Cardiac MRI Utility in Predicting Development of Right Ventricle Dysfunction After Cone Procedure

April 6, 2022

A multidisciplinary team of cardiologists and cardiothoracic surgeons from the Heart Institute at UPMC Children’s Hospital of Pittsburgh published results from a new study exploring findings from cardiac MRI imaging prior to operative repair of Ebstein’s anomaly with the cone procedure that can predict the likelihood of postoperative right ventricular dysfunction.

Tarek Alsaied, MD, assistant professor of Pediatrics in the Department of Pediatrics at the University of Pittsburgh School of Medicine, was the study's lead author. Luciana Da Fonseca Da Silva, MD, was the senior author.

The development of the cone procedure by José Pedro Da Silva, MD, to repair the tricuspid valve due to the congenital heart malformation known as Ebstein’s anomaly was a revolution in surgical technique that continues to be refined and studied by the team at the Da Silva Center for Ebstein’s Anomaly at UPMC Children’s.

As revolutionary as the technique has been, the surgery still carries risks and the potential for postoperative complications. Of particular concern in the postoperative domain is right ventricular dysfunction, which occurs to varying degrees in a significant proportion of patients undergoing the procedure.

To better understand the risks and patient factors that may contribute to the development of right ventricular dysfunction after a cone procedure, the study team evaluated preoperative cardiac magnetic resonance imaging to see what characteristics may be associated with a higher risk of right ventricular dysfunction.

“We know that persistent or more severe forms of right ventricle dysfunction lead to worse long-term outcomes in this patient population, so our study was designed to explore factors as seen on cardiac MRI that may be predictive of postoperative ventricle dysfunction,” says Dr. Alsaied. “Having this information in advance of surgery will help inform the planning process and perhaps postoperative management protocol.”

Study Highlights

The study looked retrospectively at 26 cases of cone repair for Ebstein’s anomaly conducted at UPMC Children’s after 2016 and which had cardiac MRI studies taken preoperatively. Right ventricular dysfunction was characterized using postoperative echocardiogram prior to discharge from the hospital. These data were then compared to a cohort of patients with minimal to no right ventricular dysfunction.

Of the 26 cases, 18 or 69% were found to have significant right ventricular dysfunction.

Patient characteristics appreciated on the preoperative MRI that correlated with worse right ventricular dysfunction included: lower right ventricular ejection fraction; a more complex valve anatomy; larger cardiac dilation; and lower left ventricular end diastolic volume.

"Together, these findings give clinicians a clearer picture of the risk profile for right ventricular dysfunction in the postoperative period," says Dr. Alsaied. “Moreover, our study gives significant credence to incorporating preoperative MRI for these patients as a standard of care. Our research continues with studying long-term outcomes in our patient population.”

Read the full paper and its findings using the study reference below.

Learn more about Dr. Alsaied and his research interests, the cone procedure developed by José Pedro Da Silva, MD, and Luciana Da Fonesca Da Silva, MD, and the Da Silva Center for Ebstein’s Anomaly at UPMC Children’s.


Alsaied T, Castrillon CD, Christopher A, Da Silva J, Morell VO, Lanford L, Goldstein BH, Feingold B, Seery T, Arora G, Hoskoppal A, Johnson JA, Tadros S, Oliveri LJ, De Fonseca Da Silva L. Cardiac MRI Predictors of Right Ventricular Dysfunction After the Da Silva Cone Operation for Ebstein’s Anomaly. Int J Cardiol Congenit Heart Dis. 2022; 7: 100342. Online ahead of print.