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Ebstein's Anomaly of the Tricuspid Valve: The Cone Repair

      Ebstein's anomaly is a cardiac malformation affecting the tricuspid valve and right ventricle with a wide range of anatomic and pathophysiologic presentations. The cone repair technique is described in detail, as applied to several types of this complex congenital heart disease. The importance of extensive mobilization of displaced and tethered tricuspid leaflets to permit a good leaflet-to-leaflet coaptation after the cone construction is highlighted. This technique was performed in 100 patients with a hospital mortality rate of 3.0%, good clinical outcome, and no need for tricuspid valve replacement. Echocardiograph results showed good anatomic and functional tricuspid valves at immediate and long-term postoperative follow-up.

      Introduction

      Ebstein's anomaly is an uncommon congenital heart defect involving the tricuspid valve (TV) and the right ventricle (RV). Its main features are downward displacement of the septal and posterior TV leaflets, redundant anterior leaflet with a sail-like format, dilation of the true right atrioventricular annulus, TV regurgitation, and right atrium and RV dilation. Tricuspid regurgitation occurs in Ebstein's anomaly, and is mainly caused by severe restriction of tricuspid leaflet tissue, particularly involving septal and posterior leaflets. There is also annular dilation; the available mobile anterior leaflet tissue is insufficient to cover the orifice during systole. Displacement of the septal and posterior leaflet divides the RV into two chambers: the atrialized RV, which is positioned between the normal atrioventricular junction and the displaced TV, and the functional RV located distal to the TV. The small capacitance of the functional RV also plays an important role in the pathophysiology of Ebstein‘s anomaly.
      The wide variety of anatomic and pathophysiologic presentations of Ebstein's anomaly has made it difficult to achieve uniform results with the surgical repair of this complex congenital heart defect. In 1993, we developed a surgical technique with the main feature of cone reconstruction of the TV.
      • da Silva J.P.
      • Baumgratz J.F.
      • Fonseca L.
      • et al.
      Anomalia de Ebstein Resultados com a reconstrução cônica da valva tricúspide.
      • da Silva J.P.
      • Baumgratz J.F.
      • da Fonseca L.
      • et al.
      The cone reconstruction of the tricuspid valve in Ebstein's anomaly The operation: early and midterm results.
      The concept of this method was to cover 360° of the right AV junction with leaflet tissue, allowing leaflet-to-leaflet coaptation. This mimics the normal TV anatomy and differs from previously applied procedures that result in a monocusp valve coapting with the ventricular septum.
      • Danielson G.K.
      • Driscoll D.J.
      • Mair D.D.
      • et al.
      Operative treatment of Ebstein anomaly.
      • Hetzer R.
      • Nagdyman N.
      • Ewert P.
      • et al.
      A modified repair technique for tricuspid incompetence in Ebstein's anomaly.
      • Carpentier A.
      • Chauvaud S.
      • Macé L.
      • et al.
      A new reconstructive operation for Ebstein's anomaly of the tricuspid valve.
      The surgical goals of this operation are to undo most of the TV anatomic defects that occurred during its embryologic development and to create a cone-like structure from all available leaflet tissue. In this article, we review the surgical maneuvers we have used to obtain the best functional TV in several anatomic variations of Ebstein's anomaly.

      Surgical Technique

      The operation is performed via median sternotomy. Cardiopulmonary bypass is instituted with aortic and bicaval cannulation. Moderate systemic hypothermia (25° to 28°C) and cold antegrade blood cardioplegia (30 mL/kg), followed by subsequent doses (10 to 15 mL/kg) at 20- to 30-minute intervals during the cross-clamp period are used for myocardial protection. The main pulmonary artery can be closed by placement of a snare, with the goal of maintaining a dry RV during the valve repair and to facilitate examination of the TV after repair, when the RV is filled with saline solution via a bulb syringe or catheter placed inside the RV.
      The main steps of the cone operation are:

       Exposure and Assessment of the TV

      This is done by transverse right atriotomy with placement of stay sutures just above the true valve annulus at the 10, 12, and 3 o'clock positions (10 and 12 go through the pericardium to avoid distortion of annular plane). The left heart is vented with a catheter inserted across the patent foramen ovale (PFO) or atrial septal defect (ASD).

       Mobilization of the TV

      The surgical methods to achieve TV mobilization in Ebstein's anomaly are based on the degree of anterior leaflet tethering, septal leaflet size, degree of posterior and septal leaflets delamination failure, and the axis of the tricuspid opening in relationship to the right ventricle outflow tract (RVOT) and to the RV apex. Mobilization of the TV (Fig. 1) is performed by complete sectioning of the abnormal tissues between the tricuspid leaflets and ventricular wall, leaving the leaflet tissues attached to the ventricle only at its distal margin (by normal papillary muscle, cords, or directly to muscle). In general, the majority of leaflet tissue is detached circumferentially, except at the 10-to-12 o'clock positions. This part should be attached to the true annulus, with no tethering to the ventricular wall to allow free movement. The aggressive detachment of the leaflet down to its distal point is a critical part of the procedure because it produces an adequate amount of tissue for construction of the cone and gives sufficient mobility of the leaflet body in the constructed cone, allowing it to move sufficiently during systole and to close with a good coaptation surface.
      Figure thumbnail gr1
      Figure 1Preoperative magnetic resonance image of a 19-year-old woman with severe Ebstein's anomaly. The arrows point at abnormal papillary muscles and endocardial bands tethering the anterior leaflet of the TV to the anterior wall of the RV (A). The dotted line in B shows the aimed systolic position for the anterior leaflet after its extensive mobilization.
      The anterior and posterior leaflets of the TV are mobilized as a single piece (Fig. 2) . This starts with an incision at its proximal attachment to the atrioventricular junction (12 o'clock position) and moves clockwise, toward the displaced posterior leaflet. The incision terminates when the posterior leaflet is completely released from its abnormal proximal attachment to the RV wall. This gives access to the space between these leaflets and the RV wall, allowing sectioning of all abnormal papillary muscle, myocardial bridges, and cordal tissues that tether these leaflets to the RV wall, restricting its movement. The posterior papillary muscle, usually positioned at the anteroposterior commissure, must be freed from its more proximal attachment to the RV wall, keeping only its supports near the RV apex. In some cases, it is necessary to completely release the posterior leaflet from its abnormal attachments to the RV, taking only its membranous portion, to permit its medial rotation to join the septal leaflet for the composition of the septal aspect of the cone.
      Figure thumbnail gr2
      Figure 2Anterior and posterior leaflets of the TV mobilized as a single piece. A, Anterior and posterior leaflets anatomy (dotted line shows the displaced and the dashed line shows the true tricuspid annulus). B, Anterior leaflet mobilization. C, Section of posterior leaflet proximal connection to RV wall. D, The completely mobilized anterior and posterior leaflets.
      The TV anteroseptal commissure is approached with the goal of creating a future space between the ventricular septum and the septal aspect of the cone, and to move the opening axis of the TV toward the RV apex. An incision is made at the proximal attachment line of anterior leaflet, approximately 1 cm anterior to the anteroseptal commissure, and continued counterclockwise down to the septal leaflet, which is mobilized to its lateral limit (Fig. 3) . Stay sutures are placed at the proximal edge of the leaflet, providing good exposure to the subvalvar apparatus of the septal aspect of the anterior leaflet, septal leaflet, and the anteroseptal commissure. The tissues that are holding the proximal portion of these leaflets to the septum are divided. In cases that present with the TV opening toward the RVOT, it is necessary to mobilize or cut the papillary muscle abnormally attached at the RVOT. In some cases, the medial papillary muscle, which is usually related to the anterior and septal leaflet at its commissure, is fused to the septum and can be mobilized deeply, giving improved mobility to that area of the future cone.
      Figure thumbnail gr3
      Figure 3Anteroseptal commissure mobilization. A, An incision is made at the proximal attachment line of anterior leaflet continues anticlockwise (B), mobilizes the medial papillary muscle (C), and reaches the septal leaflet (D), which is mobilized as deep as possible.

       Cone Construction

      The cone is constructed by using all the available tissue that has been mobilized. Basically, it is accomplished by two vertical suturing of leaflets: posterior to septal and septal to anterior. A 5-0 polypropylene running suture technique is used for adults and a 6-0 polypropylene interrupted suture technique is applied in children. Typically, the cone tends to be narrower posteriorly, where the leaflet tissue is more deficient; this area must be made wider by vertical plication of the leaflet tissue in the constructed cone. In some cases, it is necessary to place some interrupted sutures at the anteroposterior commissure (proximal circumference) to widen that portion of the cone.
      The septal leaflet is incorporated to the cone in such a way that the range length of the septal part of the cone is longer than the septal vertical distance between the final TV hinge line to its distal attachment to the ventricular septum. This is important to allow the septal component of the cone to move anteriorly in the coaptation process with the anterior component of the cone during systole. Also, this will prevent tension at the suture line at the septal aspect of the annular attachment of the cone.
      The principal methods for the septal leaflet incorporation to the cone are as follows:
      • 1
        Placing a vertical suture joining the septal leaflet superior edge to the septal edge of the anterior leaflet, followed by a second suture line uniting the septal leaflet inferior edge to the lateral edge of the posterior leaflet (Fig. 4A-C) . This approach is used for septal leaflet that are large after they have been mobilized.
        Figure thumbnail gr4
        Figure 4Septal leaflet Incorporation: A, A vertical suture joins the septal leaflet superior edge to the medial edge of the anterior leaflet. B and C, A second suture line unites the septal leaflet inferior edge to the lateral edge of the posterior leaflet. In cases with small septal leaflet it is combined with the completely detached posterior leaflet by a vertical suture (D), followed by a horizontal suture (E). V, vertical suture; H, horizontal suture.
      • 2
        Combining the septal leaflet with the completely detached posterior leaflet. These leaflet plication and combining maneuvers will increase the depth of the cone and reduce its proximal circumference (Fig. 4D and E).

       Plication of the RV and the True Tricuspid Annulus

      This begins with the vertical plication of the thin and attenuated RV free wall. This usually aneurysmal portion of the atrialized component is defined by the area of attachment of the posterior leaflet as it enters the RV cavity and the septum. The RV plication starts by placement of a 4-0 polypropylene stitch at the distal part of this triangular shaped area, with the apex situated at the distal atrialized ventricle and the base at the true annulus (proximally). The vertical plication is performed using 4/0 polypropylene in two layers, with gentle superficial bites to avoid coronary injury or distortion. This creates a corresponding reduction above the true annulus in the true atrium that is closed either separately or with continuation of the suture line. If the tricuspid annulus requires additional reduction, this is performed at multiple sites: first at the anteroseptal and then at the anteroposterior position of the true tricuspid annulus. These multiple plications decrease the chance of right coronary artery distortion or kinking.

       Cone Attachment to True Tricuspid Annulus

      The cone is attached proximally to the true annulus over 360° and with no tension in either the horizontal or vertical plane (Figure 5, Figure 6) .
      Figure thumbnail gr5
      Figure 5Cone attachment to true tricuspid annulus. The constructed cone (A) is reattached to the true tricuspid annulus starting at the anterior position (B) and completing the attachment (C), taking superficial bites when suturing near the atrioventricular node area (arrow).
      Figure thumbnail gr6
      Figure 6Cone construction done by rotation of the posterior leaflet, which was combined with the septal leaflet (A), before attachment to the true tricuspid annulus (B). AL, anterior leaflet; PL, posterior leaflet; SL, septal leaflet.
      Judgment is required so that the proximal cone circumference is correct for the true annular dimension. The true annulus can be further reduced by separate plication at 2-3 o'clock and 9 o'clock. The cone proximal circumference can be reduced by leaflet plication. The initial attachment and assessment is carried out with the placement of 5/0 propylene single sutures to obtain an even distribution of the valve in the tricuspid annulus. Then, the suture line is completed with a running suture. Special care should be taken when suturing the area of the annulus, just medial to the coronary sinus, because of the risk of heart block. The use of a prosthetic ring may be considered for reinforcement in patients with a fragile adult size annulus.

       ASD Treatment

      The ASD/PFO are closed in a valved fashion, in a way that allows blood shunting from right to left in case of postoperative RV failure. The opening size of the resulting orifice should be proportional to the degree of RV dysfunction or enlargement. This can be accomplished with the single-stitch technique in cases of PFO or using a polytetrafluoroethylene (PTFE) patch with an extension flap positioned inside the left atrium to allow unidirectional blood flow towards the left atrium. In cases of severe RV dysfunction, the single-stitch technique represented in Figure 6 can be performed with placement near the PFO anterior corner. This will result in a less restrictive PFO. The bidirectional Glenn procedure as an adjunct to Ebstein's anomaly repair is recommended in dysfunctional RV by some authors.
      • da Silva J.P.
      • da Fonseca L.
      • Moreira L.F.P.
      • et al.
      Cone reconstruction in Ebstein's anomaly repair: early and long-term results.
      • Dearani J.
      • Bacha E.
      • da Silva J.P.
      Cone reconstruction of the tricuspid valve for Ebstein‘s anomaly: anatomic repair.
      • Dearani J.A.
      • O'Leary P.W.
      • Danielson G.K.
      Surgical treatment of Ebstein malformation: state of the art in 2006.
      We have considered its application in some patients, but it has not been applied in this case series.

       Special Anatomic Types of Ebstein's Anomaly

      In some anatomic situations, the three leaflets are connected at the commissures and the distal attachment of the TV to the RV is well formed. In these cases, after mobilization from their displaced hinge line and release of its abnormal connections to the RV wall, some plications are made at its distal and proximal edges, reducing its proximal and distal circumferences and widening the septal and posterior leaflets to give a cone shape to the TV.
      Patients presenting with Carpentier's type D anatomy of Ebstein's anomaly can also be treated with the cone technique. Figure 7 depicts one of the four patients successfully repaired by taking down the leaflets as a single piece, keeping only the distal direct attachment of the leaflet to the RV. Vertical fenestrations were provided at the distal third of this large leaflet. Then, the lateral and medial edges of this leaflet were sutured together resulting in a cone-like structure.
      Figure thumbnail gr7
      Figure 7Preoperative magnetic resonance images and intraoperative photos depicts the heart's anatomy of a 4-year-old girl with type D Ebstein's anomaly (Carpentier's classification). Images A, B, and C show that the TV leaflets are tethered to the RV wall and image D shows that there is only a small hole (H) communicating the atrialized to the functional RV.
      As in all other cases, the cone was revised and any holes/fenestrations in the proximal two thirds of the cone's membranous tissues are closed to have similar depth circumferentially and to prevent regurgitation leaks. Also, fenestrations should be present, natural or surgically created, at the distal one third of the cone to allow unrestricted forward blood flow in diastole.
      From November 1993 to April 2011, 100 consecutive patients with Ebstein's anomaly with a mean age of 17.5 ± 13.6 years (median, 13.5 years) underwent the cone repair in our department at the Beneficencia Portuguesa Hospital in Sao Paulo, Brazil. They had the following associated anomalies: ASD or PFO in 89 patients, accessory conduction pathway (WPW) in 15, VSD in 1, pulmonary stenosis in 3, pulmonary atresia in 3, and partial anomalous pulmonary venous return in 1 patient.

      Results

      Three hospital deaths occurred (3.0%), all due to low cardiac output secondary to RV dysfunction (2 patients) or biventricular dysfunction (1 patient). Four patients (4.0%) died during long-term follow-up, owing to endocarditis, heart failure and arrhythmia, sudden death, and swimming pool accident. There were four re-repairs (4.0%) because of recurrence of tricuspid regurgitation. No patient required TV replacement. Echocardiograms from a follow-up study conducted in our initial 52 consecutives patients showed that the degree of TV regurgitation had significantly improved on early studies; this improvement was maintained at long-term follow-up studies (Fig. 8) . TV stenosis was observed in only one patient during long-term follow-up, which was mild on echocardiogram and had no clinical consequences.
      Figure thumbnail gr8
      Figure 8Tricuspid regurgitation degree: comparison of echocardiographic data in patients subjected to the cone repair of Ebstein's anomaly. It was shown significant improvement in tricuspid regurgitation when comparing early PO with preoperative data and no difference comparing early PO with late PO. Mean ± confidence interval of 95%. Preop, preoperative; PO, postoperative.

      Discussion

      Usually, the mechanism of tricuspid insufficiency in Ebstein's anomaly is related to restrictive leaflet movements. This is because of failure of leaflet delamination, which results in more distal attachment of their hinge line to the RV, and to the presence of muscular bridges and abnormal papillary muscles that tether the TV leaflets to the RV wall, restricting their movements. To create a competent TV using the cone technique, it is very important to perform extensive mobilization of the displaced or tethered leaflets. Otherwise, repair will result in failure of leaflet coaptation or excessive tension in the leaflet suture line cause by pulling of the leaflet that was kept improperly attached to the free RV wall, which will undergo strong tension when the RV is filled. We consider these concepts essential tools to minimize the incidence of tricuspid insufficiency after the cone procedure and, also, to prevent postoperative dehiscence of the suture line because of diastolic tension. The incorporation septal leaflet construction of the septal aspect of the cone, which is frequently made by its combination with the posterior leaflet, is a very important component of the cone technique. It helps prevent both stenosis and insufficiency of the TV.
      TV functions after the cone procedure were quite good at the time of hospital discharge
      • da Silva J.P.
      • Baumgratz J.F.
      • Fonseca L.
      • et al.
      Anomalia de Ebstein Resultados com a reconstrução cônica da valva tricúspide.
      • da Silva J.P.
      • Baumgratz J.F.
      • da Fonseca L.
      • et al.
      The cone reconstruction of the tricuspid valve in Ebstein's anomaly The operation: early and midterm results.
      and also at long-term follow-up.
      • da Silva J.P.
      • da Fonseca L.
      • Moreira L.F.P.
      • et al.
      Cone reconstruction in Ebstein's anomaly repair: early and long-term results.
      This technique could be performed with low hospital mortality, few surgical reinterventions, and good long-term outcome. Also, there was no need for TV replacement in this series of patients.
      Because the cone technique gives a more anatomic design to the TV as compared with previous techniques, it has been adopted in renowned heart centers as the method of choice for the repair of Ebstein's anomaly.
      • Dearani J.
      • Bacha E.
      • da Silva J.P.
      Cone reconstruction of the tricuspid valve for Ebstein‘s anomaly: anatomic repair.
      Although successful, some issues related to the cone technique are still pending, which will be discussed based on general concepts, our observations, and the scarce published reports available.

       Annuloplasty Ring or Suture Reinforcement of the TV Annulus

      It is a fallacy to think that it is unnecessary to reinforce the new tricuspid annulus after the cone repair because patients with Ebstein's anomaly tend to have low pulmonary pressure. We observed a few adult patients with postoperative systolic pulmonary pressures between 40 and 50 mm/Hg. Also, it is possible that pulmonary pressure can increase temporarily in the presence of pulmonary complications. During our initial experience with the cone technique, some of our patients required reoperation related to postoperative tricuspid regurgitation because of suture dehiscence at the septal and posterior regions of the cone attachment to the new tricuspid annulus. These observations suggest that the new tricuspid annulus should be reinforced, either by extra interrupted sutures or by an annuloplasty ring for the adult tricuspid annulus. The latter reinforcement method has been advised by the Children's Hospital of Boston group at a lecture presentation of non-published data (Pedro del Nido - EACTS 2010 Géneve).

       Resection Versus Plication of the Dilated Atrialized RV

      We adopted the vertical plication described by Carpentier et al,
      • Carpentier A.
      • Chauvaud S.
      • Macé L.
      • et al.
      A new reconstructive operation for Ebstein's anomaly of the tricuspid valve.
      which consist of the thin atrialized RV exclusion by endocardial plicature. There are two concerns about this technique: 1) it can kink the right coronary artery trunk or damage its branches, and 2) because this technique does not electrically isolate the excluded area, it can maintain re-entrant circuits that may be the source of serious postoperative ventricular arrhythmias. This area would be difficult to reach with endocardial ablation catheter in the future. We have addressed these two issues by making a less extensive plication near the atrioventricular junction to cause less folding of the right coronary artery, therefore causing less coronary kinking. Regarding ventricular arrhythmias, we have isolated the area to be plicated by transmural cryoablation prior to plication in patients with preoperative ventricular arrhythmia. Some surgeons use surgical resection of the atrialized RV area, when the RV is massively dilated.
      • Dearani J.A.
      • O'Leary P.W.
      • Danielson G.K.
      Surgical treatment of Ebstein malformation: state of the art in 2006.

       Bidirectional Glenn Procedure in RV Dysfunction

      Early after the cone procedure, some RV dysfunction is expected. This occurs because of damage of the RV wall related to surgical maneuvers and to the myocardial injury caused by the extended ischemic time necessary to perform this somewhat complex operation, superimposed to variable degrees of RV impairment as part of the Ebstein's malformation. Bearing in mind that many patients may present temporary postoperative RV dysfunction, we have routinely used a valved ASD that allows blood flow from the right to the left atrium aiming to reduce RV preload and increase LV preload, therefore helping to prevent low cardiac output in the early postoperative period caused by severe RV dysfunction. The ASD stays functionally closed from the beginning of the postoperative course in the majority of patients, but in approximately 10% of cases there was important right-to-left blood shunting causing a moderate drop in oxygen saturation. Usually, oxygen saturation increases in a few days as RV function improves. Additionally, the resulting RV decompression may prevent (avoid) excessive tension at the TV, decreasing the risk of suture dehiscence and TV regurgitation.
      Some authors have addressed the problems related to postoperative RV dysfunction by diverting the superior caval blood flow to the right pulmonary artery. This bidirectional cavopulmonary shunt (BCPS), also called the Glenn procedure, was reported by Chauvaud et al,
      • Chauvaud S.
      • Fuzellier J.F.
      • Berrebi A.
      • et al.
      Bi-directional cavopulmonary shunt associated with ventriculo and valvuloplasty in Ebstein's anomaly: benefits in high risk patients.
      who used it in 36% of patients with Ebstein's anomaly as an adjunctive procedure to Carpentier's operation in patients with severe right ventricular dysfunction. According to their report, improved results were seen with this procedure. These authors and others
      • Chauvaud S.
      • Fuzellier J.F.
      • Berrebi A.
      • et al.
      Bi-directional cavopulmonary shunt associated with ventriculo and valvuloplasty in Ebstein's anomaly: benefits in high risk patients.
      • Malhotra S.P.
      • Petrossian E.
      • Reddy V.M.
      • et al.
      Selective right ventricular unloading and novel technical concepts in Ebstein's anomaly.
      used this technique to reduce RV preload in cases of severe RV dysfunction, thus obtaining a significant reduction in mortality caused by RV failure. The BCPS was also described by Quinonez et al,
      • Quinonez L.G.
      • Dearani J.A.
      • Puga F.J.
      • et al.
      Results of the 1.5-ventricle repair for Ebstein anomaly and the failing right ventricle.
      reporting on 14 patients from the Mayo Clinic who underwent surgical treatment of Ebstein's anomaly (TV replacement in 13 and TV repair in 1) having the creation of a BCPS as an adjunctive procedure. This approach was conducted mostly as a planned procedure in anticipation of RV failure, but was also done as a salvage procedure owing to postoperative hemodynamic instability. Considering the serious clinical situation of the patients, they had excellent result with only one death, outlining the relevance of this procedure for a subset of patient.
      Recently, Liu and coworkers
      • Liu J.
      • Qiu L.
      • Zhu Z.
      • et al.
      Cone reconstruction of the tricuspid valve in Ebstein anomaly with or without one and a half ventricle repair.
      reported the performance of the BCPS procedure in addition to the cone operation. The fact that they applied this method to a high proportion of patients (20 of 30) raised our attention. However, their series of young patients had good clinical outcome at mid-term follow-up.
      We think that it is important to use one of these two methods after the cone operation to prevent low postoperative cardiac output and also to protect the dysfunctional RV from distension. We prefer to use the valved closure of ASD routinely, despite initial cyanosis in some patients and the possibility of paradoxical thromboembolism, because the RV dysfunction is completely or partially reversible with time; consequently, oxygen saturation progressively improves.
      • da Silva J.P.
      • da Fonseca L.
      • Moreira L.F.P.
      • et al.
      Cone reconstruction in Ebstein's anomaly repair: early and long-term results.
      In case of low oxygen saturation (<75%) we would add a BCPS for older patients or a small (3.0 mm) modified Blalock-Tausig shunt for neonates. We tend to anticoagulate patients with a dilated RV and/or with right-to-left atrial shunting. Despite the BCPS advantage of providing better oxygenation, we do not use it routinely because it may be associated with pulsations of the head and neck veins and other complications.
      • Kopf G.S.
      • Laks H.
      • Stansel H.C.
      • et al.
      Thirty-year follow-up of superior vena cava–pulmonary artery (Glenn) shunts.

      Conclusions

      The cone procedure for reconstruction of the TV in Ebstein's malformation results in a full coaptation of the leaflets. It can be performed with low mortality and morbidity. The tricuspid regurgitation repair is efficacious and durable for the majority of patients.

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