Ann Thorac Surg 2007;83:676-678
© 2007 The Society of Thoracic Surgeons
Case Reports
Pericardial Patch Augmentation of Both Anterior and Septal Leaflets in Ebstein’s Anomaly
Noyan Timucin Ogus*,
Cenk Indelen, MD,
Tekin Yildirim, MD,
Ozer Selimoglu, MD,
Murat Basaran, MD
Cardiovascular Surgery Service, Goztepe Safak Hospital, Istanbul, Turkey
Accepted for publication July 10, 2006.
* Address correspondence to Dr Ogus, Caferaga Mh. Bahariye C. 54/1, Kadikoy, Istanbul, Turkey. (Email: togus{at}superonline.com).
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Abstract
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In Ebstein’s anomaly, the aim of surgical intervention is the restoration of tricuspid valve competence. In some circumstances, however, paucity of the leaflet tissue precludes successful repair and negatively influences the long-term durability of the valvuloplasty procedure. We report a modified technique that provides satisfactory results for right atrioventricular valve function.
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Introduction
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Ebstein’s anomaly is a rare, complex congenital anomaly characterized by downward displacement of the septal and posterior leaflets of the tricuspid valve, an "atrialized" right ventricular chamber, and various degrees of anterior leaflet tethering [1]. Excellent results have been reported by many surgeons using different forms of valvuloplasty techniques, with or without ventricular plication [2–6]. The morphologic heterogeneity is the most challenging aspect of the anomaly, and the pathologic anatomy may vary widely between patients. We report a patient in whom we restored tricuspid valve competence by augmenting both anterior and septal leaflets with pericardial patches.
A 22-year-old woman was referred to our clinic with dyspnea, cyanosis, and fatigue. There was a pansystolic murmur at the left sternal border on physical examination, and an electrocardiogram demonstrated a right bundle branch pattern with right atrial enlargement. Transthoracic echocardiographic evaluation established the definitive diagnosis of Ebstein’s anomaly, and a surgical intervention was planned.
The operation was performed through a median sternotomy, and a large pericardial piece was harvested for later use. Cardiopulmonary bypass (CPB) was instituted with standard aortic and bicaval cannulations, and the patient was cooled to 28°C. After the aorta was cross-clamped, crystalloid cardioplegia was administered through the aortic root. A right atriotomy parallel to atrioventricular groove was fashioned, and the detailed anatomy of the right atrioventricular valve was studied. There was abnormal muscular and chordal bands attaching the anterior leaflet to the right ventricular free wall, and the leaflet size was not too large. The septal and posterior leaflets were hypoplastic, and the distance of downward displacement of septal and posterior leaflets was 2 cm from the atrioventricular junction to the most distal attachments.
The repair was started with the detachment of the anterior leaflet from the annulus, with the exception of its commissure at the anteroseptal area. Towards the patient’s right, the detachment included the anterior leaflet/posterior leaflet commissure, and abnormal bands were transected to obtain sufficient leaflet size and mobility. The detached anterior leaflet was then rotated in a clockwise fashion until its free detached edge at the anterior leaflet/posterior leaflet commissure reached the right aspect of the septal leaflet. Its free edge was then reattached to the newly formed tricuspid annulus by using single 6-0 polyprolene suture.
Despite extensive mobilization, the size of the anterior leaflet was not large enough to cover the newly formed tricuspid valve orifice; thus, instead of direct anastomosis, the size of the anterior leaflet was augmented with an untreated, appropriately sized pericardial patch placed between the free posterior border of the anterior leaflet and the tricuspid annulus. The posterior leaflet was extremely small, and it was simply excluded by placing the anterior leaflet over it. The rudimentary septal leaflet was detached, and the mobility of the leaflet was enhanced by the dissection of all muscular attachments between the leaflet tissue and the septum.
To avoid excess traction, an untreated rectangular piece of pericardium was tailored to cover the defect between the anatomic annulus and the detached posterior edge of the septal leaflet. The appropriately sized pericardial patch was sutured onto the place with a continuous 6-0 polyprolene suture, taking care of the adjacent conduction bundle. A bicuspid functional right atrioventricular valve was then created (Fig 1), and the right ventricle was filled with saline solution to check its function. The patent foramen ovale was closed with a single stitch.
The cross-clamp and CPB times were 67 and 84 minutes, respectively. Intraoperative transesophageal echocardiography showed a satisfactory result with no regigurtation. The patient’s postoperative course was uneventful, and she was discharged without any complication on postoperative day 8. At 6 years of follow-up, an echocardiographic evaluation revealed a well-functioning bicuspid right atrioventricular valve with trivial regurgitation. The patient is still in New York Heart Association class I.
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Comment
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In Ebstein’s anomaly, the restoration of tricuspid valve competence is the most critical step determining the success of the surgical intervention. Previously described techniques that create a monocuspid valve generally use the anterior leaflet as the sole valve-closing structure and the septum as the opposing structure for coaptation. Therefore, an adequately sized, mobile anterior leaflet is a prerequisite for the achievement of tricuspid valve competence.
Some patients, however, may not be candidates for these techniques because of anterior leaflet abnormalities. In patients with restricted anterior leaflet mobility, complete dissection of free wall attachments may be considered, but this maneuver also does not guarantee an adequate postoperative leaflet coaptation, especially in patients with an inadequately sized anterior leaflet [2].
Although many valvuloplasty techniques have been described for the repair of the tricuspid valve, a standard surgical technique has not been established because of the variations of pathologic features. Our repair technique consists of the combination of the reported techniques and shares common advantages of all these previously described techniques.
Pericardial patch augmentation of the anterior leaflet was first described by Van Son and colleagues [7]. Their report claimed that the paucity of anterior leaflet valve tissue is the most important factor determining the success of the repair. We totally agree with them, but we have also observed that the body of the augmented anterior leaflet may not be sufficiently large to cover the newly formed tricuspid valve orifice. Therefore, in our patient, the septal leaflet was also augmented with another pericardial patch.
Septal leaflet augmentation offers two distinct advantages. The entire tricuspid valve orifice could be easily covered with the leaflet tissue without excessive traction and tension. The use of septal leaflet rather than septum as the opposing structure for coaptation is an important component that increases the long-term durability of this modification, as previously mentioned by Ullmann [8]. The only concern with the pericardial patch augmentation is the calcification of the pericardial piece. We believe that the use of untreated pericardial patch is an important measure to prevent late calcification. Indeed, we did not observe any valvular dysfunction at the end of 6 years of follow-up.
In conclusion, a paucity of leaflet tissue in some circumstances precludes successful valve repair and negatively influences the long-term durability of the surgical procedure. The augmentation of both septal and anterior leaflets is associated with a satisfactory long-term outcome for right atrioventricular valve function.
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References
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- Wu Q, Huang Z. A new procedure for Ebstein’s anomaly Ann Thorac Surg 2004;77:470-476.[Abstract/Free Full Text]
- Hetzer R, Nagdyman N, Ewert P, et al. A modified repair technique for tricuspid incompetence in Ebstein’s anomaly J Thorac Cardiovasc Surg 1998;115:857-868.[Abstract/Free Full Text]
- Danielson GK, Driscoll DJ, Mair DD, Warnes CA, Oliver Jr WC. Operative treatment of Ebstein’s anomaly J Thorac Cardiovasc Surg 1992;104:1195-1202.[Abstract]
- Starnes VA, Pitlick PT, Bernstein D, Griffin ML, Choy M, Shumway NE. Ebstein’s anomaly appearing in the neonateA new surgical approach. J Thorac Cardiovasc Surg 1991;101:1082-1087.[Abstract]
- Carpentier A, Chauvaud S, Mace L, et al. A new reconstructive operation for Ebstein’s anomaly of the tricuspid valve J Thorac Cardiovasc Surg 1988;96:92-101.[Abstract]
- Quaegebeur JM, Sreeram N, Fraser AG, et al. Surgery for Ebstein’s anomaly: the clinical and echocardiographic evaluation of a new technique J Am Coll Cardiol 1991;17:722-728.[Abstract]
- Van Son JA, Kinzel P, Mohr FW. Pericardial patch augmentation of anterior tricuspid leaflet in Ebstein’s anomaly Ann Thorac Surg 1998;66:1831-1832.[Abstract/Free Full Text]
- 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;78:918-924discussion 924–5.[Abstract/Free Full Text]
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Abstract
Introduction
