Coronary blood supply of the inferior wall of the right ventricle in hearts with Ebstein malformation: relevance to vertical plication  Iki Adachi, MD,

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Coronary blood supply of the inferior wall of the right ventricle in hearts with Ebstein malformation: relevance to vertical plication  Iki Adachi, MD, Siew Yen Ho, PhD, FRCPath, FESC, Karen P. McCarthy, BS, Hideki Uemura, MD, FRCS  The Journal of Thoracic and Cardiovascular Surgery  Volume 136, Issue 6, Pages 1437-1441 (December 2008) DOI: 10.1016/j.jtcvs.2008.06.029 Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Diagram of inferior (diaphragmatic) surface of heart, seen by lifting up cardiac apex to show coronary arterial blood supply of inferior ventricular wall. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 1437-1441DOI: (10.1016/j.jtcvs.2008.06.029) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Schematic illustrations of ventricles in cross-section showing vertical plication of atrialized right ventricle (RV). In Carpentier method or its modification, plication procedure is not simple folding of right ventricular free wall (left). Instead, right ventricular free wall is folded against septum (right). When there is rightward deviation of posterior descending branch, branch compromise would be more likely in adjacent than in free wall plication. LV, Left ventricle. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 1437-1441DOI: (10.1016/j.jtcvs.2008.06.029) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Photographs illustrating inferior wall surface of 2 hearts with Ebstein malformation displayed in same orientation as diagram in Figure 1. Longitudinal fold (between small arrows) was made in each heart to simulate surgical vertical plication of atrialized chamber. Posterior descending branch is indicated by red dotted line, and accompanying vein (middle cardiac vein) is marked by blue dotted line. A, Heart has posterior descending branch with rightward deviation. Inset in lower right corner is higher magnification of boxed area. Posterior descending branch and its venous counterpart are involved with plication procedure. B, Longitudinal suture line is extended from ventricular cavity to atrium as described in literature,4-6 so that reduction of tricuspid annulus is accomplished. In this heart, posterior descending branch runs exactly on septum and therefore is free from any compromise. This tricuspid annular reduction makes atrioventricular groove distorted, however, resulting in kinking of right coronary artery along groove (arrowhead in inset, which represents angled view of boxed area). Sutures on both heart specimens are to secure previous incisions. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 1437-1441DOI: (10.1016/j.jtcvs.2008.06.029) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions