Ann Thorac Surg 2004;78:924-925
© 2004 The Society of Thoracic Surgeons
Invited commentary
Edward L. Bove, MD
Department of Surgery, University of Michigan, 1500 East Medical Center Dr, F7830 Mott Children's Hospital, Ann Arbor, MI 48109, USA
elbove{at}umich.edu
Ullmann and colleagues present a novel approach to the repair of the tricuspid valve in Ebstein's anomaly. The essence of their technique involves ventricularization of the atrialized chamber by detachment of the displaced septal leaflet and reattachment to the true annulus. The anterior leaflet, mobilized as necessary according to the specific anatomic findings, then functions as a monocusp closing against the barrier made by the repositioned septal leaflet. Their series includes 23 patients undergoing operation over a 10-year span but, importantly, excludes 5 patients whose anatomy was judged too severe for valvuloplasty. However, despite the generally favorable anatomy in their patients, 3 had valve dehiscence with 1 death and 1 underwent conversion to a Fontan procedure. The survivors have generally done well, and only 2 have more than moderate residual tricuspid valve regurgitation at late follow-up.
The concept that the atrialized portion of the right ventricle need not be plicated but may be simply left as part of the right ventricle (ventricularization) is not new but goes against most currently employed techniques that involve reduction or plication of this chamber. The authors have demonstrated that good results are possible with their approach, raising the question of whether patients with Ebstein's anomaly should undergo valve repair earlier in life with the expectation that the atrialized portion of the right ventricle will recondition more easily to ventricular workloads. Perhaps the most surprising finding in this series is the lack of heart block after reattachment of the septal leaflet to the true or anatomic annulus of the tricuspid valve. The penetrating bundle passes unguarded in this region, and the authors appropriately emphasize that superficial sutures must be taken. It should be emphasized, however, that their approach resulted in valve dehiscence in 3 patients, so this technique is not without potential problems. The main purported advantage, according to the authors, is the "favorable restoration of right ventricular geometry and function." Unfortunately, few supporting data are presented to substantiate that claim. Perhaps additional studies, including magnetic resonance and radionuclide imaging, would strengthen their conclusion by examining regional wall motion. Nonetheless, the authors should be congratulated for presenting this novel technique, which provides additional support to the notion that these patients may be better served by earlier repair.
Related Article
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Ventricularization of the atrialized chamber: A concept of Ebstein's anomaly repair
- Michael V. Ullmann, Sabine Born, Christian Sebening, Matthias Gorenflo, Herbert E. Ulmer, and Siegfried Hagl
Ann. Thorac. Surg. 2004 78: 918-924.
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