Valve preserving treatment of Ebstein's Anomaly: Perioperative and Follow-up Results

We have read with interest the recent article on treatment of Ebstein's anomaly. The study involved 10 patients, describing in detail surgical procedures, both pre- and postoperative assessment of tricuspid valve function, and overall improvement of the clinical conditions. Nevertheless, we believe this study to be inconsequential due to its sparse patient collective and neglect of existing literature.

Undoubtedly, the Ebstein anomaly offers a wide morphological spectrum. The authors state that tricuspid insufficiency develops due to a lack of coaptation of the tricuspid leaflets. Wheras a certain tricuspid insufficiency is one of the main features of Ebstein's, it is in our view rather the underlying, often varying, morphology of the valve apparatus and a possible dilatation of the right ventricle in time, which influences the clinical state and prognosis (C. Schreiber et al., J Thorac Cardiovasc Surg 1999; 117: 148 - 155). The authors state that indications for operation include development of symptoms with NYHA III. We would like to amplify these findings. Our experience over more than 20 years, and our analysis of postoperative deaths in a patient collective of up to 84 patients at present, clearly showed that surgical intervention is indicated even in patients in functional class II who reveal clinical deterioration, present with arrythmia, a cardiothoracic ratio above 0.65, or progressive cyanosis (N. Augustin et al., Ann Thorac Surg 1997; 63: 1650 - 6). Morphological and clinical findings do not neccessarily support exclusively the techniques advocated by Carpentier et al. (J Thorac Cardiovasc Surg 1988;96:92-101) or Chauvaud et al. (Cardiol Young 1996; 6: 4 - 11), in which the cavity of the right ventricle is restored by transferring the valvar plane and plicating the atrialized ventricle. In contrast, the “single-stitch technique”, which has been successfully applied at our institution since 20 years and was described by Schmidt-Habelmann et al. in 1981 (Thorac Cardiovasc Surg 1981; 29: 155 - 7), implies the creation of a monocusp valve only. This approach yields excellent long-term results with substantial improvement in functional performance and clinical status. Likewise, we emphasize the importance of echocardiographic assessment, both prior to surgery for evaluation of the individual approach, and in the postoperative period for quantification of valve and cardiac function, which has long been a well recognized diagnostic tool in our center.