Modified Starnes procedure as a bridge to 2-ventricle repair in neonatal Ebstein’s anomaly: A paradigm shift

Severe tricuspid valve regurgitation secondary to Ebstein’s anomaly represents several challenges in neonates. It can result in significant respiratory and/or hemodynamic compromise that mandates urgent interventions. When conservative management fails, 2 surgical options are available: tricuspid valve repair or single ventricle palliation. The overall results of neonatal tricuspid valve repair are unsatisfactory especially in sick neonates and those with preoperative hemodynamic instability. Single ventricle palliation utilizing the Starnes procedure with right ventricular exclusion provides a quicker way to improve hemodynamics and allows rapid decompression of the right ventricle but carries the long-term disadvantages of the single ventricle pathway. We were recently faced with a challenging case of neonatal Ebstein’s anomaly resulting in severe tricuspid valve regurgitation (TR) and significant hemodynamic and respiratory instability. We performed an initial stage I palliation with a modified Starnes’ procedure, which allowed stabilization and rapid recovery of the patient to be followed 5 months later with conversion to 2-ventricle repair using the cone technique. We believe combining these 2 strategies for suitable neonatal candidates may be a useful technique that should be considered in the algorithm for neonatal Ebstein’s anomaly.

Transthoracic Guidance Of Percutaneous Tricuspid Valve Repair: a case report

Background Percutaneous tricuspid valve (TV) repair for tricuspid regurgitation (TR) is arising as a viable treatment option in high-risk patients and can lead to symptom control an improvement in quality of life (QoL). Newest devices have greatly increased safety and efficacy of interventional TR therapy. However, as with any emerging medical procedure, safety aspects need to be considered and procedural risks gradually reduced. Case summary We present the case of an 87-year-old woman with massive TR despite successful percutaneous mitral valve repair. The patient was turned down for surgery and eventually underwent percutaneous TV repair using the TriClipTM (Abbott Medical) device. Significant TR reduction with sustained procedural success at thirty-day follow-up were associated with functional and clinical improvement. Transthoracic echocardiographic guidance of the procedure, thanks to excellent parasternal TV visualization, is highlighted, while the complex anatomy of the TV is pointed out. Discussion TR is an individual predictor of morbidity but frequently found in elderly patients who are deemed very high risk for surgical treatment. This case underscores the use of modern interventional techniques and devices for addressing TR and improving QoL, whether as a stand-alone procedure or as part of complete interventional therapy of the atrioventricular valves.