Surgical Management of Ebstein's Anomaly in Elderly Patients: A Report of Two Cases

Ebstein's anomaly (EA) is a rare congenital defect of the tricuspid valve (TV), typically characterized by downward displacement of the septal and posterior leaflets into the right ventricle, resulting in tricuspid regurgitation (TR), right heart enlargement, and heart failure. While surgical outcomes for EA have improved significantly in pediatric and young adult populations, data on surgical intervention in elderly patients remain limited. Elderly patients often present with comorbidities and diminished physiological reserve, which complicate both surgical decision-making and perioperative management. We present two elderly patients with EA who underwent TV surgery. Case 1 involved a 73-year-old man with a long-standing history of severe TR, cardiomegaly, alcoholic cirrhosis, and chronic kidney disease. Despite preserved biventricular systolic function on echocardiography, signs of right ventricular dysfunction were present. The patient underwent tricuspid valve replacement (TVR) due to concerns about tissue fragility and prolonged bypass time. Although initially stable postoperatively, he developed aspiration pneumonia followed by septic shock and ultimately died from multiorgan failure on postoperative day 73. Case 2 involved a 71-year-old woman with preserved cardiac function and mild frailty. She underwent tricuspid valvuloplasty using the cone technique. Despite temporary postoperative circulatory instability requiring mechanical circulatory support, she recovered well and was discharged on postoperative day 80. These cases highlight the importance of individualized surgical planning in elderly EA patients. While echocardiographic indices may suggest preserved ventricular function, they may not fully reflect clinical reserve, particularly in long-standing disease. Earlier surgical intervention, prior to the onset of irreversible right ventricular remodeling or systemic decline, may improve outcomes even in elderly patients. Evaluation of frailty, comorbidities, and right ventricular function should guide the decision-making process. Our experience suggests that timely and tailored surgical strategies can lead to acceptable outcomes in selected elderly patients with EA.