Volume 13, Issue 2 , Pages 101-108, Summer 2008
Management of Neonatal Ebstein's Anomaly
Article Outline
- Indications for Surgery
- Principles of Biventricular Repair
- Operative Technique
- Conclusions
- References
- Copyright
Although most patients with Ebstein's anomaly live through infancy, those who present clinically as neonates are a distinct and usually catastrophically ill group. Furthermore, 45% of seemingly “asymptomatic” neonates with Ebstein's anomaly die in infancy. This appears to be due, in large part, to the persistent elevation in pulmonary vascular resistance, which is a major impediment to successful antegrade ejection from the small, poorly effective right ventricle. In its extreme form, this situation produces physiologic pulmonary atresia, with profound cyanosis, and reliance on a patent ductus for pulmonary blood flow. Additionally, the high pulmonary vascular resistance worsens tricuspid insufficiency, which increases right-to-left shunting across any atrial septal defect. This leads to a spiral of deeper hypoxemia and acidosis. These children also have massive cardiomegaly, crowding a chest with already small lungs.
Indications for Surgery
Implicit in the discussion of surgery for Ebstein's anomaly is the recognition that the neonatal presentation is generally one of uniform fatality and is unique from that of the older child coming to surgery. First reported by Celermajer and coworkers from the United Kingdom, the Great Ormond Street Echo (GOSE) Score has important prognostic value in stratifying risk of death.1 The GOSE score is based on a calculated ratio of the sum of the right atrial and “atrialized” right ventricular areas, to the sum of the remaining chambers, derived from a four-chamber echocardiographic view. From this GOSE Score, an assessment of mortality risk can be generated. It should be noted that even Grade 3 (ratio = 1.1-1.4) carries with it a separate risk of late death (45%), even in the acyanotic neonate. Cyanosis is a uniformly morbid sign, with 50% risk of early death, culminating in 100% mortality in the setting of a GOSE Score of 3 or 4. Other risk factors include “functional” pulmonary atresia, a large atrial septal defect, massive cardiomegaly with a cardiothoracic ratio >0.85, and severe (4/4) tricuspid insufficiency. Current recommendations are for a biventricular repair in the first few weeks of life. In less symptomatic neonates, additional factors mandating surgery are as follows: a GOSE Score of 4, a cardiothoracic ratio >0.80, and severe tricuspid insufficiency. In severely affected neonates, indications are as follows: severe cyanosis, GOSE Score 3 or 4 with mild cyanosis, a cardiothoracic ratio >0.80, and severe tricuspid insufficiency.
Principles of Biventricular Repair
Operations for Ebstein's anomaly in children date back to Hardy and Lillehei in the 1950s.2, 3 However, it is only recently that an approach to neonates has evolved. We first attempted a two-ventricle repair in three critically ill neonates with Ebstein's anomaly in 1994 and subsequently applied this strategy to all neonates with Ebstein's anomaly requiring surgery. The guiding principles of the repair are as follows: (1) creation of a competent tricuspid valve, based on the anterior leaflet; (2) reduction of right atrial volume; (3) closure of the atrial septal defect, leaving a small fenestration; and (4) repair of all associated defects, including pulmonary atresia.
All cases are performed utilizing cardiopulmonary bypass with bicaval cannulation, moderate hypothermia or circulatory arrest, and antegrade aortic root cardioplegia. The free wall of the right atrium is widely excised, making the remaining atrium more mechanically efficient and also reducing the intrathoracic volume occupied by the heart. It is vital to identify the course of the right coronary artery before performing the reduction atrioplasty, as inadvertent division of the right coronary can result in a fatality. A detailed assessment of the anterior tricuspid leaflet must now take place, with an eye toward the adequacy of the leaflet size as well as any tethering of the anterior leaflet to the free wall of the right ventricle. Specifically assessed is the leading edge of the leaflet, which may insert directly into the free wall of the right ventricle without discernible papillary muscles or chordae.
Operative Technique
Figure 1.
An important aspect of the repair is to ensure that severe tricuspid regurgitation does not recur during intermittent episodes of pulmonary hypertension. The Sebening suture is very helpful in this regard. A pledgetted 4/0 braided suture is placed through a dominant papillary muscle of the anterior leaflet and fixed to the interventricular septum, usually at the site of the laminated septal leaflet. This keeps the free wall of the right ventricle and the anterior leaflet in apposition to the posterior aspect of the tricuspid annulus.
Figure 2.
When the anterior leaflet is sail-like and free, and the annulus is very dilated (>20 mm), a pledgetted suture is placed through the annulus at the antero-posterior commissure, brought through the medial wall of the coronary sinus well away from the atrioventricular node, and tied down. This creates a double orifice tricuspid valve with the left orifice being the functional tricuspid valve and the right orifice being closed with running or interrupted sutures. A functional orifice of >13 mm is usually perfectly satisfactory. ASD = atrial septal defect.
Figure 3.
The right-sided orifice of the tricuspid valve has been closed, creating a competent valve. A fenestrated closure of the large atrial septal defect has also been done, leaving a 3-mm residual. RV = right ventricle.
Figure 4.
When the anterior leaflet leading edge has fixed muscular attachments to the free wall of the right ventricle, the leaflet is detached along the annulus, and these attachments are then freed up to allow the anterior leaflet to move more freely. The annulus is reduced in size, and the leaflet reattached. This has the effect of rotating the leaflet in a clockwise fashion.
Figure 5.
Occasionally the anterior leaflet can be enlarged or augmented with a patch of untreated autologous pericardium, to produce a sail-like leaflet which has the ability to coapt effectively.
Figure 6.
In the presence of anatomical pulmonary atresia, or in situations where the tricuspid valve repair is suboptimal or the branch pulmonary arteries are hypoplastic, creating a competent pulmonary valve is very helpful. My approach is to use either a small aortic homograft or a bovine jugular vein graft. RV = right ventricle.
Conclusions
We have operated on 28 symptomatic neonates and young infants since 1994, with 22 hospital survivors with a biventricular repair. There were no late deaths, and the majority of children followed now are between 4 and 12 years of age. One patient required a re-repair with creation of a hemi-Fontan, and there were two subsequent tricuspid valve replacements. Interestingly, despite the well-known association of Ebstein's anomaly with arrhythmias and accessory pathway tachyarrhythmias such as Wolff–Parkinson–White syndrome (seen in roughly 15% of patients), we have only experienced this once during the perioperative period, and never in the follow-up period. If the development of arrhythmias is a byproduct of later repair, after right ventricular dysfunction and atrial distension have accrued, then that would argue for earlier complete surgical correction. Successful neonatal repair of Ebstein's anomaly is very feasible. The possible need for reintervention for tricuspid valve repair/replacement some time in the future needs to be contrasted with the advantages of a physiologically normal circulation, particularly during the formative years of life. The usefulness of adding a Sebening suture to reinforce the repair cannot be overemphasized. Adding a pulmonary valve replacement in situations where the right ventricle is functionally very small, or the tricuspid valve repair is less than perfect, also needs to be stressed. Finally, the perioperative management of these patients is critical to ensure a good outcome.
References
- Outcome in neonates with Ebstein's anomaly. J Am Coll Cardiol. 1992;19:1041–1046
- Ebstein's anomaly: A functional concept and successful definitive repair. J Thorac Cardiovasc Surg. 1964;48:927–940
- . Ebstein's anomaly of the tricuspid valve with suggestions of a new form of surgical therapy. Dis Chest. 1958;33:297–304
PII: S1522-2942(08)00032-9
doi:10.1053/j.optechstcvs.2008.04.001
Published by Elsevier Inc.
Volume 13, Issue 2 , Pages 101-108, Summer 2008
