The American Association for Thoracic Surgery (AATS) 2024 Expert Consensus Document: Management of neonates and infants with Ebstein anomaly.

Objectives Symptomatic neonates and infants with Ebstein Anomaly (EA) require complex management. A group of experts was commissioned by the American Association for Thoracic Surgery to provide a framework on this topic focusing on risk stratification and management. Methods The EA Clinical Congenital Practice Standards Committee is a multinational and multidisciplinary group of surgeons and cardiologists with expertise in EA. A citation search in PubMed, Embase, Scopus, and Web of Science was performed using key words related to EA. The search was restricted to the English language and the year 2000 or later and yielded 455 results, of which 71 were related to neonates and infants. Expert consensus statements with class of recommendation and level of evidence were developed using a modified Delphi method, requiring 80% of members votes with at least 75% agreement on each statement. Results When evaluating fetuses with EA, those with severe cardiomegaly, retrograde or bidirectional shunt at the ductal level, pulmonary valve atresia, circular shunt, left ventricular dysfunction, or fetal hydrops should be considered high risk for intrauterine demise and postnatal morbidity and mortality. Neonates with EA and severe cardiomegaly, prematurity (<32 weeks), intrauterine growth restriction, pulmonary valve atresia, circular shunt, left ventricular dysfunction, or cardiogenic shock should be considered high-risk for morbidity and mortality. Hemodynamically unstable neonates with a circular shunt should have emergent interruption of the circular shunt. Neonates in refractory cardiogenic shock may be palliated with the Starnes procedure. Children may be assessed for later bi-ventricular repair following the Starnes procedure. Neonates without high-risk features of EA may be monitored for spontaneous closure of the PDA. Hemodynamically stable neonates with significant pulmonary regurgitation at risk for circular shunt with normal RVSP should have an attempt at medical closure of the PDA. A medical trial of PDA closure in neonates with functional pulmonary atresia and normal RVSP (>20-25 mmHg) should be performed. Hemodynamically stable neonates without pulmonary regurgitation, but inadequate antegrade pulmonary blood flow, may be considered for a PDA stent or systemic to pulmonary artery shunt. Conclusion Risk stratification is essential in neonates and infants with Ebstein anomaly. Palliative comfort care may be reasonable in neonates with associated risk factors that may include prematurity, genetic syndromes, other major medical comorbidities, ventricular dysfunction, or sepsis. Unstable neonates with a circular shunt should have emergent interruption of the circular shunt. Unstable neonates are most commonly palliated with the Starnes procedure. Stable neonates should undergo ductal closure. Stable neonates with inadequate pulmonary flow may have ductal stenting or a systemic-to-pulmonary artery shunt. Subsequent procedures following Starnes palliation include either single ventricle palliation or biventricular repair strategies.