic (ROC). RESULTS Preoperative SPO2 was 95.7 ± 5.20%. Cardiopulmonary bypass, aortic cross-clamp, postoperative mechanical ventilation, and hospitalization time were 101.7 ± 28.26 min, 60.9 ± 18.04 min, 16 h (8, 22), and 8 days (7, 11), respectively. The incidence of total postoperative adverse events, including low cardiac output syndrome, mechanical ventilation more than 3 days, postoperative hospitalization more than 2 weeks, postoperative reintubation, extracorporeal membrane oxygenation assistance, and death, was 13.1% (n = 13). Low preoperative SPO2 (p = .001, odds ratio [OR] = 0.834), GOS score (p = .021, OR = 0.368), and cardiopulmonary bypass time (p = .034, OR = 1.021) were risk factors for adverse events. Multivariate logistic regression analysis showed that low preoperative SPO2 (p = .002, OR = 0.846) and GOS score (p = .043, OR = 0.577) were independent risk factors for adverse events. The areas of SPO2 and GOS score under the ROC curve were 0.764 and 0.740, respectively. CONCLUSIONS Low preoperative SPO2 and GOS score were predictors of adverse events after cone reconstruction, and SPO2 was more convenient and objective than the GOS score.
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Affiliation(s)
- Yao Yang
- Pediatric Cardiac Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Wei Zhang
- Pediatric Cardiac Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yang Liu
- Pediatric Cardiac Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Gang Li
- Pediatric Cardiac Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Han Zhang
- Pediatric Cardiac Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xing Fan
- Pediatric Cardiac Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Junwu Su
- Pediatric Cardiac Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yinglong Liu
- Pediatric Cardiac Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiangming Fan
- Pediatric Cardiac Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Cesna S, Eicken A. Percutaneous techniques for treatment of tricuspid valve dysfunction in congenital heart disease - an emerging therapy. Expert Rev Cardiovasc Ther 2020; 19:817-824. [PMID: 33336614 DOI: 10.1080/14779072.2021.1865154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Tricuspid valve (TV) dysfunction treatment experiences exponential growth of the interest over the last years. New techniques for percutaneous tricuspid valve treatment are either on the market or in the early stages of development.Areas covered: Deficiency of uniform guideline-based recommendations leads to diverse TV dysfunction treatment options. The current review describes the development of surgical techniques for TV dysfunction in Ebstein's anomaly and transition to a variety of new technologies. Then, the focus is on the potential of percutaneous interventions to reduce the total number of open-heart surgeries in patients with congenital heart disease (CHD) after TV replacement with a bioprosthesis to improve TV function.Expert opinion: TV dysfunction is usually a complex combination of anatomical cardiac features in CHD. Compared to adults with secondary TV dysfunction, CHD patients usually are younger and have experienced several open-heart surgeries at a young age. Therefore, TV dysfunction can affect long-term life expectancy and quality of life significantly. So far, surgery was the gold standard for TV dysfunction treatment. The duration of TV plasty or bioprosthesis is limited, while the risk of re-do operations increases with every procedure. Percutaneous TV implantation may reduce the total number of open-heart surgeries over a patient's life.
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Affiliation(s)
- Sigitas Cesna
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania.,Centre of Cardiology and Angiology, Department of Cardiovascular Diseases, Vilnius University Hospital Santaros Clinics, Vilnius, Lithuania
| | - Andreas Eicken
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center, Munich, Technische Universität München, Munich, Germany
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Lee CH, Lim JH, Kim ER, Kim YJ. Cone Repair in Adult Patients with Ebstein Anomaly. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 53:243-249. [PMID: 33020344 PMCID: PMC7553823 DOI: 10.5090/kjtcs.20.113] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 09/02/2020] [Indexed: 11/25/2022]
Abstract
Ebstein anomaly is a rare congenital heart malformation typically involving the tricuspid valve and the right ventricle that has a wide range of anatomical and pathophysiological presentations. Various surgical repair techniques for Ebstein anomaly have been reported because of its near-infinite anatomical variability. Cone repair for Ebstein anomaly can achieve nearly anatomical reconstruction of the tricuspid valve with promising outcomes. In this article, the surgical techniques for cone repair in adult patients with Ebstein anomaly are described in detail, and clinical experiences and technically challenging cases are presented.
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Affiliation(s)
- Chang-Ha Lee
- Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Bucheon, Korea
| | - Jae Hong Lim
- Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Bucheon, Korea
| | - Eung Rae Kim
- Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Bucheon, Korea
| | - Yong Jin Kim
- Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Bucheon, Korea
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Sánchez-Quintana D, Cabrera JA, Picazo-Angelin B, Cabrera A, Anderson RH. Histological examination of the potential arrhythmic substrates in the setting of Ebstein's malformation. J Anat 2020; 237:155-165. [PMID: 32115720 DOI: 10.1111/joa.13179] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 02/13/2020] [Accepted: 02/14/2020] [Indexed: 11/29/2022] Open
Abstract
Cardiac arrhythmias, notably Wolff-Parkinson-White syndrome, are known to represent a major issue in patients with Ebstein's malformation of the tricuspid valve. Abnormal conducting circuits, however, can also be produced by pathways extending either from the atrioventricular node or the ventricular components of the atrioventricular conduction axis, direct to the crest of the muscular ventricular septum. We hoped to provide further information on the potential presence of such pathways by investigations of six autopsied examples of Ebstein's malformation. All were studied by histological sectioning on the full extent of the atrioventricular conduction axis, with limited sectioning of the right atrioventricular junction supporting the inferior and antero-superior leaflets of the deformed tricuspid valve. We used the criteria established by Aschoff (Verhandlungen der Deutschen Gesellschaft für Pathologie, 14, 1910, 3) and Mönckeberg (Verhandlungen der Deutschen Gesellschaft für Pathologie, 14, 1910, 64) over a century ago to define abnormal connections across the atrioventricular junctions, as these definitions retain their validity for the identification of gross myocardial connections across the insulating tissues of the atrioventricular junctions. In one specimen, we found two discrete accessory myocardial connections across the parietal right atrioventricular junction. In all of the hearts, we found so-called nodoventricular connections, and in one heart we also observed a well-formed connection originating from the penetrating atrioventricular bundle. In addition to accessory myocardial connections across the parietal right atrioventricular junction, therefore, our histological findings demonstrate a potential role for direct connections between the atrioventricular conduction axis and the ventricular myocardium in the setting of Ebstein's malformation.
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Affiliation(s)
- Damián Sánchez-Quintana
- Department of Human Anatomy and Cell Biology, Faculty of Medicine, University of Extremadura, Badajoz, Spain
| | - José Angel Cabrera
- Unidad de Arritmias, Departamento de Cardiología, Hospital Universitario Quirón-Salud Madrid and Complejo Hospitalario Ruber Juan Bravo, Universidad Europea de Madrid, Madrid, Spain
| | - Beatriz Picazo-Angelin
- Sección de Cardiología Pediátrica, Departamento de Enfermedades Cardiovasculares, Hospita Regional Universitario Carlos Haya de Málaga, Málaga, Spain
| | | | - Robert H Anderson
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
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Cieplucha A, Trojnarska O, Bartczak-Rutkowska A, Kociemba A, Rajewska-Tabor J, Kramer L, Pyda M. Severity Scores for Ebstein Anomaly: Credibility and Usefulness of Echocardiographic vs Magnetic Resonance Assessments of the Celermajer Index. Can J Cardiol 2019; 35:1834-1841. [DOI: 10.1016/j.cjca.2019.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/28/2019] [Accepted: 08/07/2019] [Indexed: 12/28/2022] Open
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Hughes ML, Bonello B, Choudhary P, Marek J, Tsang V. A simple measure of the extent of Ebstein valve rotation with cardiovascular magnetic resonance gives a practical guide to feasibility of surgical cone reconstruction. J Cardiovasc Magn Reson 2019; 21:34. [PMID: 31242903 PMCID: PMC6595703 DOI: 10.1186/s12968-019-0546-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 05/29/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Once surgical management is indicated, variation of Ebstein valve morphology affects surgical strategy. This study explored practical, easily measureable, cardiovascular magnetic resonance (CMR)-derived attributes that may contribute to the complexity and risk of cone reconstruction. METHODS A retrospective assessment was performed of Ebstein anomaly patients older than 12 years age, with pre-operative CMR, undergoing cone surgical reconstruction by one surgeon. In addition to clinical data, the CMR-derived Ebstein valve rotation angle (EVRA), area ratios of chamber size, indexed functional RV (RVEDVi) and left ventricular (LV) volumes, tricuspid valve regurgitant fraction (TR%) and other valve attributes were related to early surgical outcome; including death, significant residual TR% or breakdown of repair. RESULTS Of 26 operated patients older than 12 years age, since program start, 20 had pre-op CMR and underwent surgery at median (range) age 20 (14-57) years. TR% was improved in all patients. Four of the 20 CMR patients (20%) experienced early surgical dehiscence of the paravalve tissue, with cone-shaped tricuspid valve intact; one of whom died. A larger EVRA correlated with Carpentier category and was significantly related to dehiscence. If EVRA >60o, relative risk of dehiscence was 3.2 (CI 1.3-4.9, p = 0.03). Those with dehiscence had thickened, more tethered anterior leaflet edges (RR 17, CI 3-100, p < 0.01), smaller pre-operative functional RVEDVi; (132 vs 177 mL/m2, p = 0.04), and were older (median 38 vs 19 years, p = 0.01). TR %, chamber area ratios and LV parameters were not different. CONCLUSIONS Comprehensive CMR assessment characterizes patients prior to cone surgical reconstruction of Ebstein anomaly. Pragmatic observation of larger EVRA, smaller RVEDVi and leaflet thickening, suggests risk of repair tension and dehiscence, and may require specific modification of cone surgical technique, such as leaflet augmentation.
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Affiliation(s)
- Marina L. Hughes
- Cardiorespiratory Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, WC1N 3JH UK
- Cardiology Department, Royal Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, CB23 3RE UK
| | - Beatrice Bonello
- Cardiorespiratory Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, WC1N 3JH UK
| | - Preeti Choudhary
- Cardiorespiratory Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, WC1N 3JH UK
| | - Jan Marek
- Cardiorespiratory Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, WC1N 3JH UK
| | - Victor Tsang
- Cardiorespiratory Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, WC1N 3JH UK
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Qureshi MY, Sommer RJ, Cabalka AK. Tricuspid Valve Imaging and Intervention in Pediatric and Adult Patients With Congenital Heart Disease. JACC Cardiovasc Imaging 2019; 12:637-651. [DOI: 10.1016/j.jcmg.2018.10.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 10/04/2018] [Accepted: 10/18/2018] [Indexed: 12/18/2022]
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Geerdink LM, Delhaas T, Helbing WA, du Marchie Sarvaas GJ, Heide HT, Rozendaal L, de Korte CL, Peer PGM, Kuipers IM, Kapusta L. Paediatric Ebstein's anomaly: how clinical presentation predicts mortality. Arch Dis Child 2018; 103:859-863. [PMID: 29567665 DOI: 10.1136/archdischild-2017-313482] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 02/20/2018] [Accepted: 02/24/2018] [Indexed: 01/20/2023]
Abstract
BACKGROUND Forecasting the prognosis of a child when diagnosed with Ebstein's anomaly is difficult. We, therefore, studied which factors at the time of diagnosis are associated with death during childhood. METHODS All consecutive patients (0-18 years) diagnosed with Ebstein's anomaly in the Netherlands between 1980 and 2014 were included. Survival curves were obtained using the Kaplan-Meier method. By using the Cox proportional hazard model, we analysed the factors (at diagnosis) that were associated with death. RESULTS We included 176 patients. Thirty-one patients (18%) died before the age of 18 years. The 1-year survival was 84% and remained stable at 82% from 35 months after diagnosis and onwards. Modified Ross Heart Failure Class 4 at the time of diagnosis was the most important risk factor for death during childhood (HR 12.5, 95% CI 4.4 to 35.9). Furthermore, diagnosis in the neonatal period (HR 4.2, 95% CI 1.5 to 12.0), severe tricuspid valve regurgitation (HR 2.4, 95% CI 1.2 to 5.0), severe right ventricular outflow tract obstruction (HR 3.7, 95% CI 1.8 to 7.7) and a patent ductus arteriosus (HR 2.8, 95% CI 1.3 to 6.0) at the time of diagnosis were univariately associated with death. Multivariable analysis showed that presentation with Heart Failure Class 4 and a ventricular septal defect is the strongest predictor of death in childhood and adolescence. CONCLUSION Patients with Ebstein's anomaly presenting with Heart Failure Class 4 and a ventricular septal defect have a high risk of death during childhood.
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Affiliation(s)
- Lianne M Geerdink
- Department of Paediatric Cardiology, Amalia Children's Hospital, Radboud University Medical Centre, Nijmegen, The Netherlands.,Department of Paediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Tammo Delhaas
- Department of Paediatric Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Willem A Helbing
- Department of Paediatric Cardiology, Sophia Children's Hospital, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Gideon J du Marchie Sarvaas
- Centre for Congenital Heart Diseases, Beatrix Children's Hospital, University Medical Centre Groningen, Groningen, The Netherlands
| | - Henriette Ter Heide
- Department of Paediatric Cardiology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Lieke Rozendaal
- Department of Paediatric Cardiology, Willem Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands
| | - Chris L de Korte
- Medical Ultrasound Imaging Centre, Department of Radiology and Nuclear Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Petronella G M Peer
- Department of Biostatistics, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Irene M Kuipers
- Department of Paediatric Cardiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Livia Kapusta
- Department of Paediatric Cardiology, Amalia Children's Hospital, Radboud University Medical Centre, Nijmegen, The Netherlands.,Department of Paediatrics, Paediatric Cardiology Unit, Tel Aviv Sourasky Medical Centre, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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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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Qureshi MY, O'Leary PW, Connolly HM. Cardiac imaging in Ebstein anomaly. Trends Cardiovasc Med 2018; 28:403-409. [PMID: 29409687 DOI: 10.1016/j.tcm.2018.01.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 12/22/2017] [Accepted: 01/09/2018] [Indexed: 11/29/2022]
Abstract
Ebstein anomaly is a congenital disorder of right ventricular myocardial development, which affects the tricuspid valve in addition to the right ventricular myocardium. Cardiac imaging by transthoracic echocardiography and cardiac magnetic resonance imaging are the key modalities used to assess timing and type of surgery. In this article, we review the current standards of echocardiographic and magnetic resonance imaging in Ebstein anomaly.
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Affiliation(s)
| | - Patrick W O'Leary
- Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN; Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
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Geerdink LM, du Marchie Sarvaas GJ, Kuipers IM, Helbing WA, Delhaas T, ter Heide H, Rozendaal L, de Korte CL, Singh SK, Ebels T, Hazekamp MG, Haas F, Bogers AJJC, Kapusta L. Surgical outcome in pediatric patients with Ebstein's anomaly: A multicenter, long-term study. CONGENIT HEART DIS 2016; 12:32-39. [DOI: 10.1111/chd.12404] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 06/14/2016] [Accepted: 07/24/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Lianne M. Geerdink
- Department of Pediatric Cardiology; Radboud University Medical Center; Nijmegen the Netherlands
- Department of Pediatric Cardiology and Intensive Care Medicine; Hannover Medical School; Hannover Germany
| | | | - Irene M. Kuipers
- Department of Pediatric Cardiology; Academic Medical Center; Amsterdam the Netherlands
| | - Willem A. Helbing
- Department of Pediatric Cardiology; Erasmus Medical Center; Rotterdam the Netherlands
| | - Tammo Delhaas
- Department of Pediatric Cardiology; Maastricht University Medical Center; Maastricht the Netherlands
| | - Henriette ter Heide
- Department of Pediatric Cardiology; University Medical Center Utrecht; Utrecht the Netherlands
| | - Lieke Rozendaal
- Department of Pediatric Cardiology; Leiden University Medical Center; Leiden the Netherlands
| | - Chris L. de Korte
- Department of Radiology, Medical Ultrasound Imaging Center; Radboud University Medical Center; Nijmegen the Netherlands
| | - Sandeep K. Singh
- Department of Cardiothoracic Surgery; Isala Clinics; Zwolle the Netherlands
| | - Tjark Ebels
- Department of Cardiothoracic Surgery; University Medical Center Groningen; Groningen the Netherlands
| | - Mark G. Hazekamp
- Department of Cardiothoracic Surgery; Leiden University Medical Center; Leiden the Netherlands
| | - Felix Haas
- Department of Cardiothoracic Surgery; University Medical Center Utrecht; Utrecht the Netherlands
| | - Ad J. J. C. Bogers
- Department of Cardiothoracic Surgery; Erasmus Medical Center; Rotterdam the Netherlands
| | - Livia Kapusta
- Department of Pediatric Cardiology; Radboud University Medical Center; Nijmegen the Netherlands
- Department of Pediatric Cardiology; Tel Aviv Sourasky Medical Center; Tel Aviv Israel
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Safi LM, Liberthson RR, Bhatt A. Current Management of Ebstein's Anomaly in the Adult. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:56. [PMID: 27439413 DOI: 10.1007/s11936-016-0478-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OPINION STATEMENT Ebstein's anomaly is a congenital malformation of the tricuspid valve and the right heart with a spectrum of clinical and morphologic presentations. Minor anomalies of the tricuspid valve may not be recognized until adulthood whereas major anomalies leading to heart failure and cyanosis require surgical intervention earlier in life. Echocardiography is the imaging modality of choice for both diagnosis and management of patients with Ebstein's anomaly. Surgical correction includes tricuspid valve repair or replacement and associated findings such as interatrial communications and arrhythmias should be addressed at the time of surgery. Pre-pregnancy evaluation should be considered in all Ebstein's anomaly patients and for those who are cyanotic, surgical correction must be considered due to the maternal and fetal ramifications of cyanosis in pregnancy. Most acyanotic Ebstein's anomaly patients are able to tolerate pregnancy with manageable or no complications. Those patients with mild anomalies and no right heart dilation can participate in sports whereas those with severe anomalies are discouraged from competitive sports. Physical activity as tolerated is important in all patients with adult congenital heart disease. Adult congenital heart specialists should evaluate patients prior to cardiac or noncardiac surgery. Longitudinal clinical follow-up in all Ebstein's anomaly patients (both repaired and unrepaired) is warranted to follow for signs and symptoms of heart failure, arrhythmias, cyanosis, and other associated findings. This should be ideally performed in collaboration with an adult congenital heart center of excellence.
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Affiliation(s)
- Lucy M Safi
- Massachusetts General Hospital, Yawkey Building, 5B, 55 Fruit Street, Boston, MA, 02114, USA.
| | - Richard R Liberthson
- Massachusetts General Hospital, Yawkey Building, 5B, 55 Fruit Street, Boston, MA, 02114, USA
| | - Ami Bhatt
- Massachusetts General Hospital, Yawkey Building, 5B, 55 Fruit Street, Boston, MA, 02114, USA
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More than valve repair: Effect of cone reconstruction on right ventricular geometry and function in patients with Ebstein anomaly. Int J Cardiol 2016; 206:131-7. [DOI: 10.1016/j.ijcard.2016.01.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 12/17/2015] [Accepted: 01/01/2016] [Indexed: 11/22/2022]
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Im YM, Park CS, Park JJ, Yun TJ. Restoration of Tricuspid Valve Mechanism at the Level of Displaced Septal and Posterior Leaflets in Ebstein's Anomaly. J Card Surg 2016; 31:168-73. [PMID: 26805702 DOI: 10.1111/jocs.12689] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Surgical techniques currently used for the repair of Ebstein's anomaly comprise reconstruction of the tricuspid valve mechanism at the level of the true annulus with or without plication of the atrialized right ventricle. However, performing this procedure for patients with a dysmorphic anterior leaflet (i.e., insufficient leaflet tissue and decreased mobility due to tethering) may necessitate technical modifications. METHODS A retrospective review was performed of 31 patients (seven males and 24 females, median age at operation 31 years) with Ebstein's anomaly, who underwent tricuspid valve repair between March 2002 and December 2014. The original Hetzer technique (annulus to annulus approximation) was employed for six patients with a well-formed anterior leaflet. In 25 patients, the tricuspid valve mechanism was restored at the displaced septal leaflet by approximating the anterior leaflet attachment in the true annulus to the displaced septal leaflet attachment in the mid-septum. A bidirectional superior cavopulmonary anastomosis was added in 27 of 31 (87%) patients. RESULTS No early or late death occurred during the median follow-up of 66 months (1-138 months). Immediate postoperative tricuspid regurgitation was trivial to mild in 22 patients, and the median preoperative, immediate postoperative, and last follow-up tricuspid regurgitation jet areas in 21 adult patients were 23.3 cm2, 10.4 cm2, and 7.0 cm2, respectively. Two patients underwent reoperation at 81 and 119 months postoperatively. Five-year freedom from severe tricuspid regurgitation or reoperation was 93.2%. CONCLUSION Restoration of the tricuspid valve mechanism at the level of displaced septal leaflet leads to excellent long-term outcomes. The addition of the bidirectional superior cavopulmonary anastomosis has contributed to the success of this technique.
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Affiliation(s)
- Yu-Mi Im
- Seoul Women's College of Nursing, Seoul, Republic of Korea
| | - Chun Soo Park
- Division of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jeong-Jun Park
- Division of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Tae-Jin Yun
- Division of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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22
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Lange R, Burri M, Eschenbach LK, Badiu CC, da Silva JP, Nagdyman N, Fratz S, Hörer J, Kühn A, Schreiber C, Vogt MO. Da Silva's cone repair for Ebstein's anomaly: effect on right ventricular size and function. Eur J Cardiothorac Surg 2014; 48:316-20; discussion 320-1. [PMID: 25535206 DOI: 10.1093/ejcts/ezu472] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 10/24/2014] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Da Silva's cone repair is a novel technique for surgical reconstruction of the tricuspid valve and the right ventricle (RV) in Ebstein's anomaly. The technique consists of extensive leaflet mobilization, longitudinal plication of the atrialized ventricle and cone-shaped reconstruction of the tricuspid valve, allowing for leaflet-to-leaflet coaptation. We evaluated the influence of Da Silva's cone repair on tricuspid competency, right ventricular size and function. METHODS From February 2010 until July 2013, 20 patients (median age 30.0 years, range 6.6-68.3 years) underwent Da Silva's cone repair. A 4- to 6-mm interatrial communication was left in all patients. Echocardiographic studies and magnetic resonance imaging (MRI) before and after the repair were evaluated. RESULTS Median follow-up was 11 (0.5-36) months. There were 2 early deaths and no late death. Echocardiography at follow-up revealed mild or absent tricuspid regurgitation in 16 patients. Two patients showed moderate tricuspid insufficiency. MRI studies showed that the mean functional RV end-diastolic volume decreased after surgery (pre 334 [135-656] ml; post 175 [115-404] ml, P < 0.001). The mean RV ejection fraction decreased (pre 47 ± 10%; post 35 ± 13%, P = 0.001), and the mean antegrade net stroke volume of the RV increased (pre 65 ± 28 ml; post 75 ± 30 ml, P = 0.057). CONCLUSIONS Da Silva's cone repair for Ebstein's anomaly creates excellent valve function in all patients. Consecutively, the size of the RV decreases and the antegrade net stroke volume increases 6 months after the operation.
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Affiliation(s)
- Rüdiger Lange
- Department of Cardiovascular Surgery, German Heart Centre Munich at the Technical University Munich, Munich, Germany DZHK (German Center for Cardiovascular Research)-partner site Munich Heart Alliance, Munich, Germany
| | - Melchior Burri
- Department of Cardiovascular Surgery, German Heart Centre Munich at the Technical University Munich, Munich, Germany
| | - Lena Katharina Eschenbach
- Department of Cardiovascular Surgery, German Heart Centre Munich at the Technical University Munich, Munich, Germany
| | - Catalin Constantin Badiu
- Department of Cardiovascular Surgery, German Heart Centre Munich at the Technical University Munich, Munich, Germany
| | - José Pedro da Silva
- Cardiovascular Surgery Division, Hospital Beneficencia Portuguesa de São Paulo Escola Paulista de Medicina-UNIFESP, São Paulo, Brazil
| | - Nicole Nagdyman
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich at the Technical University Munich, Munich, Germany
| | - Sohrab Fratz
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich at the Technical University Munich, Munich, Germany
| | - Jürgen Hörer
- Department of Cardiovascular Surgery, German Heart Centre Munich at the Technical University Munich, Munich, Germany
| | - Andreas Kühn
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich at the Technical University Munich, Munich, Germany
| | - Christian Schreiber
- Department of Cardiovascular Surgery, German Heart Centre Munich at the Technical University Munich, Munich, Germany
| | - Manfred Otto Vogt
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich at the Technical University Munich, Munich, Germany
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Abstract
Ebstein's anomaly is a complex congenital disorder of the tricuspid valve. Presentation in neonatal life and (early) childhood is common. Disease severity and clinical features vary widely and require a patient-tailored treatment. In this review, we describe the natural history of children and adolescents with Ebstein's anomaly, including symptoms and signs presenting at diagnosis. Current classification strategies of Ebstein's anomaly are discussed. We report on diagnostic methods for establishing the severity of disease that might enhance decision on the timing of surgical intervention. Furthermore, we describe different surgical options for severely ill neonates and multiple surgical interventions after infancy. Only with ample knowledge and understanding of the above, this complex and diverse group of patients can be correctly treated in order to improve not only duration, but also quality of life.
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Kühn A, De Pasquale Meyer G, Müller J, Petzuch K, Fratz S, Röhlig C, Hager A, Schreiber C, Hess J, Vogt M. Tricuspid valve surgery improves cardiac output and exercise performance in patients with Ebstein's anomaly. Int J Cardiol 2013; 166:494-8. [DOI: 10.1016/j.ijcard.2011.11.033] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Revised: 10/25/2011] [Accepted: 11/24/2011] [Indexed: 10/14/2022]
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Negoi RI, Ispas AT, Ghiorghiu I, Filipoiu F, Negoi I, Hostiuc M, Hostiuc S, Ginghina C. Complex Ebstein's Malformation: Defining Preoperative Cardiac Anatomy and Function. J Card Surg 2013; 28:70-81. [DOI: 10.1111/jocs.12032] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Ruxandra Irina Negoi
- Universityof Medicine and Pharmacy “Carol Davila”; Bucharest Romania
- “Prof. Dr. C.C. Iliescu” Institute of Cardiovascular Diseases; Bucharest Romania
| | | | - Ioana Ghiorghiu
- “Prof. Dr. C.C. Iliescu” Institute of Cardiovascular Diseases; Bucharest Romania
| | - Florin Filipoiu
- Universityof Medicine and Pharmacy “Carol Davila”; Bucharest Romania
| | - Ionut Negoi
- Universityof Medicine and Pharmacy “Carol Davila”; Bucharest Romania
| | - Mihaela Hostiuc
- Universityof Medicine and Pharmacy “Carol Davila”; Bucharest Romania
| | - Sorin Hostiuc
- Universityof Medicine and Pharmacy “Carol Davila”; Bucharest Romania
| | - Carmen Ginghina
- Universityof Medicine and Pharmacy “Carol Davila”; Bucharest Romania
- “Prof. Dr. C.C. Iliescu” Institute of Cardiovascular Diseases; Bucharest Romania
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Fratz S, Janello C, Müller D, Seligmann M, Meierhofer C, Schuster T, Schreiber C, Martinoff S, Hess J, Kühn A, Vogt M, Stern H. The functional right ventricle and tricuspid regurgitation in Ebstein's anomaly. Int J Cardiol 2012; 167:258-61. [PMID: 22280553 DOI: 10.1016/j.ijcard.2011.12.081] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Accepted: 12/22/2011] [Indexed: 11/30/2022]
Abstract
BACKGROUND The size of the functional right ventricle of patients with Ebstein's anomaly is, according to contemporary opinion, small. However, the in vivo size of the functional right ventricle in patients with Ebstein's anomaly is unknown. Furthermore, it is unknown how the apical displacement and regurgitant fraction of the tricuspid valve in Ebstein's anomaly affects the size of the functional right ventricle. Therefore the primary aim of this study was to determine the volume of the functional right ventricle in patients with Ebstein's anomaly. The secondary aim of this study was to assess correlation of the volume of the functional right ventricle to the apical displacement and regurgitant fraction of the tricuspid valve. METHODS Thirty-two consecutive patients with Ebstein's anomaly without previous cardiac surgery or shunts were studied prospectively by cardiovascular magnetic resonance. Functional right ventricle, left ventricle, and atrialized right ventricle volumes and tricuspid valve regurgitation were measured. RESULTS Functional right ventricle end diastolic volumes were median 127 ml/m² (range: 76-339 ml/m²) and were median 2.5 (range: 1.3-8.8) times larger than the left ventricle volumes. Furthermore, functional right ventricle volumes correlated in a strong positive fashion with tricuspid valve regurgitation (p<0.001, R(2)=0.65) and modestly with the atrialized right ventricle volumes (p=0.027, R(2)=0.16). CONCLUSION Patients with untreated Ebstein's anomaly have large functional right ventricles. The size of the enlarged functional right ventricle seems to depend on the degree of tricuspid valve regurgitation and not on the size of the atrialized right ventricle or the age of the patient.
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Affiliation(s)
- Sohrab Fratz
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Klinikum an der Technischen Universität München, Munich, Germany.
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Romfh A, Pluchinotta FR, Porayette P, Valente AM, Sanders SP. Congenital Heart Defects in Adults : A Field Guide for Cardiologists. ACTA ACUST UNITED AC 2012. [PMID: 24294540 DOI: 10.4172/2155-9880.s8-007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Advances in cardiology and cardiac surgery allow a large proportion of patients with congenital heart defects to survive into adulthood. These patients frequently develop complications characteristic of the defect or its treatment. Consequently, adult cardiologists participating in the care of these patients need a working knowledge of the more common defects. Occasionally, patients with congenital heart defects such as atrial septal defect, Ebstein anomaly or physiologically corrected transposition of the great arteries present for the first time in adulthood. More often patients previously treated in pediatric cardiology centers have transitioned to adult congenital heart disease centers for ongoing care. Some of the more important defects in this category are tetralogy of Fallot, transposition of the great arteries, functionally single ventricle defects, and coarctation. Through this field guide, we provide an overview of the anatomy of selected defects commonly seen in an adult congenital practice using pathology specimens and clinical imaging studies. In addition, we describe the physiology, clinical presentation to the adult cardiologist, possible complications, treatment options, and outcomes.
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Affiliation(s)
- Anitra Romfh
- Department of Cardiology, Children's Hospital Boston, Boston, MA 02115, USA ; Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
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Improvements in exercise performance after surgery for Ebstein anomaly. J Thorac Cardiovasc Surg 2011; 141:1192-5. [DOI: 10.1016/j.jtcvs.2010.08.083] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Revised: 07/12/2010] [Accepted: 08/30/2010] [Indexed: 11/24/2022]
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Anderson RH. The triangle of Koch in the setting of Ebstein's malformation. Rev Esp Cardiol 2010; 63:633-4. [PMID: 20515619 DOI: 10.1016/s1885-5857(10)70136-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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30
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El triángulo de Koch en el contexto de la malformación de Ebstein. Rev Esp Cardiol (Engl Ed) 2010. [DOI: 10.1016/s0300-8932(10)70154-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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van Noord PT, Scohy TV, McGhie J, Bogers AJJC. Three-dimensional transesophageal echocardiography in Ebstein's anomaly. Interact Cardiovasc Thorac Surg 2010; 10:836-7. [PMID: 20154345 DOI: 10.1510/icvts.2009.229476] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Three-dimensional (3D) transthoracic echocardiography has advantages over traditional two-dimensional (2D) echocardiography in visualizing tricuspid valve morphology in Ebstein's anomaly. We describe the application of intra-operative 3D transesophageal echocardiography during a tricuspid valve repair procedure in a patient with Ebstein's anomaly. Intra-operatively three-dimensional transesophageal echocardiographic (3D TEE) data sets revealed morphology and function of the tricuspid valve, right ventricle outflow tract (RVOT) and pulmonary valve before and after repair. Tricuspid valve leaflet morphology and coaptation as visualized with 3D TEE proved to be consistent with intra-operative findings. Analysis of the tricuspid valve, RVOT and pulmonary valve in the multi-planar review (MPR) mode revealed a bicuspid pulmonary valve, which had not been noticed on the preoperative 2D echocardiographic work-up. In this patient with Ebstein's anomaly, 3D TEE provided additional information on morphology and function of tricuspid valve, RVOT and pulmonary valve.
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Affiliation(s)
- Peter T van Noord
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
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Multiplanar review of three-dimensional echocardiography gives new insights into the morphology of Ebstein's malformation. Cardiol Young 2010; 20:49-53. [PMID: 20085664 DOI: 10.1017/s1047951109991971] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION We aimed to assess the ability of the multiplanar review modality of three-dimensional echocardiography to examine the dynamic morphology and the functional characteristics of malformed tricuspid valves in patients previously identified as having Ebstein's malformation. Based on these characteristics, we attempted to differentiate Ebstein's malformation from tricuspid valvar dysplasia. METHODS Using three-dimensional multiplanar review, analysed with either Qlab 6.0 or Tomtech Image Arena 3.0, we studied 23 patients, aged from 1 day to 70 years, previously diagnosed using cross-sectional echocardiography as having Ebstein's malformation. RESULTS Using the features of rotational abnormality, and the orientation, of the effective tricuspid valvar orifice as diagnostic features of Ebstein's malformation, we reclassified 11 patients (48 per cent) as exhibiting tricuspid valvar dysplasia. In addition, we studied the dynamic morphology as well as the function of the tricuspid valve. Surgical treatment was undertaken on 10 patients, revealing good correlation with the findings obtained using three-dimensional multiplanar review. In those with Ebstein's malformation, we found varying degrees of rotation, with the effective valvar orifice always directed towards the right ventricular outflow tract. The opening of the orifice of dysplastic tricuspid valves, in contrast, was towards the apex of the right ventricle. The degree of delamination, and abnormalities of subcordal apparatus, were similar in the two groups. DISCUSSION Three-dimensional multiplanar review permits accurate definition of the dynamic morphology of Ebstein's malformation, permitting clear differentiation from tricuspid valvar dysplasia.
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Adachi I, Ho SY, McCarthy KP, Uemura H. Coronary blood supply of the inferior wall of the right ventricle in hearts with Ebstein malformation: relevance to vertical plication. J Thorac Cardiovasc Surg 2009; 136:1437-41. [PMID: 19114186 DOI: 10.1016/j.jtcvs.2008.06.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2008] [Revised: 04/16/2008] [Accepted: 06/15/2008] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Vertical plication of the atrialized chamber in Ebstein malformation has been subject to debate. A major argument against it is risk of coronary arterial injury; however, the coronary anatomy in the malformation remains incompletely investigated. METHODS We examined 17 autopsied hearts with the malformation. Special attention was paid to the coronary blood supply of the right ventricular inferior wall, focusing on the course of the posterior descending branch and its relationship with the interventricular septum. RESULTS The right coronary artery was dominant in 11 cases (65%); the remaining 6 had left dominance. In 6 right-dominant hearts, the right coronary artery gave rise to the branch before reaching the crux of the heart. This early takeoff caused the entire branch to be deviated rightward. Another 2 right-dominant hearts showed rightward deviation of the branch course after an initial short segment along the septum. In contrast, in 2 left-dominant hearts, the left circumflex artery ran beyond the crux and then gave rise to the branch, again resulting in rightward deviation of the branch. These deviations allowed the branch to run on the thin walled part of the right ventricular inferior wall where endocardial stitches are placed during typical vertical plication. CONCLUSION The posterior descending branch was frequently (10/17, 59%) deviated toward the right side relative to the interventricular septum in hearts with Ebstein malformation. Because of this and the thinness of the atrialized ventricular wall, care should be taken to the branch even with superficial endothelial stitches.
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Affiliation(s)
- Iki Adachi
- Cardiac Morphology Unit, Imperial College London, National Heart & Lung Institute, London, UK
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Vettukattil JJ, Bharucha T, Anderson RH. Defining Ebstein's malformation using three-dimensional echocardiography. Interact Cardiovasc Thorac Surg 2007; 6:685-90. [PMID: 17890234 DOI: 10.1510/icvts.2007.156612] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Ebstein's malformation is difficult to visualise, for both the echocardiographer and the surgeon. The essence of the problem in Ebstein's malformation is the deviation of the hingepoints of the leaflets towards the junctions of the inlet and apical trabecular parts of the right ventricle. Three-dimensional echocardiography offers new insights into the morphology and function of malformed valves, and allows elucidation of all the features. It allows clear visualisation of the valve leaflets, showing the precise morphology of the valve leaflets, the extent of their formation, the level of their attachment, and their degree of coaptation. Visualisation of the mechanism of regurgitation or stenosis is possible, as is more accurate quantification of the regurgitant jet or jets. Subchordal apparatus may be seen more clearly using three-dimensional echocardiography, and their functional anatomy understood. The multiplanar review modality allows examination of the three-dimensional data set even in patients with sub-optimal echocardiographic imaging. Previously, much of this information could only be well-understood at the time of surgery or post mortem, meaning that the majority of the specimens fully examined were at the poorly functioning end of the spectrum. This information is of use in furthering our understanding of this complex lesion as it functions in vivo, and demonstrating which anatomical pathology is significant in producing functional and physiological consequences. It is also of use for the clinician in selecting which patients are amenable to surgical intervention, for either single or biventricular repair, and for the surgeon in planning how to approach the operation. Correlation between three-dimensional echocardiographic findings and surgical findings has already been established, but the effect of this enhanced anatomical knowledge on surgical planning and surgical outcome requires further investigation.
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Affiliation(s)
- Joseph J Vettukattil
- Wessex Congenital Cardiac Centre, Southampton University NHS Trust, Tremona Road, Southampton, SO16 6YD, UK.
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Komoda T, Komoda S, Nagdyman N, Berger F, Hetzer R. Combination of a Hetzer operation and a Sebening stitch for Ebstein's anomaly. Gen Thorac Cardiovasc Surg 2007; 55:355-9. [DOI: 10.1007/s11748-007-0146-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
EBSTEIN’S ANOMALY IS A RARE congenital heart defect characterized by displacement of the tricuspid valve leaflets into the right ventricle.1The defect was first described by Wilhelm Ebstein in 1866.2This anomaly of the tricuspid valve causes the right atrium to thin and become enlarged, resulting in a wide range of clinical presentations.3Clinical presentation depends on the severity of the pathologic findings, which vary considerably from patient to patient. Some infants may present with cyanosis, respiratory distress, heart failure, and even death, whereas others may not present with mild symptoms until adolescence or adulthood.
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Affiliation(s)
- Sarah E Pashia
- NICU, St. John's Mercy Medical Center, St. Louis, Missouri, USA.
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Anderson RH, Becker AE. Normal and Abnormal Anatomy. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Dearani JA, Oleary PW, Danielson GK. Surgical treatment of Ebstein's malformation: state of the art in 2006. Cardiol Young 2006; 16 Suppl 3:12-20. [PMID: 17378036 DOI: 10.1017/s1047951106000710] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Ebstein's malformation is a congenital anomaly of the tricuspid valve and right ventricle that is characterized by several features, each of which can exhibit a spectrum of malformation. The first is adherence of the leaflets of the tricuspid valve to the underlying myocardium, this representing failure of delamination during development. This feature involves the septal and inferior leaflets, but rarely the anterior leaflet (Fig. 1). The second feature is anterior and apical rotational displacement of the functional annulus (Fig. 2). The third abnormality is dilation of the “atrialized” portion of the right ventricle, with variable degrees of hypertrophy and thinning of the wall. The fourth finding is redundancy, fenestrations, and tethering of the anterior leaflet. A fifth abnormality is dilation of the right atrioventricular junction, this being the true tricuspid valvar annulus. The final feature is variable ventricular myocardial dysfunction. Each heart with Ebstein's malformation is different, and there is an infinite variability that can occur with the above mentioned characteristics. These anatomical and functional abnormalities cause important tricuspid regurgitation, which results in right atrial and right ventricular dilation, and atrial and ventricular arrhythmias.
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Affiliation(s)
- Joseph A Dearani
- Divisions of Pediatric Cardiology, Mayo Clinic and Foundation, Rochester, Minnesota, USA.
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Martinez RM, O'Leary PW, Anderson RH. Anatomy and echocardiography of the normal and abnormal tricuspid valve. Cardiol Young 2006; 16 Suppl 3:4-11. [PMID: 17378035 DOI: 10.1017/s1047951106000709] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Perhaps because it guards the inlet to the lesser circulation, the morphologically tricuspid valve has received less attention in terms of its anatomy than the well-explored mitral valve, which will receive attention in a subsequent review in this supplement.1 As we will show in our initial review, nonetheless, the approach to morphological analysis is the same for both valves, irrespective of whether the specific morphology is displayed in the autopsy room or the echocardiographic laboratory. It is essential that the valve be analysed so as to reveal the precise structure of each if its components – the so-called valvar complex.2 Equally important, in the current era, with the burgeoning use of three-dimensional displays that place the heart firmly within the context of the body, it is essential that the components of the valve be described as seen relative to the bodily axis,3 rather than following the present custom of describing the heart as though it is removed from the body and positioned on its own apex.
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Affiliation(s)
- Richard M Martinez
- The Congenital Heart Institute of Florida (CHIF), Department of Pediatric Cardiology, Pediatric Cardiology Associates I, The University of South Florida, 100 First Street South, #550, St. Petersburg, FL 33701, USA.
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Sarris GE, Giannopoulos NM, Tsoutsinos AJ, Chatzis AK, Kirvassilis G, Brawn WJ, Comas JV, Corno AF, Di Carlo D, Fragata J, Hraska V, Jacobs JP, Krupianko S, Sairanen H, Stellin G, Urban A, Ziemer G. Results of surgery for Ebstein anomaly: A multicenter study from the European Congenital Heart Surgeons Association. J Thorac Cardiovasc Surg 2006; 132:50-7. [PMID: 16798302 DOI: 10.1016/j.jtcvs.2005.10.062] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2005] [Revised: 09/04/2005] [Accepted: 10/10/2005] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Since most centers' experience with Ebstein anomaly is limited, we sought to analyze the collective experience of participating institutions of the European Congenital Heart Surgeons Association with surgery for this rare malformation. METHODS The records of all 150 patients (median age 6.4 years) who underwent surgery for Ebstein anomaly in the 13 participating Association centers between January 1992 and January 2005 were reviewed retrospectively. Patients with congenitally corrected transposition were excluded. RESULTS Most patients (81%) had Ebstein disease type B or C and significant functional impairment (61% in New York Heart Association class III or IV) and 16% had prior operations. Surgical procedures (n = 179) included valve replacement (n = 60, 33.5%), valve repair (n = 49, 27.3%), 1(1/2) ventricle repair (n = 46, 25.6%), palliative shunt (n = 13, 7.26%), and other complex procedures (n = 11, 6.14%). There were 20 hospital deaths (operative mortality 13.3%) after valve replacement in 5 patients, valve repair in 3, 1(1/2) ventricle repair in 7, palliative procedures in 3, and miscellaneous procedures in 2. Younger age and palliative procedures were univariate risk factors for operative death, but only age was an independent predictor on multivariable analysis. CONCLUSIONS Most patients coming to surgery presented in childhood and were significantly symptomatic. More than half underwent valve replacement or repair, but a considerable proportion had severe disease necessitating 1(1/2) ventricle repair or palliative procedures. Operative mortality did not differ significantly among repair, replacement, and 1(1/2) ventricle repair but was associated with palliative procedures for severe disease early in life, young age being the only independent predictor of operative death.
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Chauvaud SM, Hernigou AC, Mousseaux ER, Sidi D, Hébert JL. Ventricular Volumes in Ebstein’s Anomaly: X-Ray Multislice Computed Tomography Before and After Repair. Ann Thorac Surg 2006; 81:1443-9. [PMID: 16564290 DOI: 10.1016/j.athoracsur.2005.10.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2005] [Revised: 10/04/2005] [Accepted: 10/04/2005] [Indexed: 10/24/2022]
Abstract
BACKGROUND This study was performed to measure right and left ventricular volumes in Ebstein's anomaly before and after operation. METHODS Twenty-six consecutive patients were operated on with tricuspid valve repair and plication of the atrialized right ventricle, associated with a bidirectional cavopulmonary shunt in 15 patients. Right ventricular (RV) and left ventricular end-diastolic and end-systolic volume indexes were measured by x-ray computerized tomography before and after surgical repair. Left ventricular stroke index and ejection fraction were calculated. RESULTS Before surgery, the mean stroke index of the atrialized RV was 36 +/- 33 mL/m2, with severe reduction in 9 patients and aneurysmal aspect in 2 patients. After surgery, the atrialized RV was no longer identifiable. Both RV end-diastolic volume index and stroke index of the remaining effective RV were reduced. Bidirectional cavopulmonary shunt was a determinant factor of decrease in the effective RV end-diastolic volume index after repair. Conversely, left ventricular ejection fraction and stroke index increased significantly after surgery. CONCLUSIONS The atrialized RV with dyskinesia seems a good indication for a plication. RV end-diastolic volume index of the effective RV decreased after surgery. In severe cases, bidirectional cavopulmonary shunt was useful by decreasing RV end-diastolic volume, thus preventing further RV dilation. In all cases left ventricular ejection fraction and stroke volume index increased after surgery.
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Affiliation(s)
- Sylvain M Chauvaud
- Department of Cardiovascular Surgery, Georges Pompidou European Hospital, Paris, France.
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Saxena R, Woytash J, Wright JR. A rare tricuspid anomaly. Arch Pathol Lab Med 2005; 129:1495-6. [PMID: 16253036 DOI: 10.5858/2005-129-1495-arta] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Rakhee Saxena
- Department of Pathology, State University of New York, Buffalo, NY, USA.
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Kanani M, Moorman AFM, Cook AC, Webb S, Brown NA, Lamers WH, Anderson RH. Development of the Atrioventricular Valves: Clinicomorphological Correlations. Ann Thorac Surg 2005; 79:1797-804. [PMID: 15854992 DOI: 10.1016/j.athoracsur.2004.06.122] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/25/2004] [Indexed: 11/25/2022]
Abstract
The atrioventricular valves are formed from a complex arrangement of an annulus and leaflets, supported by a subvalvar apparatus that is composed of tendinous cords and papillary muscles. Although much has been said and written about their development, the exact nature of the process has yet to be fully elucidated. We believe that this is vital, since unraveling this complex process holds the key to the understanding of many of the congenital malformations that may afflict the valves.
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Ullmann MV, Born S, Sebening C, Gorenflo M, Ulmer HE, Hagl S. Ventricularization of the atrialized chamber: A concept of Ebstein's anomaly repair. Ann Thorac Surg 2004; 78:918-24; discussion 924-5. [PMID: 15337020 DOI: 10.1016/j.athoracsur.2004.02.134] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/18/2004] [Indexed: 11/28/2022]
Abstract
BACKGROUND We report results of a technique of Ebstein's anomaly repair by creating a predominantly monocuspid valve with simultaneous ventricularization of the atrialized right ventricular (aRV) chamber. METHODS Between March 1993 and April 2003, Ebstein's anomaly repair by valvuloplasty with combined ventricularization was performed in 23 patients aged 13.6 (4.1-52.6) years presenting with tricuspid valve regurgitation (TVR) (I degrees, n = 1; II degrees, n = 3; III degrees, n = 13; IV degrees, n = 6). Valvuloplasty consisted of creating a predominantly monocuspid valve at the level of the anatomical atrioventricular junction resulting in a ventricularization of the atrialized chamber. Postoperatively all survivors were examined regularly with an actual prospective evaluation. RESULTS One early death (4.4%) occurred and was caused by right heart failure. Follow-up was 4.6 (0.5-10.9) years. Important recurrent atrioventricular valve regurgitation caused by rupture of fixation sutures occurred in 3 patients (13%), necessitating reintervention at 3 (0.03-4) months (revalvuloplasty, n = 2; TV replacement, n = 1). One patient presenting with hypoplastic right ventricle with consecutive right heart failure underwent creation of a total cavopulmonary connection at 10 months. At present all patients are doing well. Actual echocardiographic examination revealed significant improvement of right atrioventricular valve regurgitation (p < 0.0001) and favorable restoration of RV geometry and function. CONCLUSIONS This technique of Ebstein's anomaly repair with ventricularization of the atrialized chamber provides excellent results regarding right atrioventricular valve function and leads to a favorable restoration of RV geometry and function.
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Affiliation(s)
- Michael V Ullmann
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany.
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Hancock Friesen CL, Chen R, Howlett JG, Ross DB. Posterior annular plication: tricuspid valve repair in Ebstein's anomaly. Ann Thorac Surg 2004; 77:2167-71. [PMID: 15172289 DOI: 10.1016/j.athoracsur.2003.11.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/25/2003] [Indexed: 11/16/2022]
Abstract
BACKGROUND Nonneonatal Ebstein's anomaly is a rare congenital anomaly for which numerous operative techniques have been described to repair the aberrant tricuspid valve, exclude the atrialized right ventricle, and address right heart dysfunction. We reviewed short-term outcomes in surgical patients treated by a simplified operative technique. METHODS Our operative approach to Ebstein's anomaly is approximation of the anteroposterior commissure to the remnant septal leaflet with closure of the cul-de-sac longitudinally. Plication of the atrialized right ventricle (1 patient) and a bidirectional cavopulmonary connection (2 patients) were performed only if necessary. All patients were followed postoperatively by their cardiac surgeon and cardiologist. RESULTS Seven patients with a mean age of 39 years (range, 3.6 to 63.8 years) underwent repair. Preoperatively all patients had 4+ tricuspid valve regurgitation and were New York Heart Association class III. Mean postoperative hospital stay was 7 +/- 2 days (range, 4 to 11 days). Mean follow-up is 42 +/- 18 months (range, 7 to 58 months). At last follow-up 5 patients are New York Heart Association class I and average tricuspid valve regurgitation is mild. CONCLUSIONS Plication of the posterior annulus without plication of the atrialized right ventricle, resiting the tricuspid valve, or performing prophylactic cavopulmonary connection appears to be a reasonable operative approach to nonneonatal Ebstein's anomaly. Long-term follow-up of this cohort is necessary to determine the durability of such a surgical approach.
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Affiliation(s)
- Magdi H Yacoub
- Imperial College School of Medicine, Heart Science Centre, Harefield Research Foundation, Harefield, Middlesex, UK.
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Chauvaud S, Berrebi A, d'Attellis N, Mousseaux E, Hernigou A, Carpentier A. Ebstein's anomaly: repair based on functional analysis. Eur J Cardiothorac Surg 2003; 23:525-31. [PMID: 12694771 DOI: 10.1016/s1010-7940(02)00836-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE 'Classical' repair of Ebstein's anomaly is usually performed with transverse plication of the atrialized chamber. However, the anterior leaflet has restricted motion which is an important factor of the tricuspid valve insufficiency. We studied the long term results of mobilization of the anterior leaflet associated with longitudinal plication of the right ventricule. METHODS From 1980 to July 2002, 191 patients (mean age 24.4+/-15 years (1-65)) were operated on. Anterior leaflet function was assessed on pre-op echocardiography and on surgical examination. Conservative surgery was possible in 187 patients (98%) and included mobilization of the anterior leaflet, longitudinal plication of the right ventricle and prosthetic annuloplasty in adults. Bidirectional cavo-pulmonary shunt was associated in 60 patients. Four patients had valve replacement. RESULTS Hospital mortality occurred in 18 patients: 9% (95%CL: 6-15%) due to right ventricle (RV) failure in nine patients. Mean follow-up was 6.4 years (0.07-22). Actuarial survival was 82% at 20 years. Tricuspid valve insufficiency was 1 or 2+ in 80% of the cases. Reoperation occurred in 8% (16 patients). A successful second repair was obtained in ten patients. Electron beam computerized tomography (20 patients) demonstrated improved left ventricle ejection fraction 56-66% (P<0.05). Supraventricular tachycardia and pre-excitation syndromes were reduced from 23 to 5%. CONCLUSION Conservative surgery is indicated for all symptomatic patients. The incidence of valve repair is high when leaflet mobilization is performed. Valve replacement can be avoided in most cases. Functional and hemodynamic results are excellent.
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Affiliation(s)
- S Chauvaud
- Department of Cardiovascular Surgery, Hôpital Européen Georges Pompidou, 20, rue Leblanc, 75015 Paris, France.
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Vettraino IM, Huang R, Comstock CH. The normal offset of the tricuspid septal leaflet in the fetus. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2002; 21:1099-1104. [PMID: 12369664 DOI: 10.7863/jum.2002.21.10.1099] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
OBJECTIVE To quantify the normal distance between the insertion of the medial leaflets of the mitral valve and tricuspid valve in the fetal heart. This mitral valve-tricuspid valve distance was compared with the distance from known cases of Ebstein anomaly. METHODS An apical 4-chamber view was obtained at end diastole in fetuses between 18 and 41 weeks' gestation. Calipers were placed parallel to the ventricular septum, with 1 caliper on the medial insertion of the mitral valve and a second caliper on the medial insertion of the tricuspid valve. The distance recorded was plotted against gestational age. Statistical analysis was performed by descriptive and linear regression techniques. RESULTS One hundred forty-five fetuses were studied. The mean +/- SD mitral valve-tricuspid valve distance in the second trimester was 2.8 +/- 0.9 mm with a range of 1.2 to 5.0 mm; in the third trimester it was 4.6 +/- 1.1 mm with a range of 2.2 to 6.9 mm. Regression analysis showed that with each 1-week increase in gestational age, there was an increase of 0.15 mm in separation between the medial leaflets of the mitral valve and tricuspid valve (beta = 0.15 +/- 0.011). CONCLUSIONS A positive correlation between mitral valve-tricuspid valve distance and advancing gestational age was found. The reference range described allows for the identification of a fetal heart with normal variation in the mitral valve-tricuspid valve distance. Further downward displacement of the medial tricuspid cusp suggests the possibility of Ebstein anomaly.
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Affiliation(s)
- Ivana M Vettraino
- Department of Obstetrics and Gynecology, William Beaumont Hospital, Royal Oak, Michigan 48073-6769, USA
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Knott-Craig CJ, Overholt ED, Ward KE, Ringewald JM, Baker SS, Razook JD. Repair of Ebstein's anomaly in the symptomatic neonate: an evolution of technique with 7-year follow-up. Ann Thorac Surg 2002; 73:1786-92; discussion 1792-3. [PMID: 12078770 DOI: 10.1016/s0003-4975(02)03507-5] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Ebstein's anomaly in the severely symptomatic neonate is usually fatal. Until recently, successful repair has not been reported and various palliative operations have been associated with prohibitive mortality. Recently, we published our initial results with biventricular repair in 3 severely symptomatic neonates. We now update our experience with emphasis on the evolution of our surgical technique and the medium-term follow-up of these patients. METHODS Since 1994, 8 severely symptomatic neonates and young infants underwent biventricular repair by one surgeon. Six had Ebstein's anomaly and 2 had physiologically similar pathology with severe tricuspid valve dysplasia, cyanosis, and gross cardiomegaly. One Ebstein patient (2 months old) had undergone a Starnes operation elsewhere. Weight of the patients at operation ranged from 2.1 to 6.4 kg (mean 2.7 kg). Five patients had either anatomical (n = 3) or functional (n = 2) pulmonary atresia. Severe (4/4) tricuspid regurgitation was present in all except 1 (Starnes operation), and cardiothoracic ratio exceeded 0.85 in all patients. Echocardiography severity scores were >1.5 in 6 (grade 4/4) and 1.3 in 1 (grade 3/4). Repair consisted of tricuspid valve repair, reduction atrioplasty, relief of right ventricular outflow tract obstruction, partial closure of atrial septal defect, and correction of all associated cardiac defects. Technique of tricuspid valve repair evolved over time: 3 had Danielson-type repairs, 3 had DeVega-type repairs, and 2 had complex repairs. RESULTS One patient died in hospital: a 2.1 kg patient with tricuspid dysplasia, anatomical pulmonary atresia, and hypoplastic pulmonary arteries. The other 7 patients are all in functional class I and in sinus rhythm. Although 3 patients had symptomatic tachyarrhythmias before surgery, no child has experienced SVT after discharge. At recent echocardiography 4 patients had mild tricuspid regurgitation, and 2 had mild-moderate (2/4) tricuspid regurgitation. Three patients are now 7 years old, 2 are almost 2 years old, and the remaining 2 patients are 1 year old. CONCLUSIONS Surgical repair of the severely symptomatic neonate with Ebstein's anomaly is feasible and safe. The repair appears durable and with good medium-term outcome.
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Affiliation(s)
- Christopher J Knott-Craig
- Section of Thoracic and Cardiovascular Surgery, Children's Hospital at Oklahoma University Medical Center, Oklahoma City 73104, USA.
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Bertram H, Bökenkamp R, Peuster M, Hausdorf G, Paul T. Coronary artery stenosis after radiofrequency catheter ablation of accessory atrioventricular pathways in children with Ebstein's malformation. Circulation 2001; 103:538-43. [PMID: 11157719 DOI: 10.1161/01.cir.103.4.538] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Complications concerning the coronary arteries that are directly related to radiofrequency catheter ablation procedures have not been reported in children. Coronary artery lesions, however, have been demonstrated after the endocardial application of radiofrequency current in young animals. METHODS AND RESULTS Two boys with Ebstein's anomaly of the tricuspid valve developed clinically asymptomatic coronary artery stenosis after radiofrequency catheter ablation of right-sided accessory atrioventricular pathways with standard catheter technology. CONCLUSIONS The complication of coronary artery stenosis demonstrates a substantial risk after right atrial free wall radiofrequency current application in children. The risk of late coronary alterations should be considered when the use of catheter ablation procedures to young patients is proposed.
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Affiliation(s)
- H Bertram
- Department of Pediatric Cardiology and Pediatric Intensive Care, Hannover Medical School, Hannover, Germany.
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