Novel Echocardiographic Metrics Predict Tricuspid Insufficiency in Pediatric Ebstein Anomaly

Objectives. The tricuspid anterior leaflet is considered important in most repair techniques for Ebstein anomaly (EA). We aim to assess the anterior leaflet morphology using novel metrics and investigate the association of the morphology with recurrent moderately severe or greater tricuspid regurgitation (TR). Methods. Seventy-four paediatric patients with EA undergoing cone reconstruction (CR) between 2010 and 2021 were included. Anterior leaflet mobility (ALM) and anterior leaflet length (ALL) were remeasured on preoperative 2D echocardiography. The prediction accuracies of ALM and ALL-I (ALL indexed to body surface area) for recurrent TR were evaluated using receiver operating characteristic (ROC) curve analyses. Results. The median age of patients was 3.3 years (interquartile range, 1.9–7.1 years). Both ALM and ALL-I correlated with the Carpentier type and GOSH score. Nine patients (12.2%) developed recurrent TR during the one-year follow-up. By univariable logistic regression analyses, ALM (odds ratio [OR], 0.89; 95% CI [confidence interval], 0.82–0.96; p  = 0.003) and ALL-I (OR, 1.39; 95% CI, 1.08–1.78; p  = 0.011) were risk factors for recurrent TR. ROC curve analyses showed that ALM (AUC = 0.81) and ALL-I (AUC = 0.77) had better predictive performance for recurrent TR compared with the GOSH score (AUC = 0.68), the Carpentier type (AUC = 0.67), and preoperative TR severity (AUC = 0.58), and the combinations of ALM and ALL-I (AUC = 0.87) improved the predictive performance compared with ALM or ALL-I alone. Conclusions. ALM and ALL-I can help optimize evaluation in the anterior leaflet morphology and predict recurrent TR after CR in pediatric EA.