Ebstein畸形的外科治疗课件

EbsteinEbstein畸形的外科治疗策略1 1.Ebstein畸形的外科治疗策略1.E Eb bs st te ei in n畸畸形形是是罕罕见见复复杂杂的的心心脏脏先先天天畸畸形形n n发发生生率率1:40,000-200,000n n先先天天性性心心脏脏病病中中:1%n n疾疾病病谱谱宽宽：轻轻轻轻型型型型 无无无无症症症症状状状状 重重重重症症症症 新新新新生生生生儿儿儿儿期期期期死死死死亡亡亡亡率率率率极极极极高高高高 手手手手术术术术死死死死亡亡亡亡率率率率高高高高Wilhelm Ebstein 1866 年首先描述形态Helen Taussig 1950 年描述临床特点2 2.Ebstein畸形是罕见复杂的心脏先天畸形发生率1:40,0解剖学特点解剖学特点1.1.DisplacementoftheseptalandposteriorleafletsoftheTVtowardtheapexoftheRV.2.2.Althoughtheanteriorleafletisattachedattheappropriatelevelofthetricuspidannulus,itislargerthannormalandmayhavemultiplechordalattachmentstotheventricularwall.3 3.解剖学特点Displacement of the septa3.ThesegmentoftheRVfromthelevelofthe3.ThesegmentoftheRVfromthelevelofthetruetricuspidannulustotheleveloftruetricuspidannulustothelevelofattachmentoftheseptalandposteriorattachmentoftheseptalandposteriorleafletsisunusuallythinanddysplastic.Theleafletsisunusuallythinanddysplastic.ThetricuspidannulusandtheRAareextremelytricuspidannulusandtheRAareextremelydilated.dilated.4.ThecavityofthefunctionalRVisreducedin4.ThecavityofthefunctionalRVisreducedinsize,usuallylacksaninletchamber,andhasasize,usuallylacksaninletchamber,andhasasmalltrabecularcomponent.smalltrabecularcomponent.4 4.3.The segment of the RV from 5.Theinfundibulumisoftenobstructedbytheredundanttissueoftheanteriorleafletaswellasbythechordalattachmentsoftheanteriorleaflettotheinfundibulum.5 5.5.The infundibulum is often o临床分型（分级）临床分型（分级）typeA:typeA:thevolumeofthetrueRVisadequate.thevolumeofthetrueRVisadequate.typeBtypeB：thereisalargeatrializedcomponentofthereisalargeatrializedcomponentoftheRV,buttheanteriorleafletmovesfreely.theRV,buttheanteriorleafletmovesfreely.typeC:typeC:theanteriorleafletisseverelyrestrictedinitsmovementandtheanteriorleafletisseverelyrestrictedinitsmovementandmaycausesignficantobstructionoftheRVOT.maycausesignficantobstructionoftheRVOT.typeD:typeD:thereisalmostcompleteatrializationoftheventriclewiththethereisalmostcompleteatrializationoftheventriclewiththeexceptionofasmallinfundibularcomponent.Theonlycommunicationexceptionofasmallinfundibularcomponent.Theonlycommunicationbetweentheatrializedventricleandtheinfundibulumisthroughthebetweentheatrializedventricleandtheinfundibulumisthroughtheanteroseptalcommissureofthetricuspidvalve.anteroseptalcommissureofthetricuspidvalve.6 6.临床分型（分级）type A:the volume of超超声声评评估估分分级级面积比值右房房化右室面积比值右房房化右室面积比值右房房化右室面积比值右房房化右室/功能右室左心房室功能右室左心房室功能右室左心房室功能右室左心房室 心脏舒张期四腔心轴面心脏舒张期四腔心轴面心脏舒张期四腔心轴面心脏舒张期四腔心轴面 1 1级：级：1.5 1.57 7.超声评估分级面积比值右房房化右室/功能右室左心房室7.病病理理生生理理特特点点：1.1.三尖瓣关闭不全三尖瓣关闭不全三尖瓣关闭不全三尖瓣关闭不全 右房明显扩大，卵圆孔右向左分流，右室扩大右房明显扩大，卵圆孔右向左分流，右室扩大右房明显扩大，卵圆孔右向左分流，右室扩大右房明显扩大，卵圆孔右向左分流，右室扩大2.2.右室功能不良右室功能不良右室功能不良右室功能不良 有效收缩部分减少，心室膨胀有效收缩部分减少，心室膨胀有效收缩部分减少，心室膨胀有效收缩部分减少，心室膨胀3.3.肺动脉发育不良肺动脉发育不良肺动脉发育不良肺动脉发育不良 三尖瓣前叶、乳头肌阻挡，生理性三尖瓣前叶、乳头肌阻挡，生理性三尖瓣前叶、乳头肌阻挡，生理性三尖瓣前叶、乳头肌阻挡，生理性PAAPAAPAAPAA4.4.左室受压，呈左室受压，呈左室受压，呈左室受压，呈“夹心饼夹心饼夹心饼夹心饼”，功能受限，功能受限，功能受限，功能受限5.5.可伴有室上性或室性心律可伴有室上性或室性心律可伴有室上性或室性心律可伴有室上性或室性心律 8 8.病理生理特点：1.三尖瓣关闭不全8.临临床床表表现现：容容容容易易易易疲疲疲疲劳劳劳劳 ，活活活活动动动动后后后后呼呼呼呼吸吸吸吸困困困困难难难难、心心心心悸悸悸悸，紫紫紫紫绀绀绀绀G G G Gi i i iu u u ul l l li i i ia a a an n n ni i i i 6 6 6 67 7 7 7例例例例非非非非手手手手术术术术，1 1 1 12 2 2 2年年年年观观观观察察察察：3 3 3 39 9 9 9%N N N NY Y Y YH H H HA A A A 1 1 1 1-2 2 2 2级级级级 6 6 6 61 1 1 1%N N N NY Y Y YH H H HA A A A 3 3 3 3-4 4 4 4级级级级 2 2 2 21 1 1 1%病病病病人人人人死死死死亡亡亡亡死死死死亡亡亡亡病病病病人人人人有有有有一一一一项项项项或或或或多多多多项项项项特特特特点点点点：1 1 1 1.N N N NY Y Y YH H H HA A A A 3 3 3 3-4 4 4 4级级级级 2 2 2 2.心心心心胸胸胸胸比比比比大大大大于于于于0 0 0 0.6 6 6 65 5 5 5 3 3 3 3.发发发发绀绀绀绀或或或或动动动动脉脉脉脉氧氧氧氧饱饱饱饱和和和和9 9 9 90 0 0 0%以以以以下下下下 4 4 4 4.明明明明确确确确诊诊诊诊断断断断时时时时处处处处于于于于婴婴婴婴儿儿儿儿阶阶阶阶段段段段9 9.临床表现：容易疲劳，活动后呼吸困难、心悸，紫绀9.术术前前基基础础治治疗疗：1.1.保持保持PDAPDA开放，增加肺内血供，改善氧开放，增加肺内血供，改善氧合：合：PGE1PGE12.2.纠正酸中毒纠正酸中毒3.3.充分镇静，过度通气，降低肺血管阻力充分镇静，过度通气，降低肺血管阻力1010.术前基础治疗：1.保持PDA开放，增加肺内血供，改善氧合：P治治疗疗原原则则：1.1.尽可能恢复三尖瓣功能尽可能恢复三尖瓣功能2.2.右房减容，改善呼吸功能右房减容，改善呼吸功能3.3.根据右室功能决定：根据右室功能决定：双心室矫治双心室矫治双心室矫治双心室矫治 右室旷置右室旷置右室旷置右室旷置 右室减负荷右室减负荷右室减负荷右室减负荷4.4.房化心室是否去除房化心室是否去除（折叠或切除）（折叠或切除）（折叠或切除）（折叠或切除）？5.5.右室流出道充分疏通右室流出道充分疏通1111.治疗原则：1.尽可能恢复三尖瓣功能11.外外科科技技术术：n n三三尖尖瓣瓣成成形形（包包括括心心室室成成形形）技技术术 1 1.D Da an ni ie el ls so on n修修复复 2 2.改改良良C Ca ar rp pe en nt ti ie er r技技术术 3 3.D De ev ve eg ga a技技术术 4 4.前前叶叶单单瓣瓣技技术术1212.外科技术：三尖瓣成形（包括心室成形）技术12.U三三尖尖瓣瓣成成形形技技术术1.Danielson 1.Danielson 修复修复EbsteinEbsteinEbsteinEbstein畸形的治疗畸形的治疗畸形的治疗畸形的治疗1313.三尖瓣成形技术1.Danielson 修复Ebstein畸形2 2.改改良良C Ca ar rp pe en nt ti ie er r修修复复 EbsteinEbsteinEbsteinEbstein畸形的外科治疗畸形的外科治疗畸形的外科治疗畸形的外科治疗1414.2.改良Carpentier修复 Ebstein畸形的外3.3.改良改良DevegaDevega技术技术runingbothendsofthepledgettedsutureinandoutalongtheannulusseparatingtheatrializedfromthefunctionalrightventriclefromAtoBthe anterior leaflet is not large or if the posterior leaflet is well developed or if both the anterior and posterior leaflets are functional but dysplastic The“play it where it lies”approach involves limited plicationThe“play it where it lies”approach involves limited plication of the tricuspid valve.Points A and B are approximated of the tricuspid valve.Points A and B are approximated with 1 or 2 mattress sutures at the level of the native valve,with 1 or 2 mattress sutures at the level of the native valve,not to the level of the true tricuspid annulus.This results in not to the level of the true tricuspid annulus.This results in approximating the apical aspects of the septal and anteriorapproximating the apical aspects of the septal and anterior leaflets,effectively creating a bicuspid valve.leaflets,effectively creating a bicuspid valve.1515.3.改良Devega技术runing both ends o4.4.前瓣单叶修复前瓣单叶修复EbsteinEbsteinEbsteinEbstein畸形的外科治疗畸形的外科治疗畸形的外科治疗畸形的外科治疗1616.4.前瓣单叶修复Ebstein畸形的外科治疗16.重重症症E Eb bs st te ei in n畸畸形形的的定定义义n n目前不明确目前不明确目前不明确目前不明确n n参考标准参考标准参考标准参考标准 PredictorsofDeathinneonateswithEbsteinsAnomalyPredictorsofDeathinneonateswithEbsteinsAnomaly cardiothoracicrationgreaterthan0.85(100%fatal)cardiothoracicrationgreaterthan0.85(100%fatal)Echocardiographyscoregrade4/4(100%fatal)Echocardiographyscoregrade4/4(100%fatal)Echocardiographyscoregradeandcyanosis(100%fatal)Echocardiographyscoregradeandcyanosis(100%fatal)Severetricuspidregurgitation(mostlyfatal)Severetricuspidregurgitation(mostlyfatal)Echocardiographyscoregrade(45%fatalininfancy)Echocardiographyscoregrade(45%fatalininfancy)Knott-CraigCJetal.AnnThoracSurg2002,76:1786Knott-CraigCJetal.AnnThoracSurg2002,76:17861717.重症Ebstein畸形的定义目前不明确17.新新生生儿儿E Eb bs st te ei in n畸畸形形的的治治疗疗n n Starnes矫治矫治(JThoracCardiovascSurg1991:101;1082-7)(JThoracCardiovascSurg1991:101;1082-7)5consecutivenewborninfants5consecutivenewborninfants Age:1-9days.Age:1-9days.Weight:3.61.8kgWeight:3.61.8kgMeanPH:7.20.05MeanPH:7.20.05Meanoxygentension:29.62.3mmHgMeanoxygentension:29.62.3mmHgMeancardiothoracicration:0.810.02Meancardiothoracicration:0.810.02ECHO:severetricuspidregurgitationECHO:severetricuspidregurgitationfunctionalpulmonaryatresiafunctionalpulmonaryatresiainallpatientsinallpatientsAllpatientswereresuscitatedwithintubationandmechanicalAllpatientswereresuscitatedwithintubationandmechanicalventilation,acidosiswascorrected,andtherapywithPGE1.ventilation,acidosiswascorrected,andtherapywithPGE1.1818.新生儿Ebstein畸形的治疗 Starnes矫治(J Thn nPreoperativeechoassessmentPreoperativeechoassessmentpatientNo.patientNo.1234512345RVdysplasiaRVdysplasia+00+00+tetheredanteriorleaflettetheredanteriorleaflet00+0+00+0+Echoscoreratio1.30.90.80.61.01Echoscoreratio1.30.90.80.61.01severeTRsevereTR+functionalpulmonaryatresiafunctionalpulmonaryatresia+1919.Preoperative echo assessment19U UCardiaccatheterizationassessmentinoneneonatesCardiaccatheterizationassessmentinoneneonates2020.Cardiac catheterization assesn nOperativetechniqueOperativetechnique UThe tricuspid orifice was closed with autologous pericardium.UThe coronary sinus beneath the patch to reduce the risk of AV block.UAn ASD was created to ensure mixing at the atrial level.2121.Operative techniqueThe tricuspThe right atrium was reduced in size by removing a segment of the right atrial free wall.A A-P shunt was established with a 4mm Gore-Tex vessel.2222.The right atrium was reduced iUResultsN No o p pe er ri io op pe er ra at ti iv ve e a an nd d l la at te e d de ea at th hs s.N No o p po os st to op pe er ra at ti iv ve e a ar rr rh hy yt th hmmi ia as s.MMe ec ch ha an ni ic ca al l v ve en nt ti il la at ti io on n t ti imme e 1 10 0.2 2 0 0.3 3d da ay ys s.P Po o2 2:4 42 2.2 2 0 0.9 9mmmmHHg g,S SOO2 2:8 83 3.2 2 1 1.9 9%2323.ResultsNo perioperative and UFollow-upOnereceivedaGlennoperationafter11mo.TworeceivedFontanproceduresat23and22moofage.2424.Follow-upOne received a Glennn双心室矫治双心室矫治(Knott-CraigCJ.Knott-CraigCJ.Repair of Ebsteins Repair of Ebsteins anomaly in the symptomatic neonate:an evolution of technique with anomaly in the symptomatic neonate:an evolution of technique with 7-year follow-up.7-year follow-up.AnnThoracSurg2002:73;1786-93)AnnThoracSurg2002:73;1786-93)8symptomaticpatients8symptomaticpatients6neonates(2-19d,2.8-3.2kg)6neonates(2-19d,2.8-3.2kg)1younginfant(2mo,3.8kg)hadundergone1younginfant(2mo,3.8kg)hadundergoneastarnesoperationelsewhereastarnesoperationelsewhere1infant(4mo,6.4kg)1infant(4mo,6.4kg)新生儿新生儿新生儿新生儿EbsteinEbsteinEbsteinEbstein畸形的治疗畸形的治疗畸形的治疗畸形的治疗2525.双心室矫治(Knott-Craig CJ.Repair oUPreoperativeassessmentn nSevere(4/4)TRwaspresentinallexcept1Severe(4/4)TRwaspresentinallexcept1(Starnesoperation)(Starnesoperation)n nCardiothoracicratioexceeded0.85inallpatientsCardiothoracicratioexceeded0.85inallpatientsn nEchocardiographyseverityscoreswereEchocardiographyseverityscoreswere1.5in6(grade4/4)1.5in6(grade4/4)and1.3in1(grade3/4)and1.3in1(grade3/4)n n 3 3patientshadanatomicalPApatientshadanatomicalPA2hadfunctionalPA2hadfunctionalPA 新生儿新生儿新生儿新生儿EbsteinEbsteinEbsteinEbstein畸形的治疗畸形的治疗畸形的治疗畸形的治疗2626.Preoperative assessmentSevere UOperativetechniqueR Re ep pa ai ir r c co on ns si is st te ed d o of f T TV V r re ep pa ai ir r R Re ed du uc ct ti io on n a at tr ri io op pl la as st ty y R Re el li ie ef f o of f R RV VOOT T o ob bs st tr ru uc ct ti io on n P Pa ar rt ti ia al l c cl lo os su ur re e o of f A AS SD D C Co or rr re ec ct ti io on n o of f a al ll l a as ss so oc ci ia at te ed d c ca ar rd di ia ac c d de ef fe ec ct ts s 新生儿新生儿新生儿新生儿EbsteinEbsteinEbsteinEbstein畸形的治疗畸形的治疗畸形的治疗畸形的治疗2727.Operative techniqueRepair consn nTricuspidvalverepair(3hadDanielson-type3hadDanielson-typerepairs,3hadDeVega-typerepairs,and2hadcomplexrepairs)repairs,3hadDeVega-typerepairs,and2hadcomplexrepairs)1.modified Danielson technique placingapledgettedsutureattheA-PcommissureandbringingthisdowntotheCS,thuscreatingadoubleorificevalve.ThelateralorificecontainingtheatrializedRV,whichbeclosedbyplicatingitvertically.Ifthelargeanteriorleafletdoesnotcoaptwellwiththeventricularseptum,apledgettedsuturefromtheanteriorpapillarymuscletotheventricularseptummaybeusedtocorrectthis新生儿新生儿新生儿新生儿EbsteinEbsteinEbsteinEbstein畸形的治疗畸形的治疗畸形的治疗畸形的治疗2828.Tricuspid valve repair(3 had2.DeVega-typeannuloplasty (the anterior leaflet is(the anterior leaflet is not large or if the posterior leaflet is well developed or if both the not large or if the posterior leaflet is well developed or if both the anterior and posterior leaflets are functional but dysplastic anterior and posterior leaflets are functional but dysplastic)runingbothendsofthepledgettedsutureinandoutalongtheannulusseparatingtheatrializedfromthefunctionalrightventriclefromAtoB新生儿新生儿新生儿新生儿EbsteinEbsteinEbsteinEbstein畸形的治疗畸形的治疗畸形的治疗畸形的治疗2929.2.DeVega-type annuloplasty(thI In n t th he e mmo or re e s se ev ve er re e f fo or rmms s o of f E EA A i in n t th he e n ne eo on na at te e 1.TheorificeoftheTVistowardtheapex1.TheorificeoftheTVistowardtheapexoftheRV.oftheRV.2.Thecommissurebetweentheanteriorand2.Thecommissurebetweentheanteriorandseptalleafletsmaybeimperforateorpatentseptalleafletsmaybeimperforateorpatentonlythroughsmallfenestrations.onlythroughsmallfenestrations.3.Theposteriorleafletmaybereasonably3.Theposteriorleafletmaybereasonablywelldevelopedandmobile.welldevelopedandmobile.新生儿新生儿新生儿新生儿EbsteinEbsteinEbsteinEbstein畸形的治疗畸形的治疗畸形的治疗畸形的治疗3030.In the more severe forms of EADetachingtheentireanteriorandposteriorleafletsfromtheannulusFreeingtheleafletsfromtheirmuscularizedattachmentsandreducingtheannulusinsizeposteriorlyReattachingtheleafletstothesmallerannulusnotonlycorrectsthedefectbutalsoeffectivelychangestheorientationoftheTVbacktotheRVOTandthefunctionalRV.FenestratingtheA-Scommissureandleafletpreventstricuspidstenosis 3131.Detaching the entire anterior n nCorrectionofallassociatedcardiacdefectsCorrectionofallassociatedcardiacdefects PAPA、PSorRVOTS:PSorRVOTS:RVOTpatchorasmallhomograftorothervalvedconduitRVOTpatchorasmallhomograftorothervalvedconduit VSD:morecomplexVSD:morecomplex n nUnloadingtheRVUnloadingtheRVFenestratedASDclosureFenestratedASDclosureAddingthehemi-Fontanconnection(inolderpatients)Addingthehemi-Fontanconnection(inolderpatients)n nReductionatrioplastyReductionatrioplastyn nOpenrightpleuralcavityandleaveadrainintheOpenrightpleuralcavityandleaveadrainintheperitonealcavityperitonealcavity 新生儿新生儿新生儿新生儿EbsteinEbsteinEbsteinEbstein畸形的治疗畸形的治疗畸形的治疗畸形的治疗3232.Correction of all associated c&Resultsn nOnepatientdiedinhospitalOnepatientdiedinhospitaln nnolatedeathsnolatedeathsn nAllareinsinusrhythmandinfunctionalclassIAllareinsinusrhythmandinfunctionalclassIn n4patientshadtracetomildTRand2hadmildto4patientshadtracetomildTRand2hadmildtomoderateregurgitationmoderateregurgitation3333.Results One patient died in ho&外科矫治新观点外科矫治新观点（Sunil P.Malhotra MD,Sunil P.Malhotra MD,Selective Right Ventricular Unloading and Novel Technical Concepts in Selective Right Ventricular Unloading and Novel Technical Concepts in Ebsteins Anomalys,Ebsteins Anomalys,SanFrancisco,CA,Jan2628,2009.SanFrancisco,CA,Jan2628,2009.）Newconecpts:Newconecpts:UsingofvalvereconstructivetechniquesthatdifferUsingofvalvereconstructivetechniquesthatdiffersubstantiallyfromthoseintheliterature:substantiallyfromthoseintheliterature:1 A“play it where it lies”approach to the tricuspid valve in which the 1 A“play it where it lies”approach to the tricuspid valve in which the reconstruction is performed at the functional orifice instead of reconstruction is performed at the functional orifice instead of moving the valve to the anatomic tricuspid annulus;moving the valve to the anatomic tricuspid annulus;2 Avoidance of detachment and reimplantation of valve leaflets;and2 Avoidance of detachment and reimplantation of valve leaflets;and3 A limited plication performed only at the level of the displaced valve 3 A limited plication performed only at the level of the displaced valve rather than complete plication of the entire atrialized RV.rather than complete plication of the entire atrialized RV.3434.外科矫治新观点（Sunil P.Malhotra MD,Newconecpts:DependingspecificphysiologicandanatomicDependingspecificphysiologicandanatomiccriteriaforselectiveuseoftheBDGincriteriaforselectiveuseoftheBDGinconjunctionwithrepairofEbsteinsanomaly.conjunctionwithrepairofEbsteinsanomaly.3535.New conecpts:35.P Pa at ti ie en nt t C Ch ha ar ra ac ct te er ri is st ti ic cs s 93.12-08.1257consecutivepatientsoutsideofthe93.12-08.1257consecutivepatientsoutsideoftheneonatalperiodneonatalperiod ThediagnosisofsevereEbsteinsanomalyofthetricuspidThediagnosisofsevereEbsteinsanomalyofthetricuspidvalvewasestablishedbyechocardiographyinallpatients.valvewasestablishedbyechocardiographyinallpatients.EchocardiographywasusedtocharacterizethedegreeofEchocardiographywasusedtocharacterizethedegreeofapicaldisplacementofthetricuspidannulus,theseverityandapicaldisplacementofthetricuspidannulus,theseverityandnatureofTR,andthedegreeofmobilityoftheanteriorleaflet.natureofTR,andthedegreeofmobilityoftheanteriorleaflet.TRwasclassifiedonascaleof1to4(1,trace;2,mild;3,TRwasclassifiedonascaleof1to4(1,trace;2,mild;3,moderate,and4,severe).moderate,and4,severe).EchocardiographyalsowasusedtoassessrightandleftEchocardiographyalsowasusedtoassessrightandleftventricularfunctionandtoidentifyanyatriallevelshunts.ventricularfunctionandtoidentifyanyatriallevelshunts.3636.Patient Characteristics 93.12-P Pa at ti ie en nt t C Ch ha ar ra ac ct te er ri is st ti ic cs sAge:7monthsto40.4yearsAge:7monthsto40.4yearsexerciseintolerancein40exerciseintolerancein40cyanosisin26cyanosisin26RVfailurein18RVfailurein18atrialdysrhythmiasin8atrialdysrhythmiasin8TRwasmoderateorseverein50patients(87.7%).TRwasmoderateorseverein50patients(87.7%).3737.Patient CharacteristicsAge:7 A A A Ap p p pp p p pr r r ro o o oa a a ac c c ch h h he e e es s s s t t t to o o o t t t th h h he e e e T T T Tr r r ri i i ic c c cu u u us s s sp p p pi i i id d d d V V V Va a a al l l lv v v ve e e e 1 The detrimental effects of a very large tricuspid annulus 3838.Approaches to the Tricuspid VaA A A Ap p p pp p p pr r r ro o o oa a a ac c c ch h h he e e es s s s t t t to o o o t t t th h h he e e e T T T Tr r r ri i i ic c c cu u u us s s sp p p pi i i id d d d V V V Va a a al l l lv v v ve e e e2 The goal of plication of the atrialized RV The“playitwhereitlies”approachinvolveslimitedplicationofthetricuspidvalve.PointsAandBareapproximatedwith1or2mattresssuturesatthelevelofthenativevalve,nottothelevelofthetruetricuspidannulus.Thisresultsinapproximatingtheapicalaspectsoftheseptalandanteriorleaflets,effectivelycreatingabicuspidvalve.3939.Approaches to the Tricuspid Va3 3 Selective use of the BDGSelective use of the BDGusing the BDG in two using the BDG in two separate and independent circumstances.separate and independent circumstances.The first is physiologic.Cyanosis at rest is a marker for The first is physiologic.Cyanosis at rest is a marker for an inadequate RV pump.If the patient is fully saturated at an inadequate RV pump.If the patient is fully saturated at rest but becomes cyanotic with exercise,this is a relative rest but becomes cyanotic with exercise,this is a relative marker of an inadequate RV pump,and we will have a low marker of an inadequate RV pump,and we will have a low threshold for placing a BDG.Typically,we will separate the threshold for placing a BDG.Typically,we will separate the patient from cardiopulmonary bypass after valve repair and patient from cardiopulmonary bypass after valve repair and monitor right and left atrial pressure.If the right atrial monitor right and left atrial pressure.If the right atrial pressure exceeds 1.5 times the left atrial pressure under these pressure exceeds 1.5 times the left atrial pressure under these relatively unstressed conditions of an open chest in an relatively unstressed conditions of an open chest in an anesthetized patient,we will perform a BDG.anesthetized patient,we will perform a BDG.If the patient presents with an intact atrial septum or an If the patient presents with an intact atrial septum or an atrial septal defect with left-to-right shunting,a BDG is not atrial septal defect with left-to-right shunting,a BDG is not performed.performed.4040.3 Selective use of the BDGusiThesecondcircumstanceforplacingaBDGisanatomicThesecondcircumstanceforplacingaBDGisanatomicandrelatestotheultimatesizeofthefunctionaltricuspidandrelatestotheultimatesizeofthefunctionaltricuspidannulusafterrepair.Ifitisnecessarytomakethefunctionalannulusafterrepair.Ifitisnecessarytomakethefunctionaltricuspidorificesubstantiallylessthan2.5cm(ina70-kgtricuspidorificesubstantiallylessthan2.5cm(ina70-kgpatient)toachieveacompetentvalve,wewillassessinflowpatient)toachieveacompetentvalve,wewillassessinflowvelocityacrossthetricuspidafterseparationfromvelocityacrossthetricuspidafterseparationfromcardiopulmonarybypassusingtransesophagealcardiopulmonarybypassusingtransesophagealechocardiography.Ifobstructionisdemonstrated,aBDGisechocardiography.Ifobstructionisdemonstrated,aBDGisplaced.Weacknowledgethatmanyofthemaneuversusedtoplaced.Weacknowledgethatmanyofthemaneuversusedtomakearegurgitantvalvecompetentinvolvereducingthevalvemakearegurgitantvalvecompetentinvolvereducingthevalveopening.ThisoptionforBDGusefreesustoaggressivelyreduceopening.ThisoptionforBDGusefreesustoaggressivelyreducethefunctionalvalveorificeasmuchasnecessarytoachieveathefunctionalvalveorificeasmuchasnecessarytoachieve