Repair of Ebstein's Anomaly: Reply

Abstract

Thank you very much for your very kind comments and interest in my article [1Wu Q. Huang Z. A new procedure for Ebstein's anomaly.Ann Thorac Surg. 2004; 77: 470-476Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar]. I wish to clarify some details in response to your letter. I agree with your description about the anatomy of the septal and posterior leaflets; we see the same in our patients. There is a mistake in my article: “Half of the septal leaflet near to the antero-septal commissure was severely hypoplastic, which made this area without valve tissue. The remainder of the septal leaflet was displaced 1.5 cm from the annulus” should be changed to: “Half of the septal leaflet near the postseptal commissure was severely hypoplastic, which made this area without valve tissue. The remainder of the septal leaflet was displaced 1.5 cm from the annulus.” As you said mobilization of the septal leaflet appears to be an impossible challenge; therefore, we detached the base of the septal leaflet to use that as some chordae tendinea or as part of the leaflet extension. As you know, there is no material better than fresh autologous pericardium. Glutaraldehyde-treated pericardium is too inflexible to preserve function of the rebuilt leaflet. What is more, we have experience that fresh autologous pericardium produced good results in mitral valve repair; therefore we believe that fresh autologous pericardium should be satisfactory for leaflet function in the tricuspid valve, which is under lower stress than the mitral valve. Furthermore, the septal leaflet is not as important as the anterior leaflet. In my article, we did not discuss the hypoplastic anterior leaflet, but we do think the anterior leaflet is the most important part to maintain normal function of the tricuspid valve. For anterior leaflet adhesion, we usually detached the free edge of the adherent leaflet, using the posterior or septal leaflet tissue to form “new chordae tendinea.” We transferred this to the free edge of the anterior leaflet, to rebuild the anterior leaflet, or we freed some parts of the muscle, which connected to the anterior papillary muscle to lengthen the muscle. We suggest that Ebstein's anomaly may be better divided into three pathologic types, which has some advantage in the surgical treatment for the anomaly. Type A (no downward displacement of anterior leaflet with septal and post leaflets anomaly) and type B (less than 1/3 of the anterior leaflet displaced downward, with septal and post leaflets anomaly) are both eligible for the new procedure to avoid the valve replacement. Type C (more than 1/3 of the anterior leaflet displaced downward and is severe hypoplasty, with septal and post leaflets anomaly, and right outflow tract stenosis often can be seen in this type) may need a Glenn procedure, 11/2 ventricle correction, total cave-pulmonary vein connection (TCPC), or heart transplantation. The anterior leaflet situation usually correlates to the size of the atrialized ventricle, the degree of the tricuspid regurgitation, and function of the right ventricle. Thanks again for your interest. I hope my team and I can meet you in the near future to share your experience. Repair of Ebstein's AnomalyThe Annals of Thoracic SurgeryVol. 79Issue 5PreviewI read with great interest the report by Drs Wu and Huang [1] on their procedure for Ebstein's anomaly. The incorporation of the abnormal septal and posterior leaflets in the repair is ingenious and innovative. Full-Text PDF