Afoke, Jonathan; Department of Cardiovascular Surgery, Mayo Clinic, Rochester, USA.
Stephens, Elizabeth H; Allison, Thomas G; Chopko, Trevor C; et al;

The Annals of thoracic surgery,2025 Oct 07

• Background: Optimum timing for surgery in asymptomatic/mildly symptomatic adult patients with Ebstein anomaly remains uncertain. This study assessed the association between pre-operative cardiopulmonary exercise testing (CPET) and mortality; and longitudinal changes in CPET.
• Methods: Retrospective review of consecutive adult patients with Ebstein anomaly who had tricuspid surgery between 2007 and 2018 with pre-operative CPET. Primary outcome was all-cause mortality and secondary outcome were changes in CPET.
• Results: The cohort included 116 patients. Ninety-four (81.1%) were NYHA Class I/II. Median age was 39.6 years and 75 (64.7%) were female. Forty-four (37.9%) had one or more prior sternotomies, 58 (50%) underwent Cone repair and 55 (47.5%) had tricuspid replacement. Median percentage predicted peak VO ₂ was 62% and ventilatory efficiency was 30 l/min/min. Fifteen (12.9%) had severe right ventricle dysfunction and median left ventricular ejection fraction was 58%. At median follow up of 9.8 years, there were 8 deaths. Ventilatory efficiency trended to be associated with mortality (p=0.075) on univariate analysis and was the largest contributor to prediction of mortality in machine learning Random Forest models. 33 patients had CPET at a median of 2.9 years after surgery. There was significant improvement in ventilatory efficiency (30 pre-operatively vs 27 l/min/l/min post-operatively, p=0.015).
• Conclusions: In those with minimal or no symptoms, ventilatory efficiency is one of the most important variables in predicting mortality after surgery. Patients may have improved ventilatory efficiency after tricuspid surgery for Ebstein anomaly. These findings highlight the role of CPET in optimizing timing of surgery.