1Division of Thoracic and Cardiovascular
Surgery, Department of Surgery, University of Virginia, Charlottesville,
VA
Disclosures: The authors have nothing to disclose
Word Count: 453
Data Availability Statement: This invited commentary does not include
any original data.
Funding Statement: This work was supported by a research grant from
NHLBI/NIH (T32HL007849). The content is solely the responsibility of the
authors and does not represent the official views of the National
Institutes of Health.
Conflict of Interest: none
IRB approval and informed consent: N/A
Corresponding Author:
Irving L. Kron, MD
Division of Thoracic and Cardiovascular Surgery
Department of Surgery
1215 Lee St., PO Box 800679
Charlottesville, VA 22908
Email: ILK@virginia.edu
Running Head:
Adverse event prediction for Ebstein’s anomaly.
Abstract:
Prediction scores and metrics are being increasingly utilized throughout
the fields of cardiothoracic and congenital cardiac surgery to identify
areas for perioperative optimization or guide therapeutic intent. Here,
we review a novel submission by Yang and colleagues to the Journal
of Cardiac Surgery identifying preoperative factors which predict
adverse postoperative outcomes from cone reconstruction for Ebstein’s
anomaly.
Commentary:
Ebstein’s anomaly (EA) is a rare congenital heart disease characterized
by apical displacement of the tricuspid valve (TV) with atrialization of
the right ventricle (RV). Right-to-left shunting and cyanosis may occur
in the presence of an atrial communication. Cone reconstruction is a
widely accepted technique that demonstrates favorable postoperative
outcomes including: improved RV synchronization, exercise capacity, New
York Heart Association (NYHA) functional class and degree of
regurgitation1-3. Efforts to predict perioperative
complications and prognosis are becoming increasingly important as
healthcare resources are further constrained4. Yang
and colleagues are to be commended on well-written manuscript evaluating
the utility of preoperative percutaneous oxygen saturation as a
predictive outcome following cone reconstruction of Ebstein’s
anomaly5.
In their single-institution, retrospective analysis of patients from
2010 to 2016, Yang et al. identified percutaneous oxygen saturation and
Great Ormond Street (GOS) scores as independent risk factors for adverse
events after cone reconstruction for EA based on multivariate logistic
regression analysis. When plotted on ROC curves, oxygen saturation and
GOS score rival other major scoring systems, however it would be
worthwhile to know how this cohort’s group STS-EACTS or STS morbidity
score correlated to these findings4.
It is of particular interest to note the number of patients with
evidence of atrial communication the adverse event group (12/13,
92.3%), even though this metric failed to reach statistical
significance on univariate analysis (p= 0.053). The authors acknowledge
the limitation in classifying the degree of inter-atrial communication.
Quantification of any shunting may further justify the impact of
systemic oxygen saturation by demonstrating the impact of more complex
lesions.
Postoperative tricuspid regurgitation (TR) significantly improves after
cone reconstruction, however RV function typically does not improve
until much later6-8. Patients in the reported cohort
who did poorly mostly had severe TR preoperatively, although this was
not significant which may be related to a small sample
size5. While all patients underwent preoperative
echocardiography, the investigators do not comment on postoperative
echocardiography data. Incorporation of postoperative echocardiography
results and if available, perioperative right heart pressure data, would
add clarification to the importance of their findings.
This article aims to identify reliable, reproducible and easily
obtainable metrics for predicting postoperative outcomes for patients
with Ebstein’s anomaly undergoing treatment with cone reconstruction. We
agree with the authors that such metrics are valuable for surgeons,
intensivists and the entire pediatric intensive care team. Preoperative
predictors can prepare teams for potential postoperative adverse events
and help guide patients’ families’ expectations during recovery.
However, it is important to temper the expectations of the predictive
ability of simple tests in the construct of complex congenital cardiac
lesions. Ultimately, this work is an important contribution as we
collectively aim to improve patient outcomes by preparing for adverse
events armed with readily available preoperative data.
References:
1. Li X, Wang SM, Schreiber C, et al. More than valve repair: Effect of
cone reconstruction on right ventricular geometry and function in
patients with Ebstein anomaly. Int J Cardiol. 2016;206:131-137.
2. Ibrahim M, Tsang VT, Caruana M, et al. Cone reconstruction for
Ebstein’s anomaly: Patient outcomes, biventricular function, and
cardiopulmonary exercise capacity. J Thorac Cardiovasc Surg.2015;149(4):1144-1150.
3. Burri M, Mrad Agua K, Cleuziou J, et al. Cone versus conventional
repair for Ebstein’s anomaly. J Thorac Cardiovasc Surg.2020;160(6):1545-1553.
4. Zeng X, An J, Lin R, et al. Prediction of complications after
paediatric cardiac surgery. European journal of cardio-thoracic
surgery : official journal of the European Association for
Cardio-thoracic Surgery. 2020;57(2):350-358.
5. Yang Y, Zhang W, Y L, et al. Preoperative Percutaneous Oxygen
Saturation is a Predictor of Postoperative Adverse Events After
Ebstein’s Anomaly Reconstruction. Journal of Cardiac Surgery.2020.
6. Lianza AC, Rodrigues ACT, Mercer-Rosa L, et al. Right Ventricular
Systolic Function After the Cone Procedure for Ebstein’s Anomaly:
Comparison Between Echocardiography and Cardiac Magnetic Resonance.Pediatr Cardiol. 2020;41(5):985-995.
7. Perdreau E, Tsang V, Hughes ML, et al. Change in biventricular
function after cone reconstruction of Ebstein’s anomaly: an
echocardiographic study. Eur Heart J Cardiovasc Imaging.2018;19(7):808-815.
8. Holst KA, Dearani JA, Said S, et al. Improving Results of Surgery for
Ebstein Anomaly: Where Are We After 235 Cone Repairs? Ann Thorac
Surg. 2018;105(1):160-168.
Figure:
Legend: Evan P. Rotar, MD, MS (left), and Irving L. Kron, MD (right)