ObjectiveEbstein's anomaly remains a relatively ignored disease. Lying in the 'No Man's land' between congenital and valve surgeons, it largely remains inadequately studied. We report our short-term results of treating it as a 'one and a half ventricle heart' and propose that the true tricuspid annulus (TTA) 'Z' score be used as an objective criterion for estimation of 'functional' right ventricle (RV).Methods22 consecutive patients undergoing surgery for Ebstein's anomaly were studied. Echocardiography was performed to assess the type and severity of the disease, tricuspid annular dimension and its 'Z' score. Patients were operated by a modification of the cone repair, with addition of annuloplasty, bidirectional cavopulmonary shunt (BCPS) and right reduction atrioplasty to provide a comprehensive repair. TTA 'Z' score was correlated later with postplication indexed residual RV volume.ResultsThere was one (4.5%) early and no late postoperative death. There was a significant reduction in tricuspid regurgitation grading (3.40±0.65 to 1.22±0.42, P<0.001). Residual RV volume reduced to 71.96±3.8% of the expected volume and there was a significant negative correlation (rho −0.83) between TTA 'Z' score and indexed residual RV volume. During the follow-up of 20.54±7.62 months, the functional class improved from 2.59±0.7 to 1.34±0.52 (P<0.001).ConclusionIn Ebstein's anomaly, a higher TTA 'Z' score correlates with a lower postplication indexed residual RV volume. Hence, a complete trileaflet repair with offloading of RV by BCPS (when the TTA 'Z' score is >2) is recommended. The short-term outcomes of our technique are promising.

Objective: Most of the rheumatic mitral valve repair literature focuses on older patients with burnt out disease. We present our midterm results of rheumatic mitral valve repair in young patients. Methods:In this retrospective-prospective study, 106 consecutive children (<18 years) underwent mitral valve repair for rheumatic etiology (2013)(2014)(2015)(2016)(2017).Patients were evaluated at regular intervals.Results: The mean age of the cohort was 13.1 AE 3.2 years; 30 (29.6%) patients had recent rheumatic activity (<8 weeks); 80 (78.4%) had mitral regurgitation; 8 (7.8%) had mitral stenosis; 14 (13.7%) had mixed lesions; 11 underwent emergency surgery for intractable heart failure; and 34 (33.3%) patients underwent autologous pericardial augmentation. All patients underwent annuloplasty (ring, band, or other); 40 (39.2%) required chordal procedures. Operative mortality was 1%. Mean follow-up was 25.6 AE 9.5 months and was 100% complete. At last follow-up, mean mitral regurgitation grade was 1.2 AE 0.3, mean mitral valve gradient was 2.96 AE 0.18, and 94.8% of patients were in New York Heart Association class I. Four patients developed recurrent rheumatic carditis (resulting in severe mitral regurgitation), but there were no thromboembolic or hemorrhagic events. Actuarial survival and freedom from reoperation at 2.5 years were 96.2% (number at risk, 38), and 97.1% (number at risk, 38), respectively.Conclusions: Rheumatic valves in children are eminently repairable. The surgeon who ventures to repair a rheumatic mitral valve should consider all lesions of the various components of the mitral valvular apparatus and must have numerous techniques in the armamentarium to effect a successful repair.

ObjectiveTo compare the early and late outcomes of off-pump coronary artery bypass grafting and coronary artery bypass graft + mitral valve repair in elderly patients with moderate chronic ischemic mitral regurgitation.MethodsOne hundred and fifty elderly (age > 70 years) patients with moderate chronic ischemic mitral regurgitation who underwent off-pump coronary artery bypass grafting (n=95) or coronary artery bypass graft + mitral valve repair (n=55) between January 2007 and December 2014 were studied. They were subdivided according to presence or absence of high operative risk. Peri-operative variables and early operative outcomes were retrospectively studied. Survival, mitral regurgitation grade, and functional outcomes were prospectively analysed.ResultsBoth groups were comparable in terms of age (P=0.23), sex (P=0.74), left ventricle ejection fraction (P=0.6) and preoperative functional class (P=0.52). The mean number of grafts for off-pump coronary artery bypass grafting group was 3.14 and coronary artery bypass graft + mitral valve repair was 3.21. Off-pump coronary artery bypass grafting group had statistically significant better early operative outcomes i.e perioperative blood transfusions, intraaortic balloon pump usage, arrhythmias, renal dysfunction, liver dysfunction, sepsis, mean hours of ventilation, intensive care unit stay and operative mortality. On a prospective follow up of 5±2.33 years (1-9 years), coronary artery bypass graft + mitral valve repair in low operative risk subgroup had better improvements in mitral regurgitation grade than off-pump coronary artery bypass grafting. Both groups had similar improvements in functional class and cumulative survival was also comparable (63.2% vs. 54.5%).ConclusionOff-pump coronary artery bypass grafting is a safer alternative to coronary artery bypass graft + mitral valve repair with better early operative outcomes and comparable late survival and functional outcomes in elderly patients with moderate chronic ischemic mitral regurgitation, especially those with higher operative risk.

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