title: Strategies for tricuspid re-repair in Ebstein malformation using the cone technique.
abstract: BACKGROUND
  Successful tricuspid repair for Ebstein malformation (EM) is challenging. Cone repair has recently emerged as the most anatomic repair technique. There are no data on tricuspid re-repair in EM. We reviewed our experience with tricuspid valve (TV) re-repair using a cone technique.
  
  
  METHODS
  Between June 2007 and October 2012, 134 patients underwent cone repair. Prior TV repair was performed in 20 patients (10 female, 50%). Median age was 15 years (range, 4 to 68 years). Four patients (20%) had prior bidirectional cavopulmonary anastomosis (BDCPA). Preoperative heart failure was present in 8 patients (40%). Recurrent tricuspid regurgitation (TR) was due to incomplete leaflet coaptation with tethered anterior leaflet in all patients; and 10 patients (50%) had diminutive septal leaflet. Prior repair techniques consisted of annuloplasty maneuvers in all patients with no or incomplete surgical delamination in all patients.
  
  
  RESULTS
  The TV re-repair using cone technique was possible in all patients. Plication of atrialized right ventricle was done in 6 patients (30%). Modifications included annuloplasty band in 16 patients (80%) and TV leaflet augmentation in 8 (40%). The BDCPA was performed in 3 patients (15%) and modified Cox-maze procedure was done in 10 (50%). There were no mortalities or reoperations. Mean follow-up was 7.7 ± 10.7 months; during follow-up, 18 patients had no or mild TR and 2 had moderate TR.
  
  
  CONCLUSIONS
  TV re-repair in EM using the cone technique is feasible, particularly when there has been no surgical leaflet delamination at initial operation. Leaflet augmentation facilitates and annuloplasty band stabilizes a competent TV re-repair. Longer follow-up is required to assess durability.
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA. dearani.joseph@mayo.edu
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Dearani
authors.forename: Sameh M
authors.initials: SM
authors.lastname: Said
authors.forename: Harold M
authors.initials: HM
authors.lastname: Burkhart
authors.forename: Roxann B
authors.initials: RB
authors.lastname: Pike
authors.forename: Patrick W
authors.initials: PW
authors.lastname: O'Leary
authors.forename: Frank
authors.initials: F
authors.lastname: Cetta
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D002675:Child, Preschool; D004437:Ebstein Anomaly / Q000601:surgery*; D005240:Feasibility Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D012086:Reoperation / Q000379:methods; D015203:Reproducibility of Results; D012189:Retrospective Studies; D016896:Treatment Outcome; D014261:Tricuspid Valve / Q000601:surgery*; D055815:Young Adult