1
|
Lou Q, Zou Y, Wu J, Chen J, Zhuang J, Wen S. Impact of Cone vs. Hetzer Repair on Postoperative Outcomes in Patients With Ebstein's Anomaly: 10-Year Experience From a Single Institution. Front Cardiovasc Med 2021; 8:710168. [PMID: 34422934 PMCID: PMC8374733 DOI: 10.3389/fcvm.2021.710168] [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: 05/15/2021] [Accepted: 07/07/2021] [Indexed: 11/24/2022] Open
Abstract
Objective: The aim of this study was to compare the early outcomes of the cone and Hetzer procedures for Ebstein's malformation. Methods: This retrospective study included patients who underwent either cone (n = 83) or Hetzer repair (n = 45) with Ebstein's malformation from January 2011 to December 2020. Results: One early death occurred in the cone group due to low cardiac output syndrome. Five cone and three Hetzer repair patients required reoperation before discharge. At discharge, the cone group had a better reduction in tricuspid valve regurgitation (TR) than the Hetzer group (74.7 vs. 51.1%, p = 0.009). Two patients in the cone group and seven patients in the Hetzer group required reoperation >30 days after their initial surgery. The cone group with no/mild TR was 75.6%, and the Hetzer group was 48.9% at the time of last follow-up (p = 0.010). Conclusion: Short-term outcomes of the cone repair are better than the Hetzer procedure. The cone repair should be the better option among patients with Ebstein's malformation who need surgical intervention.
Collapse
Affiliation(s)
- Qi Lou
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China.,Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yiping Zou
- College of Medicine, Shantou University, Shantou, China
| | - Jinlin Wu
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jimei Chen
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jian Zhuang
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shusheng Wen
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China.,Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| |
Collapse
|
2
|
Schulz A, Marathe SP, Chávez M, Sleeper LA, Emani SM, Marx GR, Del Nido PJ, Baird CW. The Association of Age and Repair Modification with Outcome after Cone Repair for Ebstein's Malformation. Semin Thorac Cardiovasc Surg 2021; 34:205-212. [PMID: 33965550 DOI: 10.1053/j.semtcvs.2021.03.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 03/04/2021] [Indexed: 11/11/2022]
Abstract
Cone repair (CR) uses native tissue for tricuspid valve (TV) repair and provides potential for growth. Results after CR were investigated in different age groups including several surgical modifications. Single institution retrospective analysis of all CR excluding neonatal procedures. Endpoints included TV reoperation, late tricuspid regurgitation (TR) and death. Between April 2006 and August 2019, 157 patients underwent CR at a median age of 11.7 years (range, 0.3-57.2). 20% (n=32) of patients had previous surgery. Repair modifications included atrial reduction (n=111,71%), right ventricular plication (n=85,55%), leaflet augmentation (n=36,23%), papillary muscle repositioning (n=50,32%), ring annuloplasty (n=70,45%). Early re-operation for recurrent TR occurred in 11 patients. Median follow-up time was 4.3 years (range, 9d-12.3y). There was no significant association between age at repair and time to TV reoperation (p=0.25). However, age <4 years at CR was identified as the most discriminating binary age threshold for the patients with TV reoperation (25.0% in <4y group vs 9.3% in the ≥4y group). Placement of an annuloplasty ring was protective against ≥moderate TR (OR=0.39, 95% CI 0.16-0.95, p=0.039). Freedom from late TV re-operation was 94.1% at 7 years. Survival was 97.9% at 6 years. Repair after age 18 years was associated with mortality in early follow-up (p=0.037). Mid-term results for CR are favorable in children and adults. Time to TV reoperation may be shorter when CR is performed before age four years, but this result requires confirmation in a larger sample. An annuloplasty ring should be considered when appropriate.
Collapse
Affiliation(s)
- Antonia Schulz
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Supreet P Marathe
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Mariana Chávez
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Sitaram M Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Gerald R Marx
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Christopher W Baird
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| |
Collapse
|
3
|
LaPar DJ, Moroi MK, Nguyen SN, Bacha EA. Neonatal Cone Valvuloplasty for Pulmonary Atresia/Intact Ventricular Septum and Ebsteinoid Valve. Ann Thorac Surg 2021; 112:e345-e347. [PMID: 33421397 DOI: 10.1016/j.athoracsur.2020.09.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/16/2020] [Accepted: 09/27/2020] [Indexed: 11/18/2022]
Abstract
Pulmonary atresia with intact ventricular septum (PA/IVS) is a rare lesion with wide anatomic variability. A rare variant exists, marked by right-sided dilatation, an Ebsteinoid tricuspid valve (TV), and severe tricuspid regurgitation. Neonatal cone valvuloplasty allows for a biventricular circulation and avoids complications of prosthetic valves; however, this technique inevitably requires reintervention to exchange the RV-PA conduit as the patient grows. We present a successful complete repair cone tricuspid valvuloplasty in a 9-day-old (2.8 kg) neonate with trisomy 21, PA/IVS, and an Ebsteinoid TV.
Collapse
Affiliation(s)
- Damien J LaPar
- Section of Congenital and Pediatric Cardiothoracic Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York; Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York.
| | - Morgan K Moroi
- Section of Congenital and Pediatric Cardiothoracic Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York; Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Stephanie N Nguyen
- Section of Congenital and Pediatric Cardiothoracic Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York; Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Emile A Bacha
- Section of Congenital and Pediatric Cardiothoracic Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York; Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| |
Collapse
|
4
|
Del Nido PJ. Commentary: Cone reconstruction for Ebstein's anomaly is here to stay. J Thorac Cardiovasc Surg 2020; 161:1110-1111. [PMID: 33431212 DOI: 10.1016/j.jtcvs.2020.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 11/30/2020] [Accepted: 12/01/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, and Harvard Medical School, Boston, Mass.
| |
Collapse
|
5
|
Neijenhuis RML, Tsang VT, Marek J, Issitt R, Bonello B, Von Klemperer K, Hughes ML. Cone reconstruction for Ebstein anomaly: Late biventricular function and possible remodeling. J Thorac Cardiovasc Surg 2020; 161:1097-1108. [PMID: 33293067 DOI: 10.1016/j.jtcvs.2020.10.124] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 09/16/2020] [Accepted: 10/09/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To evaluate late-term tricuspid valve competence and biventricular function following cone reconstruction for Ebstein anomaly, and to explore biventricular remodeling. METHODS Consecutive adult and pediatric patients who underwent cone reconstruction from 2009 to 2019 were reviewed for inclusion in this retrospective cardiac magnetic resonance imaging study. Tricuspid valve competence was assessed with tricuspid regurgitation fraction. Biventricular systolic function was assessed by ejection fraction, cardiac index, indexed stroke volume, and indexed aortic and pulmonary artery beat volume. Biventricular remodeling was assessed by planimetered areas (right atrium, functional right ventricle, left heart), and indexed end-diastolic and end-systolic ventricular volumes. Paired t tests or Wilcoxon signed-rank tests were used for analyses. RESULTS Of 58 included patients, 50 underwent cardiac magnetic resonance imaging. Twelve patients had both preoperative and late postoperative cardiac magnetic resonance imaging with a median follow-up of 5.11 years (interquartile range, 3.12-6.07 years). Focusing on these, tricuspid regurgitation fraction decreased (from 69% to 10%; P = .014), right ventricle ejection fraction remained stable, and antegrade pulmonary artery beat volume increased (from 26.7 to 41.6 mL/beat/m2; P = .037). The left ventricle stroke volume (from 30.4 to 44.1 mL/m2; P = .015) and antegrade aortic beat volume (from 28.5 to 41.1 mL/beat/m2; P = .014) also increased, and the left ventricle stroke volume improved progressively with time since surgery (P = .048). Whereas the right atrium area decreased (P = .004), the functional right ventricle and left heart area increased (cm2, P = .021 and P = .004). Right ventricle volumes showed a tendency to normalize and left ventricle indexed end-diastolic volume increased (from 50 to 69 mL/m2; P = .03) over time. CONCLUSIONS Cone valve integrity was sustained. Biventricular function improved progressively during follow-up, and there are positive signs of biventricular remodeling late after cone reconstruction.
Collapse
Affiliation(s)
- Ralph M L Neijenhuis
- Cardiothoracic Unit, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Victor T Tsang
- Cardiothoracic Unit, Great Ormond Street Hospital for Children, London, United Kingdom; Grown-up Congenital Heart Unit, St Bartholomew's Hospital, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom.
| | - Jan Marek
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Department of Cardiology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Richard Issitt
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Digital Research Environment, Great Ormond Street Hospital for Children, London, United Kingdom; Department of Perfusion, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Beatrice Bonello
- Department of Cardiology, Great Ormond Street Hospital for Children, London, United Kingdom; Centre for Cardiovascular Imaging, Great Ormond Street Hospital for Children, London, United Kingdom
| | | | - Marina L Hughes
- Department of Cardiology, Great Ormond Street Hospital for Children, London, United Kingdom; Centre for Cardiovascular Imaging, Great Ormond Street Hospital for Children, London, United Kingdom
| |
Collapse
|
6
|
Right Ventricular Systolic Function After the Cone Procedure for Ebstein's Anomaly: Comparison Between Echocardiography and Cardiac Magnetic Resonance. Pediatr Cardiol 2020; 41:985-995. [PMID: 32335735 DOI: 10.1007/s00246-020-02347-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 04/08/2020] [Indexed: 10/24/2022]
Abstract
Although the Cone procedure has improved outcomes for patients with Ebstein´s anomaly (EA), neither RV systolic function recovery in long-term follow-up nor the best echocardiographic parameters to assess RV function are well established. Thus, we evaluated RV performance after the Cone procedure comparing two-dimensional (2DEcho) and three-dimensional (3DEcho) echocardiography to cardiac magnetic resonance (CMR). We assessed 27 EA patients after the Cone procedure (53% female, median age of 20 years at the procedure, median post-operative follow-up duration of 8 years). Echocardiography was performed 4 h apart from the CMR. RV global longitudinal strain (GLS), fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE), myocardial performance index and tissue Doppler S' velocity were assessed using 2DEcho, whereas 3DEcho was used to evaluate RV volumes and ejection fraction (RVEF). Echocardiographic variables were compared to CMR-RVEF. All patients were in the NYHA functional class I. Median TAPSE was 15.9 mm, FAC 30.2%, and RV-GLS -15%; median RVEF by 3DEcho was 31.9% and 43% by CMR. Among 2DEcho parameters, RV-GLS and FAC had a substantial correlation with CMR-RVEF (r = - 0.63 and r = 0.55, respectively); from 3DEcho, the indexed RV volumes and RVEF were closely correlated with CMR (RV-EDVi, r = 0.60, RV-ESVi, r = 0.72; and RVEF r = 0.60). RV systolic function is impaired years after the Cone procedure, despite a good clinical status. FAC and RV-GLS are useful 2DEcho tools to assess RV function in these patients; however, 3DEcho measurements appear to provide a better RV assessment.
Collapse
|
7
|
Burri M, Mrad Agua K, Cleuziou J, Beran E, Nagdyman N, Kühn A, Ziegelmueller JA, Ewert P, Da Silva JP, Lange R. Cone versus conventional repair for Ebstein's anomaly. J Thorac Cardiovasc Surg 2020; 160:1545-1553. [PMID: 32711971 DOI: 10.1016/j.jtcvs.2020.05.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 04/30/2020] [Accepted: 05/02/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We aimed to investigate tricuspid valve function and adverse events after conventional repair and valve replacement for Ebstein's anomaly and compare them with cone repair. METHODS The medical records of 151 patients (mean age, 25 years; 62% were female) who underwent operation in a single center from 1985 to 2018 were retrospectively analyzed. To determine tricuspid valve regurgitation during follow-up, serial echocardiographic examination was used (n = 2397, tricuspid regurgitation grades were graphed for every patient). RESULTS Thirty-nine patients underwent cone repair, 107 patients underwent other repair techniques, and 5 patients underwent valve replacement. The operative mortality was 1.3% (n = 2). Failed valve repair (defined as in-hospital death, conversion to replacement, or in-hospital reoperation) was less frequent after cone repair than after other repair techniques (5%, n = 2 vs 20%, n = 21, P = .039). Mean follow-up was 12.3 years (cone repair: 3.7 years). The 5-year cumulative incidence of moderate or greater recurrent tricuspid regurgitation was lower after cone repair than after other repair techniques (8% vs 32%, P = .03). Among the patients undergoing other repair techniques, the 15-year cumulative incidence of moderate or greater recurrent tricuspid regurgitation, severe tricuspid regurgitation, and reoperation was 58%, 37%, and 31%, respectively. During follow-up, 18 patients died (13 of cardiac and 5 of noncardiac causes). Among patients who died of cardiac causes, 10 of 13 had all 3 characteristics-moderate or greater tricuspid regurgitation, atrial fibrillation, and New York Heart Association classification III and IV-at their last medical evaluation. CONCLUSIONS Before cone repair, recurrent tricuspid regurgitation was considerable. Cone repair provided a higher rate of successful repair and a lower incidence of moderate or greater recurrent tricuspid regurgitation at the midterm follow-up.
Collapse
Affiliation(s)
- Melchior Burri
- Department of Cardiovascular Surgery, German Heart Centre Munich at the Technical University Munich, Munich, Germany.
| | - Karim Mrad Agua
- Department of Cardiovascular Surgery, German Heart Centre Munich at the Technical University Munich, Munich, Germany
| | - Julie Cleuziou
- Department of Congenital and Paediatric Cardiovascular Surgery, German Heart Centre Munich at the Technical University Munich, Munich, Germany; Insure (Institute for Translational Cardiac Surgery), Department of Cardiovascular Surgery, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Elisabeth Beran
- Department of Congenital and Paediatric Cardiovascular Surgery, German Heart Centre Munich at the Technical University Munich, Munich, Germany; Insure (Institute for Translational Cardiac Surgery), Department of Cardiovascular Surgery, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Nicole Nagdyman
- Department of Pediatric Cardiology and Congenital Heart Disease, 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
| | | | - Peter Ewert
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich at the Technical University Munich, Munich, Germany
| | - Jose Pedro Da Silva
- Department of Paediatric Cardiovascular Surgery, UPMC Children's Hospital, Pittsburgh, Pa
| | - Rüdiger Lange
- Department of Cardiovascular Surgery, German Heart Centre Munich at the Technical University Munich, Munich, Germany; Insure (Institute for Translational Cardiac Surgery), Department of Cardiovascular Surgery, German Heart Center Munich at the Technical University of Munich, Munich, Germany; DZHK (German Center for Cardiovascular Research)-partner site Munich Heart Alliance, Munich, Germany
| |
Collapse
|
8
|
Mid-term outcomes of individualized surgeries in patients with Ebstein's anomaly. Heart Vessels 2019; 34:1332-1339. [PMID: 30848337 DOI: 10.1007/s00380-019-01358-5] [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: 10/09/2018] [Accepted: 02/08/2019] [Indexed: 10/27/2022]
Abstract
The variable anatomy of Ebstein's anomaly leads to its various surgical procedures. The long-term outcomes of different operations were not well established. Thirty-five patients with Ebstein's anomaly who underwent operations from 2006 to 2018 in our department were retrospectively reviewed. Individualized surgical plans were performed according to the preoperative echocardiography and surgeons' preference. Tricuspid repair, either Danielson's or Carpentier's technique, was the primary choice in patients who had sufficient tricuspid leaflets and adequate right ventricle, while tricuspid replacement was used when a reliable repair is not achievable. Additional bidirectional cavopulmonary shunt was performed in those who had unstable hemodynamics despite of high central venous pressure after separation from cardiopulmonary bypass. The perioperative and follow-up data were collected. The age was 26.9 (0.6-54) years [16 children (age < 14, and 19 adults (age ≥ 14)]. Preoperative tricuspid regurgitation was severe in 30, moderate in 4, and mild in the remaining 1 patient. Preoperative cardiac-associated malformations include 20 atrial septal defects, 2 ventricular septal defects, 2 pulmonary stenosis, and 1 sub aortic ridge, and these were operated simultaneously. Among all the surgical patients, 2 needed additional reoperation during the same admission, and ultimately, 29 patients had biventricular repair, including 21 tricuspid repair and 8 replacements. The other 6 patients had cavopulmonary connection and achieved 1.5 ventricular repair (3 tricuspid repair and 3 replacements). In all the 24 tricuspid repair patients, Danielson's procedure was used in 17, while Carpentier's technique was used in the other 7 patients. The average cardiopulmonary bypass time was 90 ± 28 min and cross-clamp time was 48 ± 24min. There were 2 perioperative deaths (5.7%) and no third-degree atrioventricular block. The postoperative in hospital stay was 13.7 ± 9.6 days. In the 33 survivors who were followed up at a median of 29.2 months, 6 patients had severe tricuspid regurgitation, and 2 of them underwent tricuspid replacement. The 5-year freedom from severe tricuspid dysfunction or reoperation was 78.5%, and no difference was found between children and adults, neither between different surgical choices. The surgeries of Ebstein's anomaly were variable, and individualized operation achieved reasonable short- and mid-term results. However, severe tricuspid regurgitation during the follow-up was not neglectable, and reoperation in such cases also achieved good outcomes. New repair strategy such as cone repair may be considered.
Collapse
|
9
|
Malhotra A, Agrawal V, Patel K, Shah M, Sharma K, Sharma P, Siddiqui S, Oswal N, Pandya H. Ebstein's Anomaly: "The One and a Half Ventricle Heart". Braz J Cardiovasc Surg 2019; 33:353-361. [PMID: 30184032 PMCID: PMC6122759 DOI: 10.21470/1678-9741-2018-0100] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 06/03/2018] [Indexed: 12/05/2022] Open
Abstract
Objective Ebstein's anomaly remains a relatively ignored disease. Lying in the 'No
Man's land' between congenital and valve surgeons, it largely remains
inadequately studied. We report our short-term results of treating it as a
'one and a half ventricle heart' and propose that the true tricuspid annulus
(TTA) 'Z' score be used as an objective criterion for estimation of
'functional' right ventricle (RV). Methods 22 consecutive patients undergoing surgery for Ebstein's anomaly were
studied. Echocardiography was performed to assess the type and severity of
the disease, tricuspid annular dimension and its 'Z' score. Patients were
operated by a modification of the cone repair, with addition of
annuloplasty, bidirectional cavopulmonary shunt (BCPS) and right reduction
atrioplasty to provide a comprehensive repair. TTA 'Z' score was correlated
later with postplication indexed residual RV volume. Results There was one (4.5%) early and no late postoperative death. There was a
significant reduction in tricuspid regurgitation grading (3.40±0.65
to 1.22±0.42, P<0.001). Residual RV volume
reduced to 71.96±3.8% of the expected volume and there was a
significant negative correlation (rho −0.83) between TTA 'Z' score and
indexed residual RV volume. During the follow-up of 20.54±7.62
months, the functional class improved from 2.59±0.7 to
1.34±0.52 (P<0.001). Conclusion In Ebstein's anomaly, a higher TTA 'Z' score correlates with a lower
postplication indexed residual RV volume. Hence, a complete trileaflet
repair with offloading of RV by BCPS (when the TTA 'Z' score is >2) is
recommended. The short-term outcomes of our technique are promising.
Collapse
Affiliation(s)
- Amber Malhotra
- Department of Cardiovascular and Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Centre (affiliated to BJ medical college, Ahmedabad), Gujarat, India
| | - Vishal Agrawal
- Department of Cardiovascular and Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Centre (affiliated to BJ medical college, Ahmedabad), Gujarat, India
| | - Kartik Patel
- Department of Cardiovascular and Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Centre (affiliated to BJ medical college, Ahmedabad), Gujarat, India
| | - Mausam Shah
- Department of Cardiovascular and Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Centre (affiliated to BJ medical college, Ahmedabad), Gujarat, India
| | - Kamal Sharma
- Department of Cardiology, U. N. Mehta Institute of Cardiology and Research Centre (affiliated to BJ medical college, Ahmedabad), Gujarat, India
| | - Pranav Sharma
- Department of Cardiovascular and Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Centre (affiliated to BJ medical college, Ahmedabad), Gujarat, India
| | - Sumbul Siddiqui
- Department of Cardiovascular and Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Centre (affiliated to BJ medical college, Ahmedabad), Gujarat, India
| | - Nilesh Oswal
- Department of Cardiology, U. N. Mehta Institute of Cardiology and Research Centre (affiliated to BJ medical college, Ahmedabad), Gujarat, India
| | - Himani Pandya
- Department of Research, U. N. Mehta Institute of Cardiology and Research Centre (affiliated to BJ medical college, Ahmedabad), Gujarat, India
| |
Collapse
|
10
|
Walsh EP. Ebstein’s Anomaly of the Tricuspid Valve. JACC Clin Electrophysiol 2018; 4:1271-1288. [DOI: 10.1016/j.jacep.2018.05.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 05/31/2018] [Indexed: 01/29/2023]
|
11
|
Beroukhim RS, Jing L, Harrild DM, Fornwalt BK, Mejia-Spiegeler A, Rhodes J, Emani S, Powell AJ. Impact of the cone operation on left ventricular size, function, and dyssynchrony in Ebstein anomaly: a cardiovascular magnetic resonance study. J Cardiovasc Magn Reson 2018; 20:32. [PMID: 29783986 PMCID: PMC5963144 DOI: 10.1186/s12968-018-0452-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 04/10/2018] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND In addition to tricuspid regurgitation (TR) and right ventricular (RV) enlargement, patients with Ebstein anomaly are at risk for left ventricular (LV) dysfunction and dyssynchrony. We studied the impact of the cone tricuspid valve reconstruction operation on LV size, function, and dyssynchrony. METHODS All Ebstein anomaly patients who had both pre- and postoperative cardiovascular magnetic resonance (CMR) studies were retrospectively identified. From cine images, RV and LV volumes and ejection fractions (EF) were calculated, and LV circumferential and longitudinal strain were measured by feature tracking. To quantify LV dyssynchrony, temporal offsets (TOs) were computed among segmental circumferential strain versus time curves using cross-correlation analysis and patient-specific reference curves. An LV dyssynchrony index was calculated as the standard deviation of the TOs. RESULTS Twenty patients (65% female) were included with a median age at cone operation of 16 years, and a median time between pre- and postoperative CMR of 2.8 years. Postoperatively, there was a decline in the TR fraction (56 ± 19% vs. 5 ± 4%, p < 0.001), RV end-diastolic volume (EDV) (242 ± 110 ml/m2 vs. 137 ± 82 ml/m2, p < 0.001), and RV stroke volume (SV) (101 ± 35 vs. 51 ± 7 ml/m2, p < 0.001). RV EF was unchanged. Conversely, there was an increase in both LV EDV (68 ± 13 vs. 85 ± 13 ml/m2, p < 0.001) and LV stroke volume (37 ± 8 vs. 48 ± 6 ml/m2, p < 0.001). There was no change in LV EF, or global circumferential and longitudinal strain but basal septal circumferential strain improved (16 ± 7% vs. 22 ± 5%, p = 0.04). LV contraction become more synchronous (dyssynchrony index: 32 ± 17 vs. 21 ± 9 msec, p = 0.02), and the extent correlated with the reduction in RV EDV and TR. CONCLUSIONS In patients with the Ebstein anomaly, the cone operation led to reduced TR and RV stroke volume, increased LV stroke volume, improved LV basal septal strain, and improved LV synchrony. Our data demonstrates that the detrimental effect of the RV on LV function can be mitigated by the cone operation.
Collapse
Affiliation(s)
- Rebecca S. Beroukhim
- Department of Pediatrics, Massachusetts General Hospital, 175 Cambridge Street, 5th Floor, Boston, MA 02114 USA
- Department of Cardiology, Boston Children’s Hospital, Boston, MA USA
- Department of Pediatrics, Harvard Medical School, Boston, MA USA
| | - Linyuan Jing
- Department of Imaging Science and Innovation, Geisinger, Danville, PA USA
| | - David M. Harrild
- Department of Cardiology, Boston Children’s Hospital, Boston, MA USA
- Department of Pediatrics, Harvard Medical School, Boston, MA USA
| | - Brandon K. Fornwalt
- Department of Imaging Science and Innovation, Geisinger, Danville, PA USA
- Department of Radiology, Geisinger, Danville, PA USA
| | | | - Jonathan Rhodes
- Department of Cardiology, Boston Children’s Hospital, Boston, MA USA
- Department of Pediatrics, Harvard Medical School, Boston, MA USA
| | - Sitaram Emani
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, MA USA
- Department of Surgery, Harvard Medical School, Boston, MA USA
| | - Andrew J. Powell
- Department of Cardiology, Boston Children’s Hospital, Boston, MA USA
- Department of Pediatrics, Harvard Medical School, Boston, MA USA
| |
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
Li JS, Chen G, Ma J, Yan ZX, Cheng DM, Chang L, Zhang HC, Liu JY. The modified cone reconstruction in the treatment of Ebstein's anomaly: Case reports. Medicine (Baltimore) 2017; 96:e8727. [PMID: 29384893 PMCID: PMC6393128 DOI: 10.1097/md.0000000000008727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE To investigate the early and mid-term clinical outcomes of the modified cone reconstruction in the treatment of Ebstein's anomaly (EA) which provide appropriate surgical treatment for clinical and reduce the incidence of re-operation and valve replacement. PATIENT CONCERNS Clinical data of 18 consecutive patients with EA in our hospital between May 2008 and August 2015 were analyzed retrospectively. All patients were diagnosed by echocardiography. Among these patients, according to New York Heart Association functional grade, there were 12 patients with grade II cardiac function and 6 patients with grade III. All patients had severe tricuspid regurgitation grade. DIAGNOSES All patients were diagnosed EA. One case was with acute arterial embolism and amputation of left lower extremity caused by paradoxical embolism of combined secundum atrial septal defect. INTERVENTIONS The modified cone reconstruction in the treatment of EA of the tricuspid valve uses its own tissues to form not only central bloodstream, but also the coaption between 2 leaflets. For those patients whose anterior leaflet developed poor and smaller, the valve leaflet was widened by using autologous pericardial. For all patients, tricuspid annulus were reinforced by autologous pericardial. One case was combined with double-orifice technique due to postoperative poor closure of the tricuspid valve. OUTCOMES There were 2 cases with arrhythmia, and they returned to normal after medication. The rest patients recovered smoothly with no death. Review of echocardiography: 1 patient with moderate regurgitation, the rest of patients' leaflets coapted well and had no tricuspid stenosis. All cases were followed up postoperatively for 9 to 38 months, and there were 14 patients with grade I cardiac function and 4 patients with grade II. LESSONS The early and mid-term clinical outcomes of the modified cone reconstruction in the treatment of EA were which can make leaflets coapt and had a strong antiregurgitation ability, reducing the incidence of re-operation, valve replacement, and postoperative mortality.
Collapse
Affiliation(s)
- Jun-Sheng Li
- Department of Cardiothoracic Surgery, Taizhou Central Hospital (Taizhou University Hospital), Taizhou, Zhejiang
| | - Gang Chen
- The Secondary Ward of Thoracic Surgery, Shanxi Provincial Cancer Hospital
| | - Jie Ma
- Department of Cardiothoracic Surgery
| | | | | | | | | | - Jiang-Yan Liu
- Department of Ultrasound, Shanxi Medical University Second Hospital, Taiyuan, Shanxi, People's Republic of China
| |
Collapse
|
14
|
Mayer JE, Del Nido PJ. Boston Children׳s Hospital Cardiovascular Program. Semin Thorac Cardiovasc Surg 2017; 28:621-625. [PMID: 28285666 DOI: 10.1053/j.semtcvs.2016.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2016] [Indexed: 11/11/2022]
Abstract
The Cardiovascular program at Boston Children's Hospital has been characterized as a "great institution" by the editors. This designation is the result of a commitment to innovation interdisciplinary collaboration, rigorous review of results and continuous self-improvement, training the next generation, and an ability to "get the right people on the bus".
Collapse
Affiliation(s)
- John E Mayer
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
15
|
Krivoshchekov EV, Ackerman JP, Yanulevich OS, Sokolov AA, Ershova NV, Dearani JA, Cetta F. Modified Cone Reconstruction of the Tricuspid Valve for Ebstein Anomaly as Performed in Siberia. Tex Heart Inst J 2017; 44:39-42. [PMID: 28265211 DOI: 10.14503/thij-16-5832] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The cone reconstruction technique, first described by da Silva and modified by Dearani and by others, has become the repair method of choice in patients with Ebstein anomaly of the tricuspid valve. This report details the outcome of the modified cone reconstruction technique in 6 children who underwent surgical correction of Ebstein anomaly at the Tomsk Institute of Cardiology in Siberia. From 2012 through 2015, 4 boys and 2 girls (age range, 11 mo-12 yr) underwent surgery to correct Ebstein anomaly. All had presented with cyanosis, exertional dyspnea, fatigue, or new-onset atrial arrhythmia, and none had undergone previous cardiac surgery. All survived the operation. One patient needed tricuspid valve replacement with a bioprosthesis after early breakdown of the cone reconstruction. As of December 2016, all the patients had no symptoms, tricuspid stenosis, or arrhythmia. This series indicates that cone reconstruction-the most anatomic repair technique for the dysmorphic Ebstein tricuspid valve-can be successfully performed in pediatric heart centers with a large experience.
Collapse
|
16
|
LI JS, Ma J, Yan ZX, Cheng DM, Chang L, Zhang HC, Liu JY. Acute arterial embolism of left lower extremity caused by paradoxical embolism in Ebstein's anomaly: A case report. Medicine (Baltimore) 2017; 96:e5901. [PMID: 28151866 PMCID: PMC5293429 DOI: 10.1097/md.0000000000005901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Ebstein's anomaly is a benign and stable congenital heart disease for asymptomatic patients. Despite a low incidence of Ebstein's anomaly (EA), patients' quality of life can be badly affected by EA without positive surgical intervention. Especially EA is associated with other congenital heart disease, such as the atrial septal defect, patent foramen ovale, and arterial embolism exclude other reasons, it is often considered to be the consequence of paradoxical embolism, and surgical intervention must be conducted. CASE REPORT An 11-year-old girl falling off the bed suffered pain from left lower extremity. Echocardiographic evaluation revealed an EA, severe tricuspid regurgitation, and secundum atrial septal defect. Both left leg amputation and cardiac surgery were conducted after recovery. Under the condition of anesthesia cardiopulmonary bypass extracorporeal circulation, atrial septal defect repair and Cone reconstruction of the tricuspid valve were performed. Patient recovered well and left hospital smoothly. DISCUSSION EA is a rare and complex congenital cardiac malformation. There are about 80% to 90% of EA patients with combined atrial septal defect and patent foramen ovale. Sudden arterial occlusion is very rare especially in childhood. When thoracic roentgenoscopy, arterial blood gas analysis, coagulation test, and echocardiographic of lower extremity deep venous system are all normal, one should consider the possibility of a paradoxical embolism. If patients have the paradoxical embolism or worsening tricuspid regurgitation, the most suitable therapeutic regimen should be chosen according to patients' condition. With surgical techniques and methods renewed continuously, cone reconstruction of the tricuspid valve has been confirmed in clinical trials, which can use its own tissues to form not only central bloodstream, but also the coaption between leaflet and leaflet.
Collapse
Affiliation(s)
| | - Jie Ma
- Department of Cardiothoracic Surgery
| | | | | | | | | | - Jiang-Yan Liu
- Department of Ultrasound, Shanxi Medical University Second Hospital, Taiyuan, Shanxi, P.R. China
| |
Collapse
|
17
|
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]
|
18
|
Mizuno M, Hoashi T, Sakaguchi H, Kagisaki K, Kitano M, Kurosaki K, Yoshimatsu J, Shiraishi I, Ichikawa H. Application of Cone Reconstruction for Neonatal Ebstein Anomaly or Tricuspid Valve Dysplasia. Ann Thorac Surg 2016; 101:1811-7. [PMID: 26916715 DOI: 10.1016/j.athoracsur.2015.11.029] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 10/18/2015] [Accepted: 11/09/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Outcomes of surgical intervention for severe tricuspid regurgitation related to Ebstein anomaly or tricuspid valve dysplasia in the neonatal period, particularly when associated with pulmonary atresia, are extremely poor. However, owing to emerging innovative surgical techniques, such as cone reconstruction, outcomes of tricuspid valve plasty in the neonatal period have gradually improved. METHODS The study retrospectively reviewed the medical records of 12 neonates who were diagnosed with severe tricuspid regurgitation and pulmonary atresia related to Ebstein anomaly (n = 9) or isolated tricuspid valve dysplasia (n = 3) between 2000 and 2013. RESULTS The first 6 patients underwent palliative therapy in anticipation of future functional single-ventricle palliation (Starnes operation). Biventricular repair was performed in the 6 patients born after 2012. As tricuspid valve plasty, cone reconstruction has been applied since 2013. Five patients underwent a Starnes operation, and 5 patients underwent biventricular repair, including 4 cone reconstructions. Four of the 5 patients who underwent a Starnes operation died in-hospital; the remaining patient underwent a Fontan operation at age 2 years. Three of the 5 patients who underwent biventricular repair survived. On echocardiogram, the 3 survivors who were treated with biventricular repair had a preoperative tricuspid regurgitation flow velocity greater than 3.0 m/s. CONCLUSIONS Biventricular repair with cone reconstruction can be applied for severe tricuspid regurgitation due to neonatal Ebstein anomaly or tricuspid valve dysplasia with associated pulmonary atresia. A tricuspid regurgitation flow velocity greater than 3.0 m/s may be an indicator of successful biventricular repair.
Collapse
Affiliation(s)
- Masanori Mizuno
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Takaya Hoashi
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
| | - Heima Sakaguchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Koji Kagisaki
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Masataka Kitano
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kenichi Kurosaki
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Jun Yoshimatsu
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Isao Shiraishi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Hajime Ichikawa
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| |
Collapse
|
19
|
Kim DJ, Suh JW, Shin YR, Shin HJ, Park HK. Tricuspid Valve Re-Repair in Ebstein Anomaly Using the Cone Technique. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2016; 49:35-8. [PMID: 26889444 PMCID: PMC4757395 DOI: 10.5090/kjtcs.2016.49.1.35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 06/27/2015] [Accepted: 07/07/2015] [Indexed: 12/03/2022]
Abstract
The management of recurrent tricuspid regurgitation after tricuspid valve repair in patients with Ebstein anomaly is difficult, and tricuspid valve replacement is most commonly performed in such patients. We report two cases of recurrent tricuspid regurgitation in patients with Ebstein anomaly that were successfully re-repaired using the cone technique. The cone repair technique is a useful surgical method for reconstructing a competent tricuspid valve, and can be applied in patients who have undergone previous tricuspid valve repair.
Collapse
Affiliation(s)
- Do Jung Kim
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Congenital Heart Disease Center, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Jee Won Suh
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Congenital Heart Disease Center, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Yu Rim Shin
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Congenital Heart Disease Center, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Hong Ju Shin
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Congenital Heart Disease Center, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Han Ki Park
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Congenital Heart Disease Center, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| |
Collapse
|
20
|
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.
Collapse
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
| |
Collapse
|
21
|
Morray B. Preoperative Physiology, Imaging, and Management of Ebstein's Anomaly of the Tricuspid Valve. Semin Cardiothorac Vasc Anesth 2015; 20:74-81. [PMID: 26620137 DOI: 10.1177/1089253215616499] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Ebstein's anomaly of the tricuspid valve (TV) refers to an embryological derangement of TV formation causing tethering of the septal and posterior leaflets of the valve to the underlying myocardium and apical displacement of the effective valve annulus, resulting in significant TV insufficiency and dilation of the right heart structures. The pathological abnormalities of the valve can vary significantly, resulting in a wide range of clinical presentations. Fetal diagnosis and neonatal presentations of the disease are typically the most severe and are associated with the highest mortality rates. Patients with less-severe disease will present later in life with symptoms of right heart failure and tachyarrhythmias. Medical and surgical management strategies are driven by the age at presentation, severity of disease, and any associated cardiac abnormalities. There are an increasing number of surgical options focused on valve repair.
Collapse
|
22
|
Ibrahim M, Tsang VT, Caruana M, Hughes ML, Jenkyns S, Perdreau E, Giardini A, Marek J. Cone reconstruction for Ebstein's anomaly: Patient outcomes, biventricular function, and cardiopulmonary exercise capacity. J Thorac Cardiovasc Surg 2015; 149:1144-50. [DOI: 10.1016/j.jtcvs.2014.12.074] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 12/17/2014] [Accepted: 12/25/2014] [Indexed: 11/28/2022]
|
23
|
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.
Collapse
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
| |
Collapse
|
24
|
Arya P, Beroukhim R. Ebstein Anomaly: Assessment, Management, and Timing of Intervention. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:338. [DOI: 10.1007/s11936-014-0338-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
|
25
|
Utility of preoperative electrophysiologic studies in patients with Ebstein’s anomaly undergoing the Cone procedure. Heart Rhythm 2014; 11:182-6. [DOI: 10.1016/j.hrthm.2013.10.045] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Indexed: 11/21/2022]
|
26
|
Anderson HN, Dearani JA, Said SM, Norris MD, Pundi KN, Miller AR, Cetta ML, Eidem BW, O'Leary PW, Cetta F. Cone Reconstruction in Children with Ebstein Anomaly: The Mayo Clinic Experience. CONGENIT HEART DIS 2013; 9:266-71. [DOI: 10.1111/chd.12155] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/24/2013] [Indexed: 11/30/2022]
Affiliation(s)
| | | | - Sameh M. Said
- Division of Cardiovascular Surgery; Mayo Clinic; Rochester Minn USA
| | - Mark D. Norris
- Division of Cardiovascular Diseases; Mayo Clinic; Rochester Minn USA
| | - Kavitha N. Pundi
- Division of Pediatric Cardiology; Mayo Clinic; Rochester Minn USA
| | - Angela R. Miller
- Division of Pediatric Cardiology; Mayo Clinic; Rochester Minn USA
| | - Michael L. Cetta
- Division of Pediatric Cardiology; Mayo Clinic; Rochester Minn USA
| | - Benjamin W. Eidem
- Division of Pediatric Cardiology; Mayo Clinic; Rochester Minn USA
- Division of Cardiovascular Diseases; Mayo Clinic; Rochester Minn USA
| | - Patrick W O'Leary
- Division of Pediatric Cardiology; Mayo Clinic; Rochester Minn USA
- Division of Cardiovascular Diseases; Mayo Clinic; Rochester Minn USA
| | - Frank Cetta
- Division of Pediatric Cardiology; Mayo Clinic; Rochester Minn USA
- Division of Cardiovascular Diseases; Mayo Clinic; Rochester Minn USA
| |
Collapse
|
27
|
Dearani JA, Said SM, Burkhart HM, Pike RB, O'Leary PW, Cetta F. Strategies for tricuspid re-repair in Ebstein malformation using the cone technique. Ann Thorac Surg 2013; 96:202-8: discussion 208-10. [PMID: 23743062 DOI: 10.1016/j.athoracsur.2013.02.067] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 02/11/2013] [Accepted: 02/15/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Successful tricuspid repair for Ebstein malformation (EM) is challenging. Cone repair has recently emerged as the most anatomic repair technique. There are no data on tricuspid re-repair in EM. We reviewed our experience with tricuspid valve (TV) re-repair using a cone technique. METHODS Between June 2007 and October 2012, 134 patients underwent cone repair. Prior TV repair was performed in 20 patients (10 female, 50%). Median age was 15 years (range, 4 to 68 years). Four patients (20%) had prior bidirectional cavopulmonary anastomosis (BDCPA). Preoperative heart failure was present in 8 patients (40%). Recurrent tricuspid regurgitation (TR) was due to incomplete leaflet coaptation with tethered anterior leaflet in all patients; and 10 patients (50%) had diminutive septal leaflet. Prior repair techniques consisted of annuloplasty maneuvers in all patients with no or incomplete surgical delamination in all patients. RESULTS The TV re-repair using cone technique was possible in all patients. Plication of atrialized right ventricle was done in 6 patients (30%). Modifications included annuloplasty band in 16 patients (80%) and TV leaflet augmentation in 8 (40%). The BDCPA was performed in 3 patients (15%) and modified Cox-maze procedure was done in 10 (50%). There were no mortalities or reoperations. Mean follow-up was 7.7 ± 10.7 months; during follow-up, 18 patients had no or mild TR and 2 had moderate TR. CONCLUSIONS TV re-repair in EM using the cone technique is feasible, particularly when there has been no surgical leaflet delamination at initial operation. Leaflet augmentation facilitates and annuloplasty band stabilizes a competent TV re-repair. Longer follow-up is required to assess durability.
Collapse
Affiliation(s)
- Joseph A Dearani
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA.
| | | | | | | | | | | |
Collapse
|
28
|
Krieger EV, Valente AM. Diagnosis and Management of Ebstein Anomaly of the Tricuspid Valve. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2012; 14:594-607. [DOI: 10.1007/s11936-012-0209-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|