Modified Starnes Procedure With Patch Occlusion of the Main Pulmonary Artery and Other Technical Modifications to Facilitate Subsequent Biventricular Repair of Ebstein Anomaly

Abstract

The Starnes procedure, introduced in 1991, has been a valuable advancement in the surgical treatment of critically ill neonates with Ebstein's anomaly (EA). However, it used to be followed by the single ventricle pathway, which presents long-term outcome limitations. In 2019, this management concept was modified by taking down the Starnes procedure and performing the Cone repair of the tricuspid valve, which resulted in a biventricular reconstruction. This approach rehabilitates the right ventricle, likely improving the patients' long-term outcomes. However, it requires modifications in the classical Starnes operation and observing certain surgical details. In cases of circular shunting, we use a patch to occlude the pulmonary artery instead of dividing and oversewing it, simplifying the succeeding pulmonary artery reconstruction. We use a PTFE fenestrated patch placed in a supra-valvar position, preserving the underneath tricuspid valve integrity, facilitating the tricuspid valve repair, and decreasing the possibility of heart block.Central message: In the current era of biventricular repair after the Starnes procedure, using a non-stick supravalvar patch to exclude the tricuspid valve and preserving the pulmonary valve structure by patch occlusion of the main pulmonary artery instead of division and oversewing it are valuable modifications of the classic Starnes operation to optimize a future biventricular repair.