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Septal Leaflet Augmentation During the Cone Procedure: Valvar Function and Anatomical Features Compared to Non-Patch Repair
Veenah K. Stoll1, Jose P. Da Silva3, Krithika Sundaram2, Carlos E. Diaz Castrillon1, Mary Schiff4, Mary Taylor4, Floyd Thoma5, Laura Seese3, Mousumi Moulik6, Tarek Alsaied6, Dale Hajovsky6, Mario Castro-Medina3, Victor Morell3, Luciana Da Fonseca Da Silva3
1Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States, 2Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States, 3Department of Pediatric Cardiothoracic Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States, 4Heart and Vascular Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States, 5Heart and Vascular Institute, UPMC, Pittsburgh, Pennsylvania, United States, 6Department of Pediatric Cardiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States
Background: Clinical outcomes after Da Silva Cone procedure with pericardial patch augmentation have been sparingly reported. This analysis from a high-volume center aims to evaluate the early outcomes of autologous pericardial patch use for septal leaflet augmentation compared to non-patch use in the Da Silva Cone repair and provide additional guidance for intraoperative decision making.
Methods: This is a single center retrospective study of 134 consecutive patients who underwent Da Silva Cone procedure for Ebstein's anomaly. Patients with a prior Starnes operation (n=14) or a tricuspid valve (TV) repair at another institution (Da Silva Cone n=6 or other repair n=6) were excluded. The remaining 108 patients were stratified into patch versus non-patch groups that were determined based on the use of septal leaflet pericardial patch augmentation. Demographic factors and pre-operative anatomical characteristics (extreme TV rotation, type of distal leaflet attachment, leaflet tethering, hypoplastic leaflets, and number of valvar orifices) were compared between the groups using Wilcoxon-Mann-Whitney, chi-square, or fisher exact tests. Our key outcome measure was a composite of Da Silva Cone re-repair during the index hospitalization or subsequent late TV-related re-operation. Multivariable regression models were used to estimate the adjusted relationship between the use of patch augmentation and the need for reintervention after Da Silva Cone repair.
Results: The patch augmentation group included 46.3% (n=50) of patients and the non-patch group included 53.7% (n=58). Age distribution was 9.3% infants (n=10), 51.9% (n=56) children, 10.2% (n=11) adolescents, and 28.7% (n=31) adults. Patch group patients were older than non-patch patients (13.1 years vs. 6.9 years, p=0.04), and they were more likely to have multiple TV orifices compared to non-patch patients (85.7% vs 58.6%, p<0.01). Pre- and post-operative TV insufficiency or right ventricular function on echocardiogram were similar between groups (p>0.05). Most patients had trivial or mild TV insufficiency (88.0% patch vs 89.7% non-patch, p>0.05) without significant stenosis observed on postoperative echocardiograms. There was also no difference in the cardiopulmonary bypass times between the groups despite the time required for the additional patch augmentation. Similar rates of late TV-related reoperation were observed between the two groups (3.5% vs 4.0%, p>0.05) at a median follow-up time of 2.6 years (IQR 1.3, 4.4). Notably, 6.9% (n=4) of the non-patch group required early re-repair compared to 0.0% of patch patients, though this finding did not reach statistical significance (p=0.12). Patch patients had 56% lower odds of the composite outcome (OR=0.44, 95% CI: 0.08-2.38, p=0.34) on multivariable analysis. Adjustment for TV rotation, type of anterior leaflet attachments, age at operation, and year of surgery did not contribute to the magnitude of the effect, and there was still no association between patch utilization and the composite outcome (OR=0.57, 95% CI: 0.09-3.86, p=0.56).
Conclusions: Septal leaflet patch augmentation is an important additive technique to the standard Da Silva Cone repair. Multiple orifices in the TV, but not the degree of rotational displacement nor leaflet tethering or hypoplasia, was associated with the need for patch usage. We also noted that surgeons were more liberal with patch use in older patients. Furthermore, patch augmentation resulted in similar TV function as well as rates of early and late TV re-repair. However, the early need for re-repair during the index hospitalization, despite not achieving statistical significance, was appreciably higher in the non-patch group. In conclusion, pericardial patch augmentation of the septal leaflet is an effective and non-inferior complement to the Da Silva Cone repair, with excellent short-term outcomes.
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