1. Strategies for Tricuspid Re-Repair in Ebstein Malformation Using the Cone Technique 
Joseph A. Dearani, MD, Sameh M. Said, MD, Harold M. Burkhart, MD, Roxann B. Pike, MD, Patrick W. O'Leary, MD, Frank Cetta, MD 
The Annals of Thoracic Surgery 
Volume 96, Issue 1, Pages (July 2013)
DOI: /j.athoracsur
Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

2. Fig 1
Intraoperative photo of a surgeon's view into the right atrium. The patient's head is to the left. (A) The anterior leaflet has been detached from the annulus. There is a linear attachment of the leading edge of the anterior leaflet with a direct papillary muscle insertion (black arrow). (B) The anterior leaflet was mobilized and is being prepared to be reattached to the anterior annulus. The arrow identifies the previous ring, which was the only repair maneuver in this patient.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

3. Fig 2
Reattachment of the septal leaflet is done to the ventricular side of the conduction tissue (dashed lined arrow), which is usually marked by a small vein and the white membranous septum.(B) Intraoperative photo showing the completed cone repair with the neo-tricuspid valve re-anchored at the true annulus. (AL = anterior leaflet; SL = septal leaflet.)
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

4. Fig 3
(A) The tricuspid annulus is usually dilated and a flexible annuloplasty ring is used beginning at the anteroseptal commissure and extending clockwise and anchored into the coronary sinus. (B) In younger patients, an eccentric ring from the anteroinferior to inferoseptal commissures can be used as this is the annular site most vulnerable to dilatation. The band serves to decrease the stress on the repair and support the reconstructed cone. (RCA = right coronary artery.)
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

5. Fig 4
(A) The tricuspid valve (TV) anterior leaflet augmentation can be performed using Cor-matrix membrane or an autologous pericardial patch to increase the leaflet height and improve coaptation. Multiple small plications along the annular free edge of the leaflet can also be performed to increase the leaflet height. (B) A triangular patch may be used to augment the reconstructed cone to increase the diameter of the neo-tricuspid valve and help avoid TV stenosis. (C) In the case of a linear attachment (ie, absent chordae with adherence of the leading edge to the endocardium), multiple vertical fenestrations are made into the linear attachment to create a new leading edge.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

6. Fig 5
Illustration showing the modified Sebening stitch (A) in which the head of the mobilized right ventricular free wall papillary muscle is approximated to the corresponding smaller head of a septal papillary muscle (as opposed to approximation to the ventricular septum in the original Sebening stitch). (B) It is important to avoid dimpling of the right ventricular free wall as this indicates excessive tension. (LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle.)
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

7. Fig 6
The surgeon's view into the right atrium; patient's head is to the left. The detached anterior leaflet has marked thickening and muscularization (black arrows).
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

8. Fig 7
Schematic illustration demonstrating the location (anterior, inferior, septal) and potential degrees of tricuspid annular dilatation. The annular portion most susceptible to dilatation is from the anteroinferior commissure to the inferoseptal commissure. The anterior annulus is also susceptible to significant dilatation. Based on these findings, we utilize a near complete ring or an eccentric ring (when somatic growth is incomplete) for tricuspid valve annuloplasty as shown in Figure 3A and B. (A = anterior; I = inferior; S = septal leaflets.)
(Modified from Acar C, et al [7], used with permission.)
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

9. Fig 8
The 4-chamber view of the preoperative echocardiogram provides the most important information about feasibility of the cone repair. (A) Notice the multiple points of attachment between the anterior leaflet and the RV free wall from the base to the apex (white arrows) and also (B) the amount of undelaminated septal leaflet (arrowheads) that is available and optimizes the likelihood of successful repair. (aRV = atrialized right ventricle; LV = left ventricle; RA = right atrium.)
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions