Assessing left ventricular pathology in patients with Ebstein anomaly using Cardiovascular magnetic resonance: Looking past the right heart

Assessing left ventricular pathology in patients with Ebstein anomaly using Cardiovascular magnetic resonance: Looking past the right heart | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessing left ventricular pathology in patients with Ebstein anomaly using Cardiovascular magnetic resonance: Looking past the right heart Aditi Gupta, Luciana Da Silva, Carlos Diaz Castrillon, Li Wang, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4219470/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 19 Jul, 2024 Read the published version in Pediatric Cardiology → Version 1 posted 8 You are reading this latest preprint version Abstract Background: Ebstein Anomaly (EA) is a malformation of the right heart, but there is data to suggest that the left ventricle (LV) can suffer from intrinsic structural and functional abnormalities which affect surgical outcomes. Hypothesis: The LV in patients with EA is hypertrabeculated with abnormalities in LV function and strain. Methods: In this retrospective single-center study, patients with EA who underwent pre-operative cardiac MRI (CMR) between the period of 2014-2023 were included along with a group of healthy-age-matched controls. Left ventricular and right ventricular volume, function and strain analyses were performed on standard SSFP imaging. LV noncompacted:compacted (NC/C) ratio and the displacement index of the tricuspid valve were measured. Results: Thirty-five EA patients were included with mean age of 21.0 +/- 16.4 years. Thirteen EA patients (37%) had mild pre-operative LV dysfunction on CMR and 1 (3%) had moderate LV dysfunction. The global circumferential and longitudinal strain were significantly lower in the reduced LVEF group compared to those with preserved LVEF (-15% vs. -16.8%, p =0.01 and −11.8% vs. −16.1%; p =0.04; respectively). A single EA patient (3%) met criteria for LVNC with a maximal NC/C ratio > 2.3. There was no statistically significant difference in NC/C ratio in the EA population (1.33 +/- 0.5) vs. controls (1.11 +/- 0.2), p = 0.16. There was an inverse correlation of LV ejection fraction (EF) with right ventricular end-diastolic volume and displacement index (DI). All patients underwent the Da Silva Cone procedure at our center. Patients with preoperative LV dysfunction had longer bypass time (163 +/- 42 vs 142 +/-38 min, p=0.17) and duration of postoperative epinephrine support (23.5 +/- 22 vs 11.2 +/- 22.3 hours, p=0.20). Conclusions: This is the largest study to date to evaluate preoperative LV structure and function in EA patients by CMR. In this cohort of 35 patients, LV non-compaction was rare, though there was a trend toward increased trabeculation. Pre-operative LV dysfunction is common and associated with more severe EA with larger RV size. The presence of LV dysfunction is relevant to perioperative management and further study with larger cohorts and longer follow up are necessary. Figures Figure 1 Figure 2 Background Ebstein anomaly (EA) is a rare and complex congenital cardiac malformation first described in 1866 and is estimated to occur in < 1% of all congenital cardiac malformations( 1 , 2 ). It is marked by malformations of the tricuspid valve, specifically tricuspid annulus dilation, apical displacement of septal and posterior leaflets, and failure of delamination of those leaflets. These structural defects lead to progressive tricuspid regurgitation (TR), right atrial dilation, right ventricular enlargement with associated dysfunction, and often clinical symptoms of heart failure( 3 , 4 ). Although the most prominent pathology is in the right heart, there is data that the left ventricle in Ebstein anomaly is also abnormal and can suffer from intrinsic structural and functional abnormalities. These include LV hypertrabeculation/non-compaction cardiomyopathy (LVNC), fibrosis, dysfunction and dyssynchrony( 5 , 6 ). LV dysfunction has been reported in 7–50% patients with EA; ( 7 , 8 , 9 , 10 ) however the mechanism of LV dysfunction in EA is yet to be elucidated. Multiple case series have described hyper trabeculation/LVNC in patients with EA; however, these are limited by image quality and small cohorts. The Da Silva cone operation is a surgical technique aimed at reconstructing the tricuspid valve to promote competence and expand the functional right ventricle by positioning the annulus at the right atrioventricular groove. There is now strong evidence demonstrating significant improvement in TR, RV end-diastolic volume (EDV),( 11 ) ( 12 ) right ventricular systolic function, and exercise tolerance during long-term follow up after the Da Silva Cone procedure( 10 , 13 , 14 , 15 ); however, there has been limited data describing preoperative LV morphology and function in these patients. Our aim was to evaluate the prevalence of hypertrabeculation/LVNC and preoperative LV dysfunction amongst a heterogenous population of referrals to the Da Silva Center for Ebstein's Anomaly, and correlate these to right ventricular parameters and perioperative care Methods Study population All patients with EA who underwent pre-operative cardiac MRI (CMR) and subsequent surgical repair with The Da Silva Cone procedure at our center between the period of 2014–2023 were included. Four patients were excluded due to limited image quality. A group of 11healthy age- and sex-matched subjects who underwent clinical magnetic resonance image (MRI) examination with normal results were included as controls. Control patients were referred for screening MRI in the setting of connective tissue disorder or arrhythmia. None of the control patients had evidence of ventricular dilation or dysfunction. The study was approved by the UPMC Institutional Review Board who waived the requirement for informed consent. Echocardiography: All patients underwent transthoracic echocardiograms preoperatively by pediatric cardiac sonographers using either Phillips IE33, Epiq 7C (Philips Medical Systems, Andover, MA) or GE VIVID E95 (GE Healthcare, Chicago, IL) ultrasound machines. LVEF measured by the bullet method was abstracted from the clinical echocardiogram reports produced at the time of study. LVEF was defined as normal > 55%, mildly reduced 40–55%, moderately reduced 30–39%, and severely reduced < 30%. Speckle tracking analysis was performed using QLAB Autostrain LV version 13.0 (Phillips Ultrasound, Inc, Bothell, WA) to provide global longitudinal strain (GLS) using apical two, three, and four chamber views. Accuracy of autocontouring was reviewed and manual corrections were applied when required. Cardiac MRI CMR studies were performed with either 1.5 T Siemens Sola (Siemens Erlangen, Germany) or 1.5 T GE HDxT (GE Healthcare Waukesha, Wisconsin) per our institutional Ebstein protocol ( 8 , 9 ). Twenty-six patients underwent CMR at our center and 9 additional patients had studies performed at their referring institution with additional postprocessing at our center. All studies included standard steady state free precession (SSFP) short axis stacks as well as 4 chamber or axial SSFP stacks through the right ventricle to accurately assess pre-operative size and function as per expert consensus guideline( 16 ). The acquired MRI data was analyzed offline by two experienced cardiologists (ABC and TA), using commercially available software CVI42 (Circle Cardiovascular Imaging Inc., Calgary, Canada). The displacement Index (DI) of the tricuspid valve was calculated as the % maximal displacement of the septal leaflet of the tricuspid valve hinge point as compared to RV length measured from the atrioventricular groove to the apex in a 4-chamber view in diastole as has been previously described ( 17 , 18 ) (Fig. 1 A). Noncompacted/Compacted (NC/C) ratio was measured twice in the diastolic phase of the short axis cine SSFP by a single observer (AG) (Fig. 1 B). A mean of the two ratios obtained was used for analysis. Ten percent of subjects were remeasured by a second observer (ABC) with excellent interrater reliability (ICC = 0.96). LV non-compaction (LVNC) was defined as a noncompacted: compacted ratio ≥ 2.3 ( 19 , 20 ). Strain: Left ventricular strain analysis by MRI was performed in Circle CVI 42 by (AG). The end diastolic and end systolic phases were manually assigned. Automated segmentation of long and short axis endocardial and epicardial borders was performed with limited manual correction when necessary. Average global longitudinal and circumferential strain values were collected. Interrater reliability for 10% of remeasured strain analyses was moderate to strong (ICC 0.79). Clinical Data Basic demographic data including age at time of CMR, sex, age at the time of Da Silva Cone procedure, and previous procedures were extracted from the electronic medical record. Perioperative records provided cross-clamp and cardiopulmonary bypass times, length of hospital stay, length of ICU stay along, and duration of post-operative milrinone and epinephrine use. No other inotropes or vasoactive medications were used in our cohort. Statistical Analysis Continuous variables were described using either the mean and standard deviation.. Variables were compared using the Wilcoxon rank-sum test. Pearson’s correlation coefficient (r) was used to assess the correlation between two continuous variables. Linear regression was used for multivariable analysis. P value < 0.05 was considered statistically significant. All data analyses were performed using SPSS (IBM SPSS Version 28, Armonk, NY). Results Thirty-five subjects with EA were included in the study with mean age at CMR of 21.5 ± 15.9 years. Eleven control subjects were included with mean age 16.6 ± 1.6 years. The age and baseline ventricular metrics are summarized in Table 1 . The Ebstein cohort had larger RV volume (RVEDV), lower RVEF and smaller LV volume. Eight EA patients (17%) had previous operations which included tricuspid valve interventions, Blalock Taussig shunt/Glenn and /or pulmonary valve replacement/RV-Pulmonary artery conduit replacement. These procedures were not mutually exclusive. All 35 patients underwent Da Silva Cone procedure at our center. Table 1 Age and baseline CMR ventricular measures Ebstein (n = 35) Normal (n = 11) P- value Age (years) 21.2 ± 16.4 16.6 ± 1.6 0.57 LVEF (%) 57.6 ± 8.6 60.0 ± 4.2 0.32 RVEF (%) 42.5 ± 15.7 53.0 ± 5.5 0.03* LV EDV (mL/m 2 ) 66.0 ± 21.6 79.6 ± 13.9 0.02* RV EDV (mL/m 2 ) 157.9 ± 90 87.6 ± 13.3 0.01* LV GCS (%) -16.4 ± 6.9 -17.2 ± 2.3 0.79 LV GLS (%) -14.0 ± 6.2 -14.5 ± 1.9 0.84 1.3 ± 0.5 0.16 Noncompaction/Compaction Index 1.1 ± 0.2 Values are mean + standard deviation. * p value < 0.05. LVEF = LV Ejection Fraction, RVEF-=RV Ejection Fraction, LVEDV = LV End diastolic volume, RVEDV = RV End diastolic volume, LV GCS = LV Global circumferential strain, LVGLS = LV Global longitudinal strain Table 2 Comparison of various parameters between normal LVEF group to low LVEF group LVEF > 55% (n = 18) LVEF ≤ 55%(n = 14) P- value Age (years) 24.4 ± 19.8 19.9 ± 11.6 0.97 Displacement Index 0.40 ± 0.14 0.47 ± 0.2 0.22 RV EF (%) 45.1 ± 16.8 39.4 ± 14.2 0.2 LV EDV (mL/m 2 ) 60.2 ± 19.8 73.2 ± 22.4 0.06 RV EDV (mL/m 2 ) 147.7 ± 76.3 170.2 ± 107.4 0.54 RV EDV/LV EDV 3.0 ± 2.6 2.7 ± 2.4 0.69 LV GCS (%) -16.8 ± 2.9 -15.0 ± 2.9 0.01* LV GLS (%) -16.1 ± 5.1 -11.8 ± 6.9 0.04* Noncompaction/Compaction Index 1.3 ± 0.5 1.3 ± 0.5 0.90 Bypass time (mins) 141.7 ± 38.5 163.3 ± 41.9 0.17 Aortic crossclamp time (mins) 100.5 ± 33.9 125.4 ± 26.2 0.09 Duration of milrinone (hrs) 47.3 ± 45.9 50.1 ± 21.5 0.49 Duration of epinephrine (hrs) 11.2 ± 22.3 23.5 ± 21.9 0.20 Values are mean + standard deviation. * p value < 0.05. LVEF = LV Ejection Fraction, RVEF-=RV Ejection Fraction, LVEDV = LV End diastolic volume, RVEDV = RV End diastolic volume, LV GCS = LV Global circumferential strain, LVGLS = LV Global longitudinal strain The operations were performed between 2016 and 2023. The timing of surgery was based on symptoms, degree of TR and RV dilation. Concurrent procedures included the following: atrial septal defect closure, pulmonary valve repair, takedown of fenestrated Starnes patch, BTT shunt or Glenn. There was no in-hospital mortality. Preoperative Echo findings Only two patients had mild LV dysfunction on preoperative echo (LVEF 40–55%). Both had confirmed LV dysfunction on pre-operative CMR. All other patients were noted to have normal LVEF by echo. Preoperative CMR findings: In the Ebstein cohort, thirteen (37%) patients had mild LV dysfunction on preoperative Cardiac MRI (EF-40-55%) and one (2.8%) patient had moderate LV dysfunction with LVEF of 37%. Amongst the patients with LV dysfunction 4 studies were performed under general anesthesia, 8 patients were awake and 2 patients’ status was not known as they were performed at outside institutions. The global circumferential and longitudinal strain were lower in the reduced LVEF group compared to those with preserved LVEF (-15% vs. -16.8%, p = 0.01 and − 11.8% vs. −16.1%; p = 0.04; respectively). The global circumferential (-16.8 +/- 2.9) and longitudinal strain (-16.1 +/-5.1) on patients with EA and normal LVEF were comparable to the control group (-17.2+/-2.2) and (-14.5 +/-1.9), respectively. There was moderate negative correlation of LVEF with TV DI (r = − 0.57) and weak negative correlation of LVEF with right ventricular end diastolic volume (RVEDV) (r=-0.27) and (Fig. 2 ). Multivariable linear regression analysis adjusted for age found LV EF to have significant negative correlation with the tricuspid valve displacement index and RVEDV after adjustment for age (Table 4). A single EA patient (3%) met criteria for LVNC with a maximal NC/C ratio > 2.3. There was a trend toward higher NC/C ratio in the EA population (1.33 +/- 0.5) vs. controls (1.14 +/- 0.2), p = 0.08. Based on previous literature( 21 ) studying normal LV trabeculation and the hypothesis that many patients with EA have abnormal trabeculation while not meeting criteria for LVNC we chose a threshold NC/C ratio of 1.2 for comparison within our population (Table 3 ). No significant differences were found in LV EF, LV longitudinal and circumferential strain, however RVEF was significantly lower in the patients with NC/C ratio > 1.2. Table 3 Comparison of various parameters between elevated left ventricular NC/C ratio (> 1.2) to lower NC/C ratio ( 1.2 (n = 19) NC/C ratio < 1.2(n = 14) P-value Age (years) 21.5 ± 15.9 20.8 ± 17.7 0.72 Displacement index 0.5 ± 0.2 0.4 ± 0.1 0.34 RV EDV/LV EDV (ml/m 2 ) 2.3 ± 1.3 2.8 ± 2.4 0.96 LVEF (%) 57.4 ± 9.8 57.3 ± 7.4 0.96 RVEF (%) 36.8 ± 15.2 49.6 ± 9.3 0.01* LV EDV (mL/m 2 ) 72.6 ± 24.1 61.6 ± 15.4 0.26 LV GCS (%) -17.2 ± 3.7 − 15.8 ± 9.9 0.72 LV GLS (%) -14.5 ± 4.4 -14.2 ± 7.8 0.78 Aortic crossclamp time (mins) 113.8 ± 30.1 106.5 ± 25.7 0.65 Bypass time (mins) 159.2 ± 39.8 143.3 ± 39.3 0.28 Duration of milrinone (hrs) 60.9 ± 72.2 29.7 ± 38.7 0.28 Duration of epinephrine (hrs) 17.9 ± 30.4 6.5 ± 14.9 0.11 Values are mean + standard deviation. * p value < 0.05. LVEF = LV Ejection Fraction, RVEF-=RV Ejection Fraction, LVEDV = LV End diastolic volume, RVEDV = RV End diastolic volume, LV GCS = LV Global circumferential strain, LVGLS = LV Global longitudinal strain Table 4: Linear regression analysis showing the association of LVEF with multiple variables Perioperative management: EA patients with preoperative LV dysfunction had longer CPB time (163 +/- 42 vs 142 +/-38 min, p = 0.17) and longer aortic cross clamp time (125 +/-26 vs 100 +/-34 min, p = 0.09) as compared to those with normal LV function. The duration of milrinone use was comparable in the two groups (50.1 +/-21.5 vs 47.3 +/-45.9, p = 0.85), but there was longer use of epinephrine in the immediate postoperative period in the group with pre-operative LV dysfunction (23.5 +/- 22 vs 11.2 +/- 22.3 hrs, p = 0.20) as compared to those with normal LV function. There were no significant differences in cardiopulmonary bypass times or aortic cross-clamp times related to LV trabeculation indices. Discussion The classic description of EA focuses on the tricuspid valve morphology and dysfunction with resultant right heart dilation and dysfunction ( 22 ). This study is consistent in that the EA patients at baseline had markedly dilated RV and lower RVEF as compared to the healthy subjects(Table 1 ). To the best of our knowledge, this is the largest study using CMR to assess left ventricular structure and function with respect to EA disease severity and management. Our findings revealed that, LV dysfunction was common in preoperative EA patients (40%) which is consistent with prior literature( 9 , 23 , 24 , 25 ). Many cases exhibited reduced LVEF likely due to RV dilatation, paradoxical septal motion, and ventricular interdependence which is consistent with prior studies. ( 26 , 27 , 28 )There has been accumulation of evidence for more than coincidental occurrence of EA and LVNC ( 29 )There has also been literature describing a genetic underpinning of EA with LVNC ( 30 ), ( 31 ), ( 32 ). The reported prevalence of LVNC has been variable (4.8–29%) in patients with EA ( 8 ),( 33 ) ( 34 ). Of note these studies used echocardiography as the main tool to diagnose LVNC in these patients which is inherently difficult with poor reproducibility.. Based on the most commonly referenced MRI Peterson criteria ( 19 ), only 1 patient (2.8%) met the diagnosis of LVNC in our study population. However, there was a trend toward higher LVNC ratio in the EA population compared to control in our cohort. Interestingly, transthoracic echocardiogram underestimated patients with LV dysfunction, detecting only two (14%) out of fourteen diagnosed to have dysfunction on CMR in the cohort. Most of the patients with mild LV dysfunction on CMR were not detected by echocardiography. This highlights the challenges of quantitative echocardiographic assessment of LV function in the setting of dyskinetic septal motion. LV dysfunction in EA has been thought to be a consequence of compression caused by a dilated RV and abnormal septal motion. The prevalence of LV hypertrabeculation provides another perspective of underlying intrinsic myocardial abnormalities. Though our study was underpowered to show correlation between hypertrabeculation and LV dysfunction, there was a trend toward increased LV NC/C ratio in the EA population compared to normal controls. A recent study found myocardial fibrosis in EA was associated with worse LV function suggesting a propensity toward myocardial fibrosis and providing support for further study of LV myocardium in EA( 35 ). While LVEF is the main criterion of systolic function in clinical practice, myocardial strain imaging techniques have been proven to identify occult myocardial dysfunction before clinically decreased LVEF ( 36 , 37 ). We postulated that myocardial strain may help to risk stratify the preoperative EA patient. In our study, the global circumferential and longitudinal strain on CMR of EA patients with normal LVEF were comparable to the control group. However, the global peak circumferential and longitudinal strain was lower in the reduced LVEF group than the strain measured in preserved LVEF groups suggesting CMR strain may have value in the pre-operative evaluation of EA It is no surprise that the most extreme forms of EA have associated LV dysfunction, but our study lends further support to specific measures of disease. RVEDV, the ratio of RVEDV/LVEDV and TV DI were used as indirect markers of severity of EA. LV dysfunction had negative correlation to increasing DI and RVEDV. This validates the ventricular interdependence mechanism as the cause of LV dysfunction whereby patients with more severe displacement of the TV hinge point had larger atrialized right ventricular chambers and thus greater impingement on left atrial and left ventricular filling. A previous study by Liu et al, reported negative correlation of LVEF to TV regurgitation but no studies thus far have reported an association with TV DI ( 38 ). In the current study, we also compared the impact of preoperative LV dysfunction to immediate postoperative stay clinical outcomes and found that there was a trend towards longer operative times (cardiopulmonary bypass and aortic cross clamp times). The correlation of more severe displacement in patients with preoperative LV dysfunction can explain the longer cross-clamp time as higher complexity surgical maneuvers are needed during the TV repair. There was also longer use of epinephrine in the immediate postop period in the ICU in those who had LV dysfunction as compared to those with normal LV function. Prior studies have reported LV dysfunction independently predictive of increased late mortality in EA( 10 ), however we conclude that LV function also has implications in the perioperative period. Limitations: Our study has several limitations. The retrospective study design led to a variable timing of the preoperative CMR in relation to the timing of surgery. We included a minority of CMR studies performed at referral centers which introduces variation in the CMR acquisition parameters. Since our institute is an international referral center for Ebstein anomaly, our study includes a significant referral bias that may include better surgical candidates, however many patients were referred following attempted prior palliation which complicates their surgical management Furthermore, many patients returned to their home centers immediately following surgery, therefore while the LV dysfunction seemed to impact the immediate perioperative period, we do not have longer term follow up to assess ventricular remodeling following the Da Silva Cone operation. Though this is the largest reported dataset of EA patients with CMR, overall, the study is limited by relatively small cohort size. The number of patients in each subgroup was small, limiting the statistical power of these findings. Larger, multi-center studies are needed to validate our results. Conclusions True LVNC is rare in this population, but our data supports increased trabeculation of the LV in EA. There is negative correlation of LV function with right heart volume and tricuspid valve displacement index, all markers of EA disease severity. No correlation was found between the degree of LV trabeculation and LV dysfunction. However, the presence of LV dysfunction is under-recognized by echocardiogram and quality CMR assessment of the LV is relevant to perioperative management of EA. Further studies with a long-term follow up are necessary. Declarations Competing interests: The authors declare that they have no competing interests. Author Contribution AG collected the data and wrote the manuscript. CDC collected data and LW analyzed the data. LDS, JDS , CD, LO, TA, AC formulated the hypothesis, analyzed the results and reviewed the manuscript. All authors read and approved the final manuscript. References Attenhofer Jost CH, Connolly HM, Edwards WD, Hayes D, Warnes CA, Danielson GK. Ebstein's anomaly - review of a multifaceted congenital cardiac condition. Swiss Med Wkly. 2005;135(19-20):269-81. Dearani JA, Mora BN, Nelson TJ, Haile DT, O'Leary PW. Ebstein anomaly review: what's now, what's next? Expert Rev Cardiovasc Ther. 2015;13(10):1101-9. Lee CM, Sheehan FH, Bouzas B, Chen SS, Gatzoulis MA, Kilner PJ. The shape and function of the right ventricle in Ebstein's anomaly. Int J Cardiol. 2013;167(3):704-10. Tobler D, Yalonetsky S, Crean AM, Granton JT, Burchill L, Silversides CK, et al. Right heart characteristics and exercise parameters in adults with Ebstein anomaly: new perspectives from cardiac magnetic resonance imaging studies. Int J Cardiol. 2013;165(1):146-50. . Yang D, Sun J, Wan K, Luo Y, Liu H, Cheng W, et al. LV geometric and substrate remodelling in patient with Ebstein anomaly - a deep insight from MRI T1 mapping fibrosis imaging. Journal of Cardiovascular Magnetic Resonance. 2016;18(S1). Goleski PJ, Sheehan FH, Chen SS, Kilner PJ, Gatzoulis MA. The shape and function of the left ventricle in Ebstein's anomaly. Int J Cardiol. 2014;171(3):404-12. Attenhofer Jost CH, Connolly HM, O'Leary PW, Warnes CA, Tajik AJ, Seward JB. Left heart lesions in patients with Ebstein anomaly. Mayo Clin Proc. 2005;80(3):361-8. Benson LN, Child JS, Schwaiger M, Perloff JK, Schelbert HR. Left ventricular geometry and function in adults with Ebstein's anomaly of the tricuspid valve. Circulation. 1987;75(2):353-9. Brown ML, Dearani JA, Danielson GK, Cetta F, Connolly HM, Warnes CA, et al. Effect of operation for Ebstein anomaly on left ventricular function. Am J Cardiol. 2008;102(12):1724-7. Li X, Wang SM, Schreiber C, Cheng W, Lin K, Sun JY, et al. More than valve repair: Effect of cone reconstruction on right ventricular geometry and function in patients with Ebstein anomaly. Int J Cardiol. 2016;206:131-7. Lange R, Burri M, Eschenbach LK, Badiu CC, da Silva JP, Nagdyman N, et al. Da Silva's cone repair for Ebstein's anomaly: effect on right ventricular size and function. Eur J Cardiothorac Surg. 2015;48(2):316-20; discussion 20-1. Brown ML, Dearani JA, Danielson GK, Cetta F, Connolly HM, Warnes CA, et al. Functional status after operation for Ebstein anomaly: the Mayo Clinic experience. J Am Coll Cardiol. 2008;52(6):460-6. Neijenhuis RML, Tsang VT, Marek J, Issitt R, Bonello B, Von Klemperer K, et al. Cone reconstruction for Ebstein anomaly: Late biventricular function and possible remodeling. J Thorac Cardiovasc Surg. 2021;161(3):1097-108. Beroukhim RS, Jing L, Harrild DM, Fornwalt BK, Mejia-Spiegeler A, Rhodes J, et al. Impact of the cone operation on left ventricular size, function, and dyssynchrony in Ebstein anomaly: a cardiovascular magnetic resonance study. J Cardiovasc Magn Reson. 2018;20(1):32. Fratz S, Chung T, Greil GF, Samyn MM, Taylor AM, Valsangiacomo Buechel ER, et al. Guidelines and protocols for cardiovascular magnetic resonance in children and adults with congenital heart disease: SCMR expert consensus group on congenital heart disease. J Cardiovasc Magn Reson. 2013;15(1):51. Leung MP, Baker EJ, Anderson RH, Zuberbuhler JR. Cineangiographic spectrum of Ebstein's malformation: its relevance to clinical presentation and outcome. J Am Coll Cardiol. 1988;11(1):154-61. Alsaied T, Castrillon CD, Christopher A, Da Silva J, Morell VO, Lanford L, et al. Cardiac MRI predictors of right ventricular dysfunction after the Da Silva cone operation for Ebstein's anomaly. International Journal of Cardiology Congenital Heart Disease. 2022;7. Petersen SE, Selvanayagam JB, Wiesmann F, Robson MD, Francis JM, Anderson RH, et al. Left ventricular non-compaction: insights from cardiovascular magnetic resonance imaging. J Am Coll Cardiol. 2005;46(1):101-5. Grothoff M, Pachowsky M, Hoffmann J, Posch M, Klaassen S, Lehmkuhl L, et al. Value of cardiovascular MR in diagnosing left ventricular non-compaction cardiomyopathy and in discriminating between other cardiomyopathies. Eur Radiol. 2012;22(12):2699-709. Dawson DK, Maceira AM, Raj VJ, Graham C, Pennell DJ, Kilner PJ. Regional thicknesses and thickening of compacted and trabeculated myocardial layers of the normal left ventricle studied by cardiovascular magnetic resonance. Circ Cardiovasc Imaging. 2011;4(2):139-46. Fratz S, Janello C, Muller D, Seligmann M, Meierhofer C, Schuster T, et al. The functional right ventricle and tricuspid regurgitation in Ebstein's anomaly. Int J Cardiol. 2013;167(1):258-61. Daliento L, Angelini A, Ho SY, Frescura C, Turrini P, Baratella MC, et al. Angiographic and morphologic features of the left ventricle in Ebstein's malformation. Am J Cardiol. 1997;80(8):1051-9. Hurwitz RA. Left ventricular function in infants and children with symptomatic Ebstein's anomaly. Am J Cardiol. 1994;73(9):716-8. Chauvaud S, Berrebi A, d'Attellis N, Mousseaux E, Hernigou A, Carpentier A. Ebstein's anomaly: repair based on functional analysis. Eur J Cardiothorac Surg. 2003;23(4):525-31. Louie EK, Lin SS, Reynertson SI, Brundage BH, Levitsky S, Rich S. Pressure and volume loading of the right ventricle have opposite effects on left ventricular ejection fraction. Circulation. 1995;92(4):819-24. Bonow RO, Borer JS, Rosing DR, Bacharach SL, Green MV, Kent KM. Left ventricular functional reserve in adult patients with atrial septal defect: pre- and postoperative studies. Circulation. 1981;63(6):1315-22. Kelly DT, Spotnitz HM, Beiser GD, Pierce JE, Epstein SE. Effects of chronic right ventricular volume and pressure loading on left ventricular performance. Circulation. 1971;44(3):403-12. Thareja SK, Frommelt MA, Lincoln J, Lough JW, Mitchell ME, Tomita-Mitchell A. A Systematic Review of Ebstein's Anomaly with Left Ventricular Noncompaction. J Cardiovasc Dev Dis. 2022;9(4). Vermeer AM, van Engelen K, Postma AV, Baars MJ, Christiaans I, De Haij S, et al. Ebstein anomaly associated with left ventricular noncompaction: an autosomal dominant condition that can be caused by mutations in MYH7. Am J Med Genet C Semin Med Genet. 2013;163C(3):178-84. Klaassen S, Probst S, Oechslin E, Gerull B, Krings G, Schuler P, et al. Mutations in sarcomere protein genes in left ventricular noncompaction. Circulation. 2008;117(22):2893-901. van Engelen K, Postma AV, van de Meerakker JB, Roos-Hesselink JW, Helderman-van den Enden AT, Vliegen HW, et al. Ebstein's anomaly may be caused by mutations in the sarcomere protein gene MYH7. Neth Heart J. 2013;21(3):113-7. Pignatelli RH, Texter KM, Denfield SW, Grenier MA, Altman CA, Ayres NA, et al. LV Noncompaction in Ebstein's anomaly in infants and outcomes. JACC Cardiovasc Imaging. 2014;7(2):207-9. Kumor M, Lipczynska M, Biernacka EK, Klisiewicz A, Wojcik A, Konka M, et al. Cardiac arrest and ventricular arrhythmia in adults with Ebstein anomaly and left ventricular non-compaction. J Cardiol. 2018;71(5):484-7. Yang D, Sun J, Luo Y, Liu H, Wan K, Zhang T, et al. Feature tracking (FT) and extracelluar volume (ECV) by cardiac magnetic resonance segmentally analyze change of LV in Ebstein:a novel perspective in myocardial remodeling. Journal of Cardiovascular Magnetic Resonance. 2016;18(Suppl 1). Smiseth OA, Torp H, Opdahl A, Haugaa KH, Urheim S. Myocardial strain imaging: how useful is it in clinical decision making? Eur Heart J. 2016;37(15):1196-207. Aletras AH, Tilak GS, Hsu LY, Arai AE. Heterogeneity of intramural function in hypertrophic cardiomyopathy: mechanistic insights from MRI late gadolinium enhancement and high-resolution displacement encoding with stimulated echoes strain maps. Circ Cardiovasc Imaging. 2011;4(4):425-34. Liu X, Zhang Q, Yang ZG, Guo YK, Shi K, Xu HY, et al. Morphologic and functional abnormalities in patients with Ebstein's anomaly with cardiac magnetic resonance imaging: Correlation with tricuspid regurgitation. Eur J Radiol. 2016;85(9):1601-6. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 19 Jul, 2024 Read the published version in Pediatric Cardiology → Version 1 posted Reviews received at journal 29 Apr, 2024 Reviews received at journal 09 Apr, 2024 Reviewers agreed at journal 08 Apr, 2024 Reviewers agreed at journal 08 Apr, 2024 Reviewers invited by journal 08 Apr, 2024 Submission checks completed at journal 06 Apr, 2024 Editor assigned by journal 06 Apr, 2024 First submitted to journal 04 Apr, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4219470","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":289438927,"identity":"71416e48-fb9c-419b-a15c-96262e2ecf44","order_by":0,"name":"Aditi Gupta","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAx0lEQVRIiWNgGAWjYPACCWZ+KIuxgQjlIEUW7JINJGqp4Dc4QKwW+Yjc4w9+1EhIG9/IPbrhB4ON7IYDBLQY3shLbOw5JmFsdiMv7WYPQ5oxYS0zcgwbeNgkks1u5JjdZmA4nEiUlsY//yTqN88Aa/lPWIu8RI5hM2+bBLOBBFjLAcJaDHjeJc6W7ZNgljjzDugXg2TjmQRtac898PHNtzpm/vbcYzd+VNjJ9hG05QAPjAliGBBQDralAUXLKBgFo2AUjAIsAACIxkWaYE1u+QAAAABJRU5ErkJggg==","orcid":"","institution":"UPMC Children’s Hospital of Pittsburgh","correspondingAuthor":true,"prefix":"","firstName":"Aditi","middleName":"","lastName":"Gupta","suffix":""},{"id":289438928,"identity":"d60dc74f-c1f2-4f06-b7cf-b361668afdb9","order_by":1,"name":"Luciana Da Silva","email":"","orcid":"","institution":"UPMC Children’s Hospital of Pittsburgh","correspondingAuthor":false,"prefix":"","firstName":"Luciana","middleName":"Da","lastName":"Silva","suffix":""},{"id":289438930,"identity":"1b9cc0ca-1213-4496-8de9-871d850a6a94","order_by":2,"name":"Carlos Diaz Castrillon","email":"","orcid":"","institution":"UPMC Children’s Hospital of Pittsburgh","correspondingAuthor":false,"prefix":"","firstName":"Carlos","middleName":"Diaz","lastName":"Castrillon","suffix":""},{"id":289438932,"identity":"e076208a-56a7-4d27-ae35-697f85552743","order_by":3,"name":"Li Wang","email":"","orcid":"","institution":"University of Pittsburgh","correspondingAuthor":false,"prefix":"","firstName":"Li","middleName":"","lastName":"Wang","suffix":""},{"id":289438933,"identity":"f947bae1-e0a4-4ce7-b3ca-4f713f266e17","order_by":4,"name":"Craig Dobson","email":"","orcid":"","institution":"UPMC Children’s Hospital of Pittsburgh","correspondingAuthor":false,"prefix":"","firstName":"Craig","middleName":"","lastName":"Dobson","suffix":""},{"id":289438936,"identity":"9a148a2c-747c-40c0-8ede-ad7df8a7a296","order_by":5,"name":"Jose Da Silva","email":"","orcid":"","institution":"UPMC Children’s Hospital of Pittsburgh","correspondingAuthor":false,"prefix":"","firstName":"Jose","middleName":"Da","lastName":"Silva","suffix":""},{"id":289438940,"identity":"f88adf5e-6dbc-4e85-8020-a6bba3af1fc5","order_by":6,"name":"Laura Olivieri","email":"","orcid":"","institution":"UPMC Children’s Hospital of Pittsburgh","correspondingAuthor":false,"prefix":"","firstName":"Laura","middleName":"","lastName":"Olivieri","suffix":""},{"id":289438944,"identity":"92de7364-6422-4d89-9dae-2d38ebdd6a46","order_by":7,"name":"Tarek Alsaied","email":"","orcid":"","institution":"UPMC Children’s Hospital of Pittsburgh","correspondingAuthor":false,"prefix":"","firstName":"Tarek","middleName":"","lastName":"Alsaied","suffix":""},{"id":289438947,"identity":"943080ec-3bf8-4731-87d2-8aef86e8e29d","order_by":8,"name":"Adam Christopher","email":"","orcid":"","institution":"UPMC Children’s Hospital of Pittsburgh","correspondingAuthor":false,"prefix":"","firstName":"Adam","middleName":"","lastName":"Christopher","suffix":""}],"badges":[],"createdAt":"2024-04-04 18:59:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4219470/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4219470/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00246-024-03585-8","type":"published","date":"2024-07-20T00:27:28+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":54518761,"identity":"f1a336bb-f536-41ca-bfc6-9f29c880725f","added_by":"auto","created_at":"2024-04-11 17:29:46","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":284331,"visible":true,"origin":"","legend":"\u003cp\u003eA: Displacement Index (DI) was calculated as the % maximal displacement of the septal leaflet of the tricuspid valve(red line) compared to the base to apex length of the right ventricle measured from a 4-chamber view in diastole (white line).Figure 1B: LV noncompacted: compacted (LVNC) ratio was measured in the diastolic phase of short axis cine SSFP (red line – length of the noncompacted layer and white line – length of the compacted layer)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4219470/v1/f9b515240740f7147407d6d3.png"},{"id":54518757,"identity":"d3b058a4-23aa-4934-aee9-e3af63dd56ed","added_by":"auto","created_at":"2024-04-11 17:29:46","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":61276,"visible":true,"origin":"","legend":"\u003cp\u003eA: \u0026nbsp;Moderate negative correlation between left ventricular ejection fraction and Displacement Index (r= -0.57). Figure 2B: Weak negative correlation between left ventricular ejection fraction and right ventricular end diastolic volume (r=- 0.27)\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4219470/v1/320726be1e1c516ece5e95a9.png"},{"id":60753950,"identity":"130e5138-faa3-48c7-9828-046007334e70","added_by":"auto","created_at":"2024-07-21 00:27:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":807531,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4219470/v1/b8d3945b-73d6-4486-b098-3c23dcabb15f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessing left ventricular pathology in patients with Ebstein anomaly using Cardiovascular magnetic resonance: Looking past the right heart","fulltext":[{"header":"Background","content":"\u003cp\u003eEbstein anomaly (EA) is a rare and complex congenital cardiac malformation first described in 1866 and is estimated to occur in \u0026lt;\u0026thinsp;1% of all congenital cardiac malformations(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). It is marked by malformations of the tricuspid valve, specifically tricuspid annulus dilation, apical displacement of septal and posterior leaflets, and failure of delamination of those leaflets. These structural defects lead to progressive tricuspid regurgitation (TR), right atrial dilation, right ventricular enlargement with associated dysfunction, and often clinical symptoms of heart failure(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Although the most prominent pathology is in the right heart, there is data that the left ventricle in Ebstein anomaly is also abnormal and can suffer from intrinsic structural and functional abnormalities. These include LV hypertrabeculation/non-compaction cardiomyopathy (LVNC), fibrosis, dysfunction and dyssynchrony(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). LV dysfunction has been reported in 7\u0026ndash;50% patients with EA; (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) however the mechanism of LV dysfunction in EA is yet to be elucidated. Multiple case series have described hyper trabeculation/LVNC in patients with EA; however, these are limited by image quality and small cohorts.\u003c/p\u003e \u003cp\u003eThe Da Silva cone operation is a surgical technique aimed at reconstructing the tricuspid valve to promote competence and expand the functional right ventricle by positioning the annulus at the right atrioventricular groove. There is now strong evidence demonstrating significant improvement in TR, RV end-diastolic volume (EDV),(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) right ventricular systolic function, and exercise tolerance during long-term follow up after the Da Silva Cone procedure(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e); however, there has been limited data describing preoperative LV morphology and function in these patients.\u003c/p\u003e \u003cp\u003eOur aim was to evaluate the prevalence of hypertrabeculation/LVNC and preoperative LV dysfunction amongst a heterogenous population of referrals to the Da Silva Center for Ebstein's Anomaly, and correlate these to right ventricular parameters and perioperative care\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e \u003cstrong\u003eStudy population\u003c/strong\u003e \u003cp\u003eAll patients with EA who underwent pre-operative cardiac MRI (CMR) and subsequent surgical repair with The Da Silva Cone procedure at our center between the period of 2014\u0026ndash;2023 were included. Four patients were excluded due to limited image quality. A group of 11healthy age- and sex-matched subjects who underwent clinical magnetic resonance image (MRI) examination with normal results were included as controls. Control patients were referred for screening MRI in the setting of connective tissue disorder or arrhythmia. None of the control patients had evidence of ventricular dilation or dysfunction. The study was approved by the UPMC Institutional Review Board who waived the requirement for informed consent.\u003c/p\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eEchocardiography:\u003c/h2\u003e \u003cp\u003eAll patients underwent transthoracic echocardiograms preoperatively by pediatric cardiac sonographers using either Phillips IE33, Epiq 7C (Philips Medical Systems, Andover, MA) or GE VIVID E95 (GE Healthcare, Chicago, IL) ultrasound machines. LVEF measured by the bullet method was abstracted from the clinical echocardiogram reports produced at the time of study.\u003c/p\u003e \u003cp\u003eLVEF was defined as normal\u0026thinsp;\u0026gt;\u0026thinsp;55%, mildly reduced 40\u0026ndash;55%, moderately reduced 30\u0026ndash;39%, and severely reduced\u0026thinsp;\u0026lt;\u0026thinsp;30%. Speckle tracking analysis was performed using QLAB Autostrain LV version 13.0 (Phillips Ultrasound, Inc, Bothell, WA) to provide global longitudinal strain (GLS) using apical two, three, and four chamber views. Accuracy of autocontouring was reviewed and manual corrections were applied when required.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eCardiac MRI\u003c/h2\u003e \u003cp\u003eCMR studies were performed with either 1.5 T Siemens Sola (Siemens Erlangen, Germany) or 1.5 T GE HDxT (GE Healthcare Waukesha, Wisconsin) per our institutional Ebstein protocol (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Twenty-six patients underwent CMR at our center and 9 additional patients had studies performed at their referring institution with additional postprocessing at our center. All studies included standard steady state free precession (SSFP) short axis stacks as well as 4 chamber or axial SSFP stacks through the right ventricle to accurately assess pre-operative size and function as per expert consensus guideline(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe acquired MRI data was analyzed offline by two experienced cardiologists (ABC and TA), using commercially available software CVI42 (Circle Cardiovascular Imaging Inc., Calgary, Canada).\u003c/p\u003e \u003cp\u003eThe displacement Index (DI) of the tricuspid valve was calculated as the % maximal displacement of the septal leaflet of the tricuspid valve hinge point as compared to RV length measured from the atrioventricular groove to the apex in a 4-chamber view in diastole as has been previously described (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eNoncompacted/Compacted (NC/C) ratio was measured twice in the diastolic phase of the short axis cine SSFP by a single observer (AG) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). A mean of the two ratios obtained was used for analysis. Ten percent of subjects were remeasured by a second observer (ABC) with excellent interrater reliability (ICC\u0026thinsp;=\u0026thinsp;0.96). LV non-compaction (LVNC) was defined as a noncompacted: compacted ratio\u0026thinsp;\u0026ge;\u0026thinsp;2.3 (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eStrain:\u003c/p\u003e \u003cp\u003eLeft ventricular strain analysis by MRI was performed in Circle CVI 42 by (AG). The end diastolic and end systolic phases were manually assigned. Automated segmentation of long and short axis endocardial and epicardial borders was performed with limited manual correction when necessary. Average global longitudinal and circumferential strain values were collected. Interrater reliability for 10% of remeasured strain analyses was moderate to strong (ICC 0.79).\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eClinical Data\u003c/strong\u003e \u003cp\u003eBasic demographic data including age at time of CMR, sex, age at the time of Da Silva Cone procedure, and previous procedures were extracted from the electronic medical record. Perioperative records provided cross-clamp and cardiopulmonary bypass times, length of hospital stay, length of ICU stay along, and duration of post-operative milrinone and epinephrine use. No other inotropes or vasoactive medications were used in our cohort.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStatistical Analysis\u003c/strong\u003e \u003cp\u003eContinuous variables were described using either the mean and standard deviation.. Variables were compared using the Wilcoxon rank-sum test. Pearson\u0026rsquo;s correlation coefficient (r) was used to assess the correlation between two continuous variables. Linear regression was used for multivariable analysis. P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. All data analyses were performed using SPSS (IBM SPSS Version 28, Armonk, NY).\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThirty-five subjects with EA were included in the study with mean age at CMR of 21.5\u0026thinsp;\u0026plusmn;\u0026thinsp;15.9 years. Eleven control subjects were included with mean age 16.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6 years. The age and baseline ventricular metrics are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The Ebstein cohort had larger RV volume (RVEDV), lower RVEF and smaller LV volume. Eight EA patients (17%) had previous operations which included tricuspid valve interventions, Blalock Taussig shunt/Glenn and /or pulmonary valve replacement/RV-Pulmonary artery conduit replacement. These procedures were not mutually exclusive. All 35 patients underwent Da Silva Cone procedure at our center.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAge and baseline CMR ventricular measures\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEbstein (n\u0026thinsp;=\u0026thinsp;35)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNormal (n\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP- value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e21.2\u0026thinsp;\u0026plusmn;\u0026thinsp;16.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e16.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVEF (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e57.6\u0026thinsp;\u0026plusmn;\u0026thinsp;8.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e60.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRVEF (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e42.5\u0026thinsp;\u0026plusmn;\u0026thinsp;15.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e53.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.03*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLV EDV (mL/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e66.0\u0026thinsp;\u0026plusmn;\u0026thinsp;21.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e79.6\u0026thinsp;\u0026plusmn;\u0026thinsp;13.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.02*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRV EDV (mL/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e157.9\u0026thinsp;\u0026plusmn;\u0026thinsp;90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e87.6\u0026thinsp;\u0026plusmn;\u0026thinsp;13.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.01*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLV GCS (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e-16.4\u0026thinsp;\u0026plusmn;\u0026thinsp;6.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e-17.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.79\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLV GLS (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e-14.0\u0026thinsp;\u0026plusmn;\u0026thinsp;6.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e-14.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e1.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNoncompaction/Compaction Index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eValues are mean\u0026thinsp;+\u0026thinsp;standard deviation. * p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05. LVEF\u0026thinsp;=\u0026thinsp;LV Ejection Fraction, RVEF-=RV Ejection Fraction, LVEDV\u0026thinsp;=\u0026thinsp;LV End diastolic volume, RVEDV\u0026thinsp;=\u0026thinsp;RV End diastolic volume, LV GCS\u0026thinsp;=\u0026thinsp;LV Global circumferential strain, LVGLS\u0026thinsp;=\u0026thinsp;LV Global longitudinal strain\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of various parameters between normal LVEF group to low LVEF group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLVEF\u0026thinsp;\u0026gt;\u0026thinsp;55% (n\u0026thinsp;=\u0026thinsp;18)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLVEF\u0026thinsp;\u0026le;\u0026thinsp;55%(n\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP- value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e24.4\u0026thinsp;\u0026plusmn;\u0026thinsp;19.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e19.9\u0026thinsp;\u0026plusmn;\u0026thinsp;11.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisplacement Index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0.40\u0026thinsp;\u0026plusmn;\u0026thinsp;0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.47\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRV EF (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e45.1\u0026thinsp;\u0026plusmn;\u0026thinsp;16.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e39.4\u0026thinsp;\u0026plusmn;\u0026thinsp;14.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLV EDV (mL/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e60.2\u0026thinsp;\u0026plusmn;\u0026thinsp;19.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e73.2\u0026thinsp;\u0026plusmn;\u0026thinsp;22.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRV EDV (mL/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e147.7\u0026thinsp;\u0026plusmn;\u0026thinsp;76.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e170.2\u0026thinsp;\u0026plusmn;\u0026thinsp;107.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRV EDV/LV EDV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e2.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLV GCS (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e-16.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e-15.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.01*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLV GLS (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e-16.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e-11.8\u0026thinsp;\u0026plusmn;\u0026thinsp;6.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.04*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNoncompaction/Compaction Index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e1.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e1.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBypass time (mins)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e141.7\u0026thinsp;\u0026plusmn;\u0026thinsp;38.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e163.3\u0026thinsp;\u0026plusmn;\u0026thinsp;41.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAortic crossclamp time (mins)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e100.5\u0026thinsp;\u0026plusmn;\u0026thinsp;33.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e125.4\u0026thinsp;\u0026plusmn;\u0026thinsp;26.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of milrinone (hrs)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e47.3\u0026thinsp;\u0026plusmn;\u0026thinsp;45.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e50.1\u0026thinsp;\u0026plusmn;\u0026thinsp;21.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of epinephrine (hrs)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e11.2\u0026thinsp;\u0026plusmn;\u0026thinsp;22.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e23.5\u0026thinsp;\u0026plusmn;\u0026thinsp;21.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eValues are mean\u0026thinsp;+\u0026thinsp;standard deviation. * p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05. LVEF\u0026thinsp;=\u0026thinsp;LV Ejection Fraction, RVEF-=RV Ejection Fraction, LVEDV\u0026thinsp;=\u0026thinsp;LV End diastolic volume, RVEDV\u0026thinsp;=\u0026thinsp;RV End diastolic volume, LV GCS\u0026thinsp;=\u0026thinsp;LV Global circumferential strain, LVGLS\u0026thinsp;=\u0026thinsp;LV Global longitudinal strain\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe operations were performed between 2016 and 2023. The timing of surgery was based on symptoms, degree of TR and RV dilation. Concurrent procedures included the following: atrial septal defect closure, pulmonary valve repair, takedown of fenestrated Starnes patch, BTT shunt or Glenn. There was no in-hospital mortality.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePreoperative Echo findings\u003c/strong\u003e \u003cp\u003eOnly two patients had mild LV dysfunction on preoperative echo (LVEF 40\u0026ndash;55%). Both had confirmed LV dysfunction on pre-operative CMR. All other patients were noted to have normal LVEF by echo.\u003c/p\u003e \u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003ePreoperative CMR findings:\u003c/h2\u003e \u003cp\u003eIn the Ebstein cohort, thirteen (37%) patients had mild LV dysfunction on preoperative Cardiac MRI (EF-40-55%) and one (2.8%) patient had moderate LV dysfunction with LVEF of 37%. Amongst the patients with LV dysfunction 4 studies were performed under general anesthesia, 8 patients were awake and 2 patients\u0026rsquo; status was not known as they were performed at outside institutions. The global circumferential and longitudinal strain were lower in the reduced LVEF group compared to those with preserved LVEF (-15% vs. -16.8%, p\u0026thinsp;=\u0026thinsp;0.01 and \u0026minus;\u0026thinsp;11.8% vs. \u0026minus;16.1%; p\u0026thinsp;=\u0026thinsp;0.04; respectively). The global circumferential (-16.8 +/- 2.9) and longitudinal strain (-16.1 +/-5.1) on patients with EA and normal LVEF were comparable to the control group (-17.2+/-2.2) and (-14.5 +/-1.9), respectively. There was moderate negative correlation of LVEF with TV DI (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.57) and weak negative correlation of LVEF with right ventricular end diastolic volume (RVEDV) (r=-0.27) and (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Multivariable linear regression analysis adjusted for age found LV EF to have significant negative correlation with the tricuspid valve displacement index and RVEDV after adjustment for age (Table\u0026nbsp;4).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eA single EA patient (3%) met criteria for LVNC with a maximal NC/C ratio\u0026thinsp;\u0026gt;\u0026thinsp;2.3. There was a trend toward higher NC/C ratio in the EA population (1.33 +/- 0.5) vs. controls (1.14 +/- 0.2), p\u0026thinsp;=\u0026thinsp;0.08. Based on previous literature(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) studying normal LV trabeculation and the hypothesis that many patients with EA have abnormal trabeculation while not meeting criteria for LVNC we chose a threshold NC/C ratio of 1.2 for comparison within our population (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). No significant differences were found in LV EF, LV longitudinal and circumferential strain, however RVEF was significantly lower in the patients with NC/C ratio\u0026thinsp;\u0026gt;\u0026thinsp;1.2.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of various parameters between elevated left ventricular NC/C ratio (\u0026gt;\u0026thinsp;1.2) to lower NC/C ratio (\u0026lt;\u0026thinsp;1.2)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNC/C ratio\u0026thinsp;\u0026gt;\u0026thinsp;1.2 (n\u0026thinsp;=\u0026thinsp;19)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNC/C ratio\u0026thinsp;\u0026lt;\u0026thinsp;1.2(n\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e21.5\u0026thinsp;\u0026plusmn;\u0026thinsp;15.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e20.8\u0026thinsp;\u0026plusmn;\u0026thinsp;17.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisplacement index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRV EDV/LV EDV (ml/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e2.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e2.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVEF (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e57.4\u0026thinsp;\u0026plusmn;\u0026thinsp;9.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e57.3\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRVEF (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e36.8\u0026thinsp;\u0026plusmn;\u0026thinsp;15.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e49.6\u0026thinsp;\u0026plusmn;\u0026thinsp;9.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.01*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLV EDV (mL/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e72.6\u0026thinsp;\u0026plusmn;\u0026thinsp;24.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e61.6\u0026thinsp;\u0026plusmn;\u0026thinsp;15.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLV GCS (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e-17.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;15.8\u0026thinsp;\u0026plusmn;\u0026thinsp;9.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLV GLS (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e-14.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e-14.2\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAortic crossclamp time (mins)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e113.8\u0026thinsp;\u0026plusmn;\u0026thinsp;30.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e106.5\u0026thinsp;\u0026plusmn;\u0026thinsp;25.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBypass time (mins)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e159.2\u0026thinsp;\u0026plusmn;\u0026thinsp;39.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e143.3\u0026thinsp;\u0026plusmn;\u0026thinsp;39.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of milrinone (hrs)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e60.9\u0026thinsp;\u0026plusmn;\u0026thinsp;72.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e29.7\u0026thinsp;\u0026plusmn;\u0026thinsp;38.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of epinephrine (hrs)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e17.9\u0026thinsp;\u0026plusmn;\u0026thinsp;30.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e6.5\u0026thinsp;\u0026plusmn;\u0026thinsp;14.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eValues are mean\u0026thinsp;+\u0026thinsp;standard deviation. * p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05. LVEF\u0026thinsp;=\u0026thinsp;LV Ejection Fraction, RVEF-=RV Ejection Fraction, LVEDV\u0026thinsp;=\u0026thinsp;LV End diastolic volume, RVEDV\u0026thinsp;=\u0026thinsp;RV End diastolic volume, LV GCS\u0026thinsp;=\u0026thinsp;LV Global circumferential strain, LVGLS\u0026thinsp;=\u0026thinsp;LV Global longitudinal strain\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\u003cp\u003eTable 4: Linear regression analysis showing the association of LVEF with multiple variables\u003c/p\u003e\n\u003cp\u003e\u003cimg 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pxFxAiilBR5jSgkwBCwqDyeS84TIaB2h1L/If91PooG6ACVggegE5eLciWDVeYhYAh76UkT7AMpwQOMdkU+MVtA3RhLqvAChe97zngW0Au3IOyNC691GFupnIn/9Es/cQxFBxTuA0pQa7RaAkqMLvKlbAKQAlPp+pJMX8M/ZFXUEzkT98DkildJzZGtAybHnRNARrpOb0ONkg94gT9pTvqgGlBxUFICSbrnPfe5TQJ1naqoBpUhjjN5wqAFJsqHMggU10eNkBs+8Txvjbzj19DaZVg+6XTqgWJ36Qgko+9ISEypHAsr5M1pn5v2LxvHWzfcB7hgfhsgQmzQiBZQHg0RJIQDnsMMOK8oKyDQMx6v2SekAlBRwEGVKEQFohqUo6OOPP748IxoCJHmfISTvUR7vDCUpH4qTAjM8FIrMEElEE4Fhypuho4AZRvkYZgfYlEsep512WvGWAUogribKTD4RSWA4gGtRWXkx1IycqI7hP8rbM4wKIInM+8I/itwzystoMOR4wNjw9t2rQTYjJz91EzEQRY164E8MQymf6FDS3DnQR0DJgJNZciJyqL8hwEkkEPhgsDk5gJTFMvoKgEUOyJk+Q3bCuJNT31evXl2mdcgjQA5gZaGJfi6/mB7CMQRE9BtGHkgi18AKWX/0ox9d+os+pjzSkUVD5foguXVN2pjaoh4AJXAUIMkngBGRrgAb5B1Yjr6mz+CBaBqgpcye0feUq03SBdjRf0OPhA4AePVR5QOS9Fv9P6aqAFXq4F2e8X581G8BL7yhD92LoWKAkl7RHvoqAIKPUQ9lir6qnu4D6TFPUh28Az/pTLqRfnJNGvoBMBVZBrrIgPdpayDUu7TVE57whPKMiB99LNpILuhHwE17ANnqgTdkB6mHcnGwgT280T4xQiINXtFndFa0PR7oS/IBJJW1DSg5DO7jn/nt2o4DgwfeExFNDoN3y5PDVAcRSiEX8V8CykVk/mK8OgHlaFwPz1TETcdGFAOFRIGIJFKkOjoQSakhislkfoqPAqDs5QGUihJQarzzIJFAihUg3WGHHZo99tijgEhKhGIxSZzhQoaa5GXVH0MbBLAyihS9T8aLgjLZGwGr8Z2hk4c/5aGA99lnnzKsBCAqH+MTUcV4ByMjnximcp1RiLwYM89abe0a4w5AMlRhID0j6hHPKKPfoiNWlzKYlLH7u+66azH8FDuAiygxw1/SBoCXR3xXPoA8ae4c6COgBOrCWWCAA+ABEsqLADYRJA6gqJo+yghH1NpuAhakkEXOBwChnwACZAv5NOVi9913LzJtbqboe9wX9QJgEcBmiPnoo48ugAsoFMEzR89wLyCl3yt7RMD0KzJtZwhlDwIeABt9MD4BuZgTXH8HeqLfAFeAmgU4m266aQEtABTdE3Mt4x0+6ZhwLv2mtyIv5aG79Lfod4AwwOovSH1MV5HGO7SF4W4rlfFWvd2zalu99dUApHQP4LfllltOtScnMfqqempn9QY+a2dZO3vv4YcfXtoGb0WMDV9bTa1c2gCg5Jwj7bHJJpuUqUW+cwDoVflEBFaUUHvji3cAhHQb2UF0snJpI3xWNzJS85F+Zg+0BQq+nnDCCQV4kiP3fdbEdljwhB+AetR98803L++x8BNYlT896t1W6LvWF0pA2ZeWmFA5ElBOiNH5mikOmBsaAIAxETFIWhoc6COgXBqcW/qljGidmgCrHOTFIMC3BrFzKQPwb+h63MRhBZYRkCliWkcpx/E+UXJOB/CK8D+c6HHkvxB5JKBcCK72OE/z8GK+W4+LmUVbJhwQwRQdNYdMdBO45PUnLQ0OiMiJgiWtPA4YMTHPUb8VUaujcJPkhqHgekrAsO82nK389UjIsM/Olk7U23QlvMEnU4TGTepsGoIRH+9Rl4huj/td48rPCJko/7D0N8MkFP5vby8yzHOZZuE5YJiUkTA8a35L/vWLB+ZBGppeTu1i2M1ct1WrVpW5Un2rm+kJpgcYoupb2RazPHSEoUBgwnDcYpZlub3bsCWZMxTf17oZEnZYgX4LJBiiXYyyAlbzsVem25gracrMuMtNRxtaxxtzM01PqN9Blxhyb1+v08z2XZ3N53QClPeY3mFaxmzPLdZ9OsIc1rEDSiFq8wyS+scBGz4z7haA8LDyrz884IHG3C6R5OXSNmTNPDVDNhZUmHbRl7rhuXlu5mJxtvpSrj6UA29sUbL33nuXhQx9KNNyKIO+bSjTIj2LM/ra1+t+a/i7T/12GDmw+MbccHI8TPq5pNFmRl7oNLyp29B3i4xsbG+/yfreXN4hrToAkt5jLuZcn59keivULRwdO6A04VVIOKl/HHDKglVxwvT51y8eGFp03CAjnm0zmbbBc8r/wQ9+cDEQyffpfGcgGEZ8St5M580o/ADORJ5MBRkln3x2fG0yTl5qV+fNA4HjzLfPedERFohykoalHPIellM9TcfrzDlsPW2cpil7Suailcm2j+Erq0iT1uSAVbuDtpxZM2VemQsHzO8zP86uD0nLjwOGq+0wEPtwLr8aDq6RxZdjj1Basp9KaDDDF/tqrvJe7BaY+f220zG8kTQ5Dtj+xUbYcZzb5N7c/zflKu+FaSPH/9lrsk9bvixMTVdmrhwGW8K1twZa7tzIVd7LvYVb9UtA2WJIz34moJx8gySg7OZ5Aspu3oxyJwHlKNzr/7MJKIdro6GGvDNCORwzFyNVAsrF4Prw70xAOTyvxpUyAWU3JxNQdvNmlDsJKEfhXv+fTUA5XBsloByOT71NlYCyt01TCpaAcvLtk4Cym+cJKLt5M8qdBJSjcK//zyagHK6NElAOx6fepkpA2dumKQVLQDn59klA2c3zBJTdvBnlTgLKUbjX/2cTUA7XRgkoh+NTb1MloOxt05SCzQQonTrjzFqfQb7Xf67H70gz0+dc0s6Uj3tO0nCesa0tBpEzhft44EECykGt9X/XElB282aUOwkoR+Fe/59NQDlcGyWgHI5PvU2VgLK3TVMK1gUoAUkbcK+11lrN0UcfXY4icyLCPvvsU66tu+665ZxX58kedNBBZTNqJ8CgSy65ZI2jwQDJK6+8svHcPe5xjzXOyn3f+97XOHd7WPJeR4Q52aE+09axabENkiPQ3vjGNw6b5cTSJaDsZnUCym7ejHInAeUo3Ov/swkoh2ujBJTD8am3qRJQ9rZpSsG6AKUjrWzAjd75znc2Fr45vu3Zz372tO1uALoPfvCD5e9Tn/pU2ZbkoosuKkeA1TV35qojwxwRBgA63areNgcInelwAvvn/eAHP2gCtNr+RFk+//nPN7///e/Lq+zBBpQ6v1tZA1A6jkx6IBlJ78hJecW1uqwL/T0BZTeHE1B282aUOwkoR+Fe/59NQDlcGyWgHI5PvU2VgLK3TVMK1gUo3/CGN0wBPADIqQRAmb3ObFTvvFpRxw996ENl6BmYtCn15Zdf3nzmM59Zo9KO83KiVRfNBCidreu4sQ033LDZZpttmm984xvllJk73elOzZZbbtlcc801JVvXDYGvvfba5UzdK664onnOc55Tjv703I033lgApGjoJpts0uywww6Nc78nTQkouzmegLKbN6PcSUA5Cvf6/2wCyuHaKAHlcHzqbaoElL1tmlKwLkAJjIkA2jj24osvLufDivo97nGPazbffPNmjz32aL7+9a83N9xwQzm/1vDzu971rvLdtdtuu22q4iKCNk+f6cSkmQCloXJnxCIRSSd+AJnOtv3ud7879R5frr766hJN9V2E8qijjipRUWDWfMrvfe97BWSKkjqxBlD9zW9+My2Phf6RgLKbwwkou3kzyp0ElKNwr//PJqAcro0SUA7Hp96mSkDZ26YpBesClL/73e/KHMrtt9++RAEdb1XPVQTyXvziFzeO/HL+8oknnlgAniHnvfbaqznmmGPKPS/51a9+VYahv/a1r3UyYyZAachdJBRRnK95zWtKhNS5tUBtTYbqY5EOQGn4HYmgGrYHas8444wSTX3HO95RIq7ynCQloOzmdgLKbt6McicB5Sjc6/+zCSiHa6MElMPxqbepElD2tmlKwboAZV1q0cZXvepV01Z7A4enn376VHTvpptuai688MIyTC5CCazdeuutJRvg9CUveUkZGq/zrb8PCyjNhwQYDbkPAyhrcPm2t72tue6665oHPehBBfTuvffeJQqbEcq6JRb3ewLKheF/AsqF4Wtfck1AOVxLJKAcjk+9TbWQgPJjH/tYiTo5v9SQpt9Jc+PAMIDyRS96USPdT37ykxJt9IYYhjacbcGMldWMFmB48803F0BZRyTf//73N+ZRBn3lK18pczJFDC3OASS0ofy+/OUvT1vU84EPfKCAVc8Cqc9//vPLgpqXv/zla0QoP/rRjzZvfetby2tEKGtAKUJpzqRFO4tJCx2hxCND+0uRFgpQWnxFhsmYqRucCwvKVgotdUBJT+jLXaMJdE3XvXG3scV/9Nyll15a9JSpNHTWYtJCA0qO/PXXX7+YVRz47jzLeyBblu/F2QClxR9PfepTi7KfCxes0jXMaj6d/QiPPPLIMocPqBwk+FYIWzACsAxL3/rWt8pCjmHTL8V0XYDym9/8ZmmXU045pTn77LPLquhvf/vbzTOf+cxy3Ypti1yQVd4ULGKkPfOMZzyjGO5ysWnK88961rOaJz7xiSUP2/kAVo9//OPLPEiG3tA250DetYI2T9Jz55xzTnk30GgOpXmVt9xyS7yifCrTcccd11h4Yx6oeZbId+80/G7IXH7kDlidNM0EKNX73HPPLWUj1/Mh81VjisB8nl/MZ2YClAw5Z0C72R5qLmTB1rHHHlsi7XTEEUccUXSOhWTtaRPyJevSzWUXALIYUfm5lG0SaWcClPrE8573vBKtp/NQOG54DcgZZTAqQJ+HfjUFRn/naLZJ//MsR7OeKsN5tGhP/x2WlM8WZvp/OEqcWPnE6ALn0vzpSRDwyt7gC5ty+OGHF/1CD+Jzm/DSlJthicxZaPj9739/2EcKmLZgkv5sk8WU+DOoPdppu34b2bHA0ULMPlECyj61xgTK0gUoKRkgIgAGYBjKYphiiTRZeYwofiADXXvttY3h1zbZIuaqq66aE6BktAzdLmfqApQMC/BoYY7FKwgYF/1znfIM+uIXvzgVHbBXpUhktEek8cmoyw8Q1NaMgjYxDxPIYtgZLkYqtgeK5xkPgNR2Q4j8iFq0jRnQIRIpesAAGn5HvseKbu8+77zzSj0WA3jNBCg5WIccckgpm3mrgM1ciREfxP+55rMY6bsAJQBiPixng/yZQtGWkZnKS87kjczzjZ0BGCTOU5tuv/324qjOBVCKwi+GPLXLPuh3F6BUP9Hak046qQA2ehjosxAPUMJrfAfcbOvFAeSQ0QWmwljU1u6D9Ga0kz5rNCJIIOApT3nKNGcz7nV9ir699KUvnXab7lC2CBBwHKNNpyVcgB9GZ0L/sQ9GZBAHcJANw3s6ci7EKYx8h3lupgglB+DhD3944Rd7y17OlehRc+b7Rgko+9YiC1yeLkBJGZ122mkNxY0oGp4Uw0FRHHjggcXri+IxtK4xCsLvOsjWW29dru24447NTjvtVL6b1xdeolXHnhGFkn94ibGQxIbdjDulZDGHCNZhhx3WOGHlhz/8YfPoRz+62W677QoAqvdMjDIth88uQLkc6tbXOswEKBmokFNGhbEPEr0Mo6mvkGv9haJn/CNyBFAyGhwrQAoB0/GdfNuMHqieC2CKcizkZxeg5ChaTKXvIlFrzot9TRnJgw8+uLHXaZBpGvo+488h2m233RoLzFzbdtttm1133bV8B9pjqDR0DEAk/4gQhy4AuqT1XhFvYEqkE9/pnH333bfoIeCGY9Qn6gKU9KLoX/CAvsYvowV2VAhSZ8DSPXoST8hZe4RAunqEQXvVIMt7gMxBkTTvEgETCdNOZBiQld/97ne/ErmP9hep3mKLLcouDoCXsugrFgiayx0UbTpoJEI/8J6YiqNPAcxsQBWNOxoAACAASURBVDii3icySr68h1O8++67N2yOZx/wgAeUOdm+q5fpFMrsGX0MfznK0W/1QWnxWV05RZw/fdhCRvz8yEc+UvLdc889i12Kusz0ia9dEUrySZcg4P7JT37ylHyS08suu6zs8eu+KK+Iqno+5jGPKX1OGvqDvgDkRZ/1O9fZD3VG7qtb6JlycYH/JaBcYAb3LfsuQElw216nsgOBrlMOFAtFyJBSeoztK1/5ymI4KBRDWK4BkYyN70AqcMhouyaiJpLJAJx//vklskUhmodn7strX/va0pkOPfTQMkwrf4oBaNVBDN8y8OEJ942/o5YnAeWoHJz78zMBSpEhBgUBVzWgBJjIMGLsDWOJ3Ooz5BaIMjzI8OsDDBVZR4Z29QPG3dAX2beoiTHpE3UBShGhmA8b5dUn1UndferTDCsQKQqGl+4ZrjMFA1igI04++eTy23fXgFV/dAy+4Dl+0Q0i3nguIgqo+MPDhz3sYUVP4bl7onTeQedom3qYN8q7mJ9dgBK/ADb6DpEdQ7pkisNuAZvvwIPIv4g58GYEYJDsGNl42tOe1jmkPRugxF9AXdvR6/LTTpx7Olw5EPkGXt7+9rcXcKsN1MNz2lQbsRuAnee1k34X5L6pJexDzMUGPoFLfYbdAjCNopErfCEPAiHqx4mRLwDrvveyFZw4oyiel0/wSTm90wgNPgKQbKCRE2BVnR0k4R0xbcdIjvcNQ7MBSv0AkQNyGvaMnLqnLIjtxVtRfPUAPtUBmMZjDoO+BSgDzoI/hubpGnXDE3VXnklQAspJcLlH7+gClOae6Fg16cA6p/mOSCcmzBQ8w4kIO0GnLMJYMjYx1MSz5tnySGN4lAdlyMFQjbx15pjDQ5kQSh2DF0ZhKbMOw9OS33KmBJSTb92ZACWFLHKCDD9GZMNvUQFGkFJn1AGnGG4UOaDwAQOgSD/xpw8hCp/x5Bx5FjHWDFkY6XJxkf91AUrDre0oE+Oor0bUyk4EeGJP1JjfyzACPq6HPsDjiD4CqYA6HRMACU/xyT2RSvoiiJE31YJRNboirfmHjKu+FHoo0vflswtQAhRAnAMCAEjHotKtdLFIrfYA1OhNPBKR42jTi4A2wFkvbhIBC6dnUN1nApT0ND1M9yKyC9gDLO3gQ8z7jJEjzlEMQ4vG0d0AYkTt9QXtHqSd9BMkWioiqR0DaAlYeCZAlHScFrxx3fQGpC/FkL734gVgGPMf1ZetI3s+8RDpe9KLXqqzfkvWvE8/966YolMemOXfbIAyIpTK3XbM8E3/Ei3VtoCvMiC6iHwAysqmrymv95F5OoqTAbADx4gDMp9h9fLwHP8loJwjw5Z68i5AKWweXlPUkdKisMNI8khFawi5U1KcbuKTwSBIseDCghCKDwGphJkhiUiP6wxMAMr99tuvnKhy73vfu7n//e9fwCrDykCEYTa0wwgxwn2biBz8GsdnAspxcHFuecwEKDlJd7vb3Yp8kldpd9555zLEBsiIYABA+hUDxHAZGtt4441LFIeB7QKUjBlDut566zVkX1+ygEkUri/UBSiBiwAAUVbGmOEPUOFZIMgiMsCIvvBJP9TGXD76NmJoRRRdiyiN6/QLw8tI7rLLLiUv+fnuHt0F2NNVdBYDXOuhKGNfPrsApfIBCSK0nBcRKXJWk8gTgA14AU+icYCUaB59C1zG1AnPiuDF7zof32cClO4BKBEtBc7wFGAh77Wc4nsAMfkqSzhfZEV5OQIhBxtttNGUIyU9+8AGBYnAAUUBKCMwYSqJ07f0F2BaYIJdCecEaNUf1Vd/BWQB06iD/ANQ6nsOhYi+d+qpp5ahZY4QuwPIkWfArq5PlHGmz5kApYgzh4H8Golj27Sz38pvDjEnQNAmgCf+bLbZZg2+aeOIUHYByic84QnNPe95z5KnZwLcz1TmcdxLQDkOLi6hPLoApc6v89SKR6eoAWUoaIqdByX8z7Mj1JT/bICSdxsUgJIR5kFSoPLTiXnEOpTvvC6eWALK4Fx+jpsDMwFKoI+xJpuiMIwoMOCP0WGcRPEBGhEdzpaoA0POGLtWA8oAYZwshkGkUrRH/gzJXBa2jJsPg/LrApTKz5GsyTwvOkSfRYCEKCMDzXirIzDivt8RHeoClPXcL2CG3pGHqTciNL4D8EAmHgJYgMNSB5TBU7JGhujBmsgbuUGAM70LpOA3/nK6ow045aLoZHcQzQQozcusASX9DdgMAyjD0fJO/YdjoY8Af9qN3ajLJN8IQngmAGWAVrIGFGl7tkoe+CKab9RsroBS1I7zLnAhL32P7PguusopYpsWAlByAtRDf8F/5NO7AXN6BQhWDrqEfjIthszTGf7aEUpt5Tn2HW85HQCpPENXlRct8L8ElAvM4L5l3wUogULDRvYKFAGkPHiVOhTB5Cl6Vmd2T0esaSZAKfrAIOgkhrZFOhkaipDi07nqCec6dgLKmrvj/b6cI7zz4dRMgFL0B2jsIhPmRdgZcbId878M7ZkDyOADTPoVZasPMKTmlQUQMIcqAEDXexbrehegZADNj1ZP8gQQGLYG5gxXAnf6tail+WqMYE3AQRegNIxJxwAg+IL/jD9AydDTU/gexNnsApSc4D7STBFK5cVTfCND4bD7BBBFHANkcuw5L4CI6JaInaHkAGLy4eTEyI77wLw05iN6zhx1MqlNDKcGCS5YJBVzUEWatS3wxRbEO6SPCKWhedQGlJwD7207IfEuIEs59CFgWZ2AIoBInqKfvos6RjQ7nq2nU9URSjZKedkStkwZyZH88c09wYy673lHF6BUpmFJ/5hpUQ4nayYSEbUoSBktDBLd1R50hn4AcGtXdlk/My9ZHS1O4pQaol8M2U9AOVOrLsN7XYBSVSkKArnWWmuVSc4E2DUrttdZZ53SCSkoQnzCCSeUdPe9732LEtPZdGbEq4r5VQwyBeA5qzLlTfmbj0I5IB6VcL57JnvzDN1jKHR2Rto1CvUhD3lI2e+yb5PsS0XG8G8hhrx5s9pJtEGEAK8pVd69dmkTQ1Ebi/b9Qb+lr6Pbg9L09dpMgFIkYyZACTg5Tz3mKDGa66+/ftmNgDPmPuBU94G111679AGRFfw3rL7uuuuWvzbwWmyedQFK5WLsDBnqt6Jm2p9hc80wGxlTP/32gAMOKOnoFyCTUxlz6PBHBAvhhdEK/d6qXHkD5PQLQxrvNU3APcOUImbAJ14DDYyvyLCRDivIgZG+UReg1CcNf6obnsVQLZ2qzqZFxNQhfARM6vnneF875+qNF8HL/fffv7QHvUy23Qsnh85uAz7lXLVqVSmPdtKeImtGjdo6gs42DA0AiUoGAANmBSXIR9gNw7FkJUi+hrjV237G0gpC0FWGyQUspNHWVnVLt3r16gI28YNDg8iI93oeKON4KI8hZjaMLuTcGUKXHwB95zvfueRHzsL2cFyAduBS5E//3XTTTafm9Ua5uz5nApT6DWDo/V1Enzg5TN9h6/BEnS06ojfUA1BGnARTbCyKBeRNVeMgRJuTCfWaBCWgnASXe/SOmQBlj4q5YouyEIDSUBglioB5TgKlYwVsRDpqhlPOFO5cCOinKJcizQQol2J9xlnmmQDlON+z0vLqApQrjQ/Ltb4zAcrlWmf1SkC5nFt3QN0SUA5gSo8uzQQoRWBEJWKencgEMCTCG9ECnjnAaOhGtMMz5lAZ/gD4DFuJBnku8lF9nr9n5Mkjj6gHT9c7RYtR5MnjZRR5z4Z1DcPxnEU8lholoOxusQSU3bwZ5U4CylG41/9nE1AO10Z5lvdwfOptqgSUvW2aUrAuQAnkAYZWJAKFVrQCiX7vsMMOU3NfzXE1vL3NNtuUeWjS3OUudylDkNIaWrVK0p/N6AFGw0KGIg1XGWoxFGb4C0g1pGb14aMe9agCKuVviNdvw0h+S2sltGGXvg3ZDtPaCSi7uZSAsps3o9xJQDkK9/r/bALK4dooAeVwfOptqgSUvW2aUrAuQGkOkblOyBwzc/Xit+FrEUIT9k1s94m0tXuxb5lrAKIoosiieVDSmrtkHo6opCELc6XMSzJXCohFVtKaTyTdgx/84AJoDaPH5HJzdwCzpUgJKLtbLQFlN29GuZOAchTu9f/ZBJTDtVECyuH41NtUCSh72zSlYF2AkmGv92kD+GKeo8ndFoBYZWtloYnpVog6qssqXGAPELTQwcpAw9UWLwCSopOAYgxpK4QIpVX4QKzVyPICHOUNRMZK0NgLzTPmUNaT7PvN5emlS0A5nR/1rwSUNTfG9z0B5fh42cecElAO1yoJKIfjU29TJaDsbdOUgs0EKBn3IIAyVsm6ZtWg6KKzjB2B5vgwq0Xt0+fefAGlM5YPOeSQsgGvVZBAK4CKrNS3yAcloCxsWHb/ElAuTJMmoFwYvvYl1wSUw7VEAsrh+NTbVAkoe9s0pWBdgNLcxthmSYTRnnEii8h8ShvfijbaGihOKoma2o+tC1AayrbNiq01kGFuEUkRSpvPx9YUkZd8AFRUA0rD5znkHVxaPp8JKBemLRNQLgxf+5JrAsrhWiIB5XB86m2qBJS9bZpSsC5AaUW2xTCO5gMaGSQgzua3jtmyT51FND5FFO1bBoAa5jYcbk83QNNGvlZ0298ujkozH9MiG3vE+W5hjXykt7mwoXP5WR1uj7sAmTYjjnmcTqo47LDDCnDtN4fXLF0Oea/Jk7iSgDI4Md7PBJTj5WffcktAOVyLJKAcjk+9TZWAsrdNUwrWBSjdBOZs4GxuI2KUzG00lzK2+bGtjzmO0ll97bdNcB3NZSGOrYOs7Jbe/Er3AUfD2TaVthk0wClyiWxB5B3yAyCdWiE/ZB5m7D3puk2RRUmXGiWg7G6xBJTdvBnlTgLKUbjX/2cTUA7XRgkoh+NTb1MloOxt05SCzQQo+13ypVu6BJTdbZeAsps3o9xJQDkK9/r/bALK4dooAeVwfOptqgSUvW2aUrAElJNvnwSU3TxPQNnNm1HuJKAchXv9fzYB5XBtlIByOD71NlUCyt42TSlYAsrJt08Cym6eJ6Ds5s0odxJQjsK9/j+bgHK4NkpAORyfepsqAWVvm6YULAHl5NsnAWU3zxNQdvNmlDsJKEfhXv+fTUA5XBsloByOT71NlYCyt01TCpaAcvLtk4Cym+cJKLt5M8qdBJSjcK//zyagHK6NhgaUb37zm8tKUqtJ868/PLDNy8c//vFsk57KJQNuu5/sM5PrM1/72tfK0ZVWrSffp/PddlCve93rki9j1hdf//rXm2c84xnl4IGUuekytxz48b3vfa950pOeVHbXWA71GbYOn/70p5unP/3pw6HJpmmGApQXX3xxs/HGGzcPfehDmz333DP/esIDZzDf6173arbbbrtyHnO2Tb9kU/tstdVWzZZbbpntM6E+g+c77bRTs8kmmzR77LFH6qqK73hDFu973/s2D3nIQ5I3FW9G0Z34umrVqiJzu+++e/J1THwdpU3G/awTxjbYYIPGp/Yed/59zE8973Of+5RDNoZFlEMBSmcBi7LY+w5Sz79+8MAeg6effno56cSRfNku/WiXaAft84Y3vKGcmX377bdn+0xAd/zgBz9orrzyyuaoo44qe2g60zzaY6V/kkFHap577rmpy8coi3SvY1KPPPLIchBA6uJ+6eFR+z0dYs/egw46qLTzSmlfutTBGA7DGJaGApRO2vCX1D8OvOhFL2quuuqq/hUsS1Q4oEPaIDxpchy47bbbmmc961nNb3/728m9dIm8yYlJpi8ljZcDDg94znOeUw4HGG/OmVsfOCCY9uQnP7kci9uH8kyqDA7fGPuQNzD51re+dVJ1yPfMgQO5KGcOzFqEpLkoZ/JMz0U53TzPRTndvBnlTi7KGYV7/X82F+UM10ZDRygXElDGUPpwRe53Kmc0C7FPihJQTorT83tPAsr58W2UpxJQdnMvAWU3b0a5k4ByFO71/9kElMO10UiA8s9//nPz2c9+tpwb/Ja3vKW59tpry1tdv+aaa8qKt2GK8ZGPfKQ3Q+rOOjbXqKbf/OY35bzjYYbQzN9yjjIeTIISUE6Cy/N/RwLK+fNuvk8moOzmXALKbt6McicB5Sjc6/+zCSiHa6ORAOXvf//7spT+tNNOK9t0nH322c31119f3vzJT36y0cmGoY997GONhT99oHe/+92NpfI1mYT70pe+tCFUs9HnPve55h3veEcCytkYNaH72s7cppe97GVT7ffTn/60tOczn/nMRnsNIpHmt73tbY0J2UG/+MUvmre//e0NpyOIk/HOd76zOBxxrf5caEBJJs3RVM8g9XvjG9/YfOtb34pLU58/+9nPmvPPP79Rd3MN0Uc/+tGyUOPSSy8tv22B8sIXvrBcMyH7ve99b/OHP/xhKo9hvvzyl78s02RqHWCurwUh+vqf/vSnadngozIrV+gQCUwMf8ELXtCcd955zXe+853yjO2AXvva105rmzqzpQYof/3rXzevfvWrS90HtdlXv/rVwrcLL7yw+d3vfleqSgbxCh/wOkgbXn311fFzjc/lDCj1NfJl3jK69dZby2/XyPF73vOeKf4FY+h792MeOv6+6U1vKry10AZ98YtfLL+le+5zn1u2aWsHDJYboCRD+KifsvMXXXRR4UHbNuKPvss+0rN0Bwo9Y1u7b3zjG+UaOX/9619f8rnxxhvLtbn++8xnPjNVrnhW8OqSSy4p5Yxr8UmXaDfzhv/4xz+WP3Kg77j+5S9/uSTVxn7TpYMCR30DlDfccEMp7wUXXDBQN7flWiU/+MEPlmcuv/zyYE9jTrV6w2CDSB+Y2BxKne8lL3nJ1ETVD3/4w42I2a9+9atiFBg2f9IwUIaCCRxm6OCEAInqBaA0uZkBsVcaQUZf+MIXmnPOOaeRPyKs0rz4xS9ufvzjHzcE1eRRe6xZpOI9jCAjZKUt0uEpAw2gfPImRO973/tKR7juuusahuiwww5rjj322Oayyy4rz/knD8/96Ec/KsBBeeXlfYQU2QtS5yGQBBZ55/Of//xiLJRRJ/Ie5N01WCkX5/EvI5TdTLPXFjl42tOe1jzucY8rkWPt5doTnvCE5qyzzmqe+MQnNsBjmxjmffbZp+EYBfm+evXq5gMf+EBcKpH4hz/84SXvqYvVl4UGlBSCbXLC+Hn1Jz7xiWbHHXdsasXhuv5Kjp/61KcWJUHRAzCvfOUrC4+OOeaY8pshJsv4dtxxxzUnnnjiQKVVVXPaVyCQUdaP1B+Rde+Wp+uMQBDjrI9T8nYtsKDm5z//eQFKANOZZ55Z+jVA6c817dDlDCwlQKnuphOpt33u6En6KYhsMtRPecpTGo478M+xoVM9Q37Js7YFFv3Wdl20XAHld7/73SmZxScy7I+8+SPbJ5xwwjSwQAZPOeWUcl+fIFv0MwOrLTyD/2TTHpPyOfTQQ8t7ljOgJH+CQ/opfQl06ZPkze4J9QgePgAvxx9/fHmGvePwsYeACP5y5tk/OgpvtQ/7yY4PS94jT20gT/KOjJAqm7bSL2pir+EGi2mUnS4y2njEEUeU9pUXGeCQcbKjfQGvNvUJUCoLeVQvMh24KMr8pS99aQ25putPPfXUUkf6lI4UUOAIqLf2q9s18po4oATqoiAExG8etW2GgEfIl8ES2TFXkpeNGTwewsWDYAAJpYZlIA0Z6+CAG+YRGMaIdyMS41nvAToBUe9n+AgFBp100knFI6GIMVu+jJByvOIVryhK2TWgQgegnIFP5SXshJASCQpAqaNQ/ieffHIBjoTUMxpHB3FPuW0VowPFO23VwRBoaO8CmhnPOqoU75rrZwLKbo5xGrQNIiPkgQxyOsgVIos333xz+R7/yDHDTiY+9alPlcuULNnSfgGSAqC5Lio9iBYSUKoDmeackS2k7PoF+YqyR7lsfUEWayKDFC/ixUeUMtL43VW3SNP+5ORR9CK3oZwZZkAT6ev2tq1Jn+AAIDymQziJgGlN+iIgSb9Enev7vi8lQMnhBhbpFsRI1NEbRpQeQTfddFNR/qJHdB3iPJ9xxhmlDV2/4oormle96lXl3qB/yxVQ6tcRPDCyEE598ABf6nUAIm/6AjlFZN/iU45PRKi0hU3ya6LbtUmbllOEkhzRf4I2+iSgDYghtjGien6TW3o1+jawol9GpB0vOTj6t3xipIMObvO2zdP2b+8VSWazQ1fQE9qQ/eWE1iQtMIv0HWUjI+pVk7rFqBMsEn2rTkPXen4uILh+fpzfRWnZHESn0/XwBiLXyh/OtlEf2MuURBgE0b/wFN0fPKMz4K02LSqgZMBVgCHwCQHrqHU0AqAMA2XupMqpiGgfIYloEYZgBOYBkIih4nXWRhFADKZSBpgUDQ/seR/QqjxIGSlowk0wCSRgoBEIGwOqQ9XkugbQeRjJ2ELJp6iVhlJWBBArL5DCsCP1oogIpfKK+FDs46AElMNxUXtzQigPUWTOCeBBuTDqNWlTBkknpGCQiDK51f4Buigpzo8odxsgRX4LCSgBRnKkLuEAUbrKWZc9yqKcD3jAA8oBBbz8UCZxX11C6bjmPsBdD0FH2mE+OXsBKOv0Imr+BhEDZPj3lltuKby9//3vX8oLNHECg6TRJoNoKQFK+oxxoJeQ73XEATgKHtJDImfaNkZ0GDiOcRhE89hr/djmz3IFlHU92RKyHsTYirixE0HkTKAigiF4DOQE0RNkDlANkpZtCfAU130uF0AJ8HHi2GT8qKPl+Egf1ItO9TU2LdIBcCGv+MJmchDr0ThpOcJkf66kDTjQASg9rw8ITrX1GV0d0x+UmeMGE9hP0gblRq1giprUfZBu6hOgNLIb8g2oiwRHcCrkOn6zP9qRgxBTnGAq/KoJVgnnqr6+qIAyjEEAyhhSE45WIeFzhjcAm6FvxrmeQ8mTfOQjH9nstddeBWz6HQZcRQEDIev999+/MdT4iEc8onhEABtBxWDM8S4CC0gysgcffHBJu++++5ZQPgUAWFDShBNg9Cwg0fZAA1ASPvcDZPiu7IZAY3hR3VwXZVA2dTF0aviAQQQCjj766KkIWd148/megHI4rulY4chQPI9//OObHXbYYdqQtpzcA1YYaBEN4JKSBdo4HwxyyCPHgayTgXAo2qVZKEBJljhBhvrIMUDJO6Xc9TtApC3HQAjwAbCQmxoEM6AUj34RRIaBk/B+4/qwn3WEMp7R10QXu0CqsjNAdAngZMRAeRmy2gnjUS8HQBk8jsgNGeWUBgH5YRTpN8aUQww0Ic8BRmGcRYdWMqAkq0YWwnjike/4FqDdNelEdgIcMpz4hsdGnnbeeedpwMgzbJEAhX7WpuUCKAV/2EzATcAFn/DN9CBTa0L3Rf0FToBDfEPkN8CO3/QSeQ35do2zCHjSOXMl9r8NKAWhBgFK+jscZEED+o1ehzsEswQYIjhkipsT54w+DtJ3fQKUNVA2uqQesAsKuYZZELnmpOJZRI1FhrVtTBtg80SR1bFNiwoooWKGSuUAvFByOjQjDdhhRiBhhYW2GT4gTDoVYygoUtcIRC3EmAKcElRGiYdEyBgpcyi823edgODyOBh9Asx794zODxwSdB2H8fKMfLyzbYjbgBKAQJS6tIQzyqhu8jAXRzl9emc0ps72mMc8pkRe2403n98JKKdzjUJkDCgH7Ym0sWGZ+M0oMNra0RBO7XGT0ZjbSzmSHfICoCEAkfOgI8dwLCdBpH0QjRNQ8vw322yzMo8J0I1yGgWgJNVPv0HKHgsNolzKGHIKyJDPmAtGZgFTjliQOuNVTaIB5lEpR8wlZWAZZ9fq4aJBgFJ/ARhr417n714M1dcRThEThi6M+XIClJyAMLjaUgQhqAaUdBZD4FoASoacbJNxtJIAJf1N5gxNh9yKLumXISd4gl/6Q01heANQ6k/kKwIRRsjMLYuopuuAKlA5iJYqoCRT1g1svvnmRbcBYaKJQIb66qd0hMgenuB17OaCD21Aifchv3jMnrOBQfgIALV1E92jLUWFoy+w5Y4INR+cXkZ03HwAJRvuvTG9R17KDijrQ0ApXS9IALu0qa+AUr/nCEUkPeQ6ACW5FgyhNwKDsJF0Tuh+jrvgQvyu6z5xQEnoYpgaKOOtEBpRwgCUCsi4EDSCE+FWDcdQqDRFYAhRHogSEPURFWL4kMoRAkJah9ApBc+1AaW0lATBJEz10KbvgwAloxsGrby0+euinIhQ1oBS2dUhhrfVDQ+UiUdUv1NnMNeDUfUZHSfeM5/PBJTTucbr5ZiIdFGGDAsFBEjpMGSVLIQB5ujUyk3nW2uttcq5rT6dsUpO7njHO5Zr66yzTolsMvx3utOdyrU73/nOzRZbbDE17FyXaJyAknxT7KKS5G3ttdeeKufee+9dlMR66603dW3bbbct/SXKow9SHkjfiH5F4ZuGUXuoMQ0EUK1J3/Z+5WB0gigw10IXuN4GlBSa0Qr9cRAx+mHE3KcD/CFthOcBFJYLoMRL7cAQkE9TMMLhVm96MSKz9IchV78jssKQiOKGAVlJgBI4IHMxvMdQ4k8NGgQLGFOBh5roXrymK4LPdEFNwFU4YPpGe+i2TrtUAaX+TK7wkU3dY489mrvd7W7N+uuvX3QeG1YT/RE8cZ0zLlgTdo6ujZXgbHKA9MgDTzmdbYeSbY22DGAjDZ1Bl0c0cy6AkgNOByHtDDzWOotMWMRWT6XRjkZD6iF1z/cJUIqmRoADxsLzmIMdch1TYAQKtAMACUshTlHofvgFD7rmhk4UUCo8Zbb11ls3jJeK6cCElBEGEAGsrbbaqqw60nCiDqIZvA6rjghKLMrRiDwg+RmSJLjyAr7ud7/7lfz95jU+8IEPLOnMHyBkNaCkGAgjo8nwMkIineZNKAtE3waUngEylNkQdczb1ACUtfwHAUrgUJ0NJYqMAXgBXkSydt9991L2mFsiqqM8ylADmdLS8/iXgHJmpmlHnYncIAaYfqCx0gAAIABJREFU/FEcFJfOxCEgl7w08kh5MFIcA23J2LtGDihIjo508nINEAJEYwihLtE4AWWdb5TT+wFkTo5yRpmUXRRWH2UIRRVEJfUvRLGrB0ViOkYbOIruU8C1sq3fP8z3GlACw+Zt1s4aw09+gSpASNn0sSB9luLTdvgbUTn3AUrPDCKGgt7Bj74TPaXelD3jTJ/iFbllOOgw8kq21B/AZmTVT9tJU8s3UEW3dBEwSoaXG+kH5LWOnqkjW8EuhSwwvAAmp4Z8MszkSxq8owPC4SGboaP1L79Dj7T5t1QBZbse+IOXnEwLTOkTPALqED6JVAJ/+MGOumZUESD1jD5s1I7c1sBMQMk8xi7w0i7LoN90hffVupYe0R/0G0Rnk3FgS99in40MCmABWhF11tb0oCHgGG0RpRSwardznwCl8uOzehmlgk0AZXINC7FHdLs6mA4jPXBNhyLtpi0EvYyWtp2tkugv/yYKKL2TQmTc/DFeQb4z2BrevRAAwgkVu+ZZBGBFA0Z+0kc0Ql51evliZuTrd7y767u84hnviHQ+UZTXb50g8nOvTqucUa76e5Tbc3G//c46vXRR51KAef4jHOERzjOLZfuYoQxzZu9whzuUaB7ADygCNfe4xz1KJNIiB+1UR8OCIaJAbd6KGNWTzqXlOIQnHM/G50IBysjfp6h/ez6hsgd4oyBNESHHFieIvIoUkj/O3F3vetdyzfXwXClaCnc+BPBsv/32he8iu6KODJQhLVFd72H8GSvDtYwxUPz//t//K+200UYbFYOkXZRTeu2kj1F+nNe/+7u/K2kp0zYtJUCp7Aw0Pm266aZT0UnGjxHUZniDB+ZjM8auMZiuiaAzDK5xDOSDN5G2zZvlCig5hRtssEHhCb4AGCiG84IPwI57ZM53kX3pBUDwEKAwCuGaQEbocgEBwYMuWi6AMuonuCI6qc8Zbt54440LTwAZPAHCAMa4v+GGG5Y02gEJCEUfNXoDrONn9HH5dU0fiDK0P0WU6Q/5rlq1qrShUQtt5ZoFfKaX0bkCRNrTO923hoI9gBkOOeSQcu3www8vjoY6WKAjnXmi2rJNfQKU6mU6hvI++tGPLmASsK/l2hoU9wXUpAe28cA1wNM1IJq+cC3Stus9cUDZLsBsv2tDN1vavD87BxJQzs4jnSf+InX7d1wf9+ckAOVcy6zubRo3PyK/9ru6ritP17255CGfpQYo67q32yV+t3kw6Jmaf4PSe2a5AsqaH111D162P9vpg4/tdDP9Xm6Asl3X2Xgy6H5c8xk06FrcG+Zz0PODrtV51e93PdLXaWa67l6fAGWUu12vuB6fg+53XRt0XT69B5QUmmhJ0ng4kIByPHxcqFz6CCgXqq59yXcpAspJ8W45A8pJ8XDQe5Y7oBxU55V0rY+AchL8XzBAaUw+qX8cMBwWq+r6V7oskS1fDF8mTY4D5km1529N7u39fpN5tbE7Qb9LurRKZ/6ruX2xOGVplT5LOxsHTI8wTSfmac6WfrncN5Vq7EcvApPmMJlvZbJt/vWDB+b0mGMGVFrAkO3Sj3aJdjCRn5Gx+Mw8y7ienwvXTvqBeVXmFpmDmLz+K6/JoBWsFhDSHcmbv/JmFF6QOXOOzcmzuC/7+nj4OkqbjPNZC9+0q3nJdoFZKe3LftnD0nzNYelvhklocr4TNijp/OsXD0xEtsl7tku/2iXaY7fddisr/eN3fi58Oznne5tttimT0JPf0/m9yy67lB0ynEmdvJnOm1H4sd9++5W9by34GCWffHZ8bTJOXgKTdppZaf2GvrAyf1gaClBaSGM/o6T+ccAWIVbQJfWTA1Y91ltQ9bOUy6tUVj1byZi0JgfqPezWvJtX5ssBQ6J2SLBiOGn5ccAOMVa4dy1eWX41/r8a2c5s7EPeAKWQflL/OJCLcvrXJnWJclFOzY3JfM9FOd18zkU53bwZ5U4uyhmFe/1/NhflDNdGQ0coE1AOx9BJp0pAOWmOz+19CSjnxq9xpE5A2c3FBJTdvBnlTgLKUbjX/2cTUA7XRgkoh+NTb1MloOxt05SCJaCcfPskoOzmeQLKbt6McicB5Sjc6/+zCSiHa6ORAKWTNmxBcfTRR5c/u9Q7JcMJHTHXIE7jcFST0wgc9eOPYnNckKOBjjrqqHIt9qe8+uqryzFxUQWnQ3z4wx8e6Ri4yGu5fSagnHuLOk6QzDpic9CWS470s7DjhBNOKKe5eIMj2KQ//vjjp44HdFzhox71qMaE/JDddmn6Bihta2LVuZMU7DHWJn3PvZNPPrn0N/3YPF0nijz0oQ+dOlfac06jcM0xj9Hf2/nVv80nlfcZZ5yxRl92+oatfty3ojLICSXe4TSgIFu0ONnC0WqDaKkBSvPvHvvYxxYeO5WkTXbXCL7F6WBOxYg2saIVT4477rjCq4c97GHlSNH6XPXIMwFlcGK8nysRUFpXoW86iStOFAqumnN40kknFbm1Cj7INjRkmW51VGOQ1dPtIxXj3kyfdLnjc+UZJ4PV6b277jvuKYO+Q4fU2zzZLUV9Bh1NmoCy5mr395EApeMRTdh0HJ0zJR3rxhg7WzbOAKYsGSSA0vJz+6AxLPaKc7zTmWeeWc6jpRRPP/30cqawBq/3SgNU7eVHSJOmcyAB5XR+zPYL8CFbzrcmsyZak8Mg59ha0AHUOC/aghrXHBkKHDrKy5xisshBcl0az9TKKfLrG6C0pQ4AqM869tBRlEGOQnT2rTOjHdmlfurpfGlTXhw5qd8iW2c4ms01wHo2QBkG11Y+eF+DRvnZrxOglJ9P588CvOecc065pqxAvTOFyTxg75i8QbSUACVDDDQDzM7gpSOdpxzk7GJb/eDb+eefX4745Ijb+occ4pfzex0r50hbvx0j6ug7Zxy3aaUBSoGIHXfcsazOxaOa8F7/d0yoIxoRuwXcewZ/kTYA0nfYYYeyQn6QIxPyPYjnJZNl9u/GG28sR/2RNzqRPqiJXrRIidySaQ6PM9LpSboH+Iv2cM46eQZA57LPI52jzzja1XvoCH0hyDvhC3qeLr/wwguLjrZq2VG5+hxdiBxDaIsc9bnpppsii6nPvgFK5SSPVrIHH6Ow5JreJNf1glBtJpgQZ9VLT5dKF3yIPOJzwTY2HzSHEqDUmDqRxiVAFD5AqYOhW265pTQmJShtAE33eCjAZng3GlXUgwGXljeOGBsCk7QmBxJQrsmTma6QVUAogBRjXZ/X7Vzl6FyUE4cJ4AywKIJEOTEycdatDu17DUyjDH0ClPqgyBbgiHjkQEhQXXf1o+TVSQTC+fZB6quv66fDEocRmEXOAVaOUIRWxjqTmyOJKHr6hjKM85OBXGkYH2WjJzivg2gpAUptgRfaBpG3OkoJEAGISL0YSIYSCO1aUcxhJ6OhV8vDf/m3kgAl54dhJeMXXHDBtCAFduAtOSb3wIjz5n3HI6vh7SuJ1zfffHMB6O5xYkJua76uNEAJMOIT4ug5Z9toJAIK2e/bbrut/HZPpFB6+rBNrsEMHE2jkcOSPiNvbYQ8DysE6Qevf/3ry084RMBLtD/0u90gACyjqvKJPhjP1599ApT4ChQD5XRiHXxTZjyAC8irqK+AnNXagL2AAWCJ7DMZ6Tjxgxz0RQGUopAaQ+dleEUfIvxMkHgIwCejW3sgACXFGMAxGlZDi5AAp4hh6TIeJcEK/peAcm6NrzNSXiGH5IzHHES5UZaIcmPAGfKgz372s0U2GXPyDpRRUrzbUKiR1mefACXPlIIJIELZ1idg6adhJPRp0RvG1PSA9ddfv1m1alVRviJoO+20U7PBBhs0G264YYkS1HUe9N17Lr300nJL/xb1DECqLeiBcEKl81tELqIFQAFeR9kBpgCg7fctJUCpfur5hz/8oVSDbNZGV5QsjCSjZnhPhEzETJsYogu+yQB/yOIVV1zRZkv5rX0HDekNTLzEL+qXASjwmdEMwKKvkqcwruRTWrYogLjIm5E1YCRASBdLVhKgxB8AHWBB+pv+zNlD7DqZjmgt+42/dM9d7nKXojMMeXNSjYBwNOnVuQJKQQF5RpAKsArnSzm8kyOLOMam1xl1ieAUWeDAwSpbb731lD4LPVUe/Mu/PgFKQDlOX+OcD5JrABKxZTG6S+9ql5B58h0OO6eA096miQJKSpCCs7m2jT91PpFKnp4og+8ET2em6Awl2HB45513LoiZQakBJQGEuHntQrq8RECVkg3hbFd4pf9OQDk3CYgIenijQFQNKCkTighReIZoAlCSZ0Nj4SyZo2Z+zsYbbzw1FNwuTZ8AJaMnEsO5Q+pdDz2bE2VKCqLoARPgBa8oI/f0Rd9PPPHEEmnUt+kA12Yiii2AEgApKhfPyN+7YiiGoaIHGBiAFhlWByKVCy0XQEnxG6UJQKk9jNQEidQGoGSw8Y3B5rjjH1llMMgmYmQ57l36ciUBSvPyAhzgmdGIiGbhJUMcIxWAB74FiYKTa9FIdm299dZr1l133TL3L/pPpPW5kgAlWdM/gQ1EDvE2Ird4XANKkWByytZzkPBcRFCEzJxtOtVokKhmAP6at13fgcQaUNJPobs9410xFC9fToG+Fv1LO9Jngl6nnHJKCWDBLk4F5FDX1CdACfiFLsVrvCffKOQ6dCvec5yQdqNnA1Bqw9D3AnawWpsmCigj6qgz8QyicAwtY0BIeB+8PsIW4WmV5uVgQg0oGRRDEBrTsI88GRTzJJIGcyAB5WC+1FfJkJOeGAXeqeHSiFCK1tTDvjWgZLQZmeisImKidqIbZBjYNJxAVs3/jaHk+t2LDSjNRdxoo42KB64s+ldE+ShfCieoBpT6oP5KkQbpz+rJK3ZPZICSIoMxrwzgO/bYY5u11lqrGJ14tgaUlB3ehfFoA0oACpCi/ANQmpYgAhHRo+UKKIFD0ZqgGlDSqwBlyK40+CPKEtcYabztouUOKPVNjiAZB87D8IqqszXhtIThDUBpUR29QKYPO+yw4iTSC+Tbn/TuAT0ASJuWO6Dk8Bge1q/pRJG+AJRGfeiD0CttQKnv69OwAACJyKF5jO4BOHSLPGpHCCD0voMOOmgqCikItcceexSdpm+EHpKnvMKB8LsGlNoZyAVe6wiluhjqpcOU35/+oz1r6hOgJNcCboieJtf4h0KuA1CqG11JhvWNGlBqJye54fEd7nCHAq5LJtW/iQNK6FfhGVONAzwSPoYaEAzvGqB0P+aiKTNDrZHD4xP5UeG4ZzhSHl0raKt6r9ivCSiHa3odChihGMhYDLeK2DEcZNCfVd/kDumk5p2QbTIuwh7RSkrU3EKyLm/GaNAQ7GIDSvVQb2VkVEVlYtEHPgAglKi6A21GFqLuIjTqHiCOkrVCG3iMe9JS6qI4QcFrn0EUPYWPRDV51YAkAEpn8JaBc8TwGCYzid5QDBJNpRiDpO86IWopDXkzdIaeApyLuNB3AYpEUyKKLLouegKIR5uIcOJlPM/Q14A0+BWfyx1Qkpt11lmnOeKII4oMhf1hPBneACxkro5QmiIQUwHIrfuGcQMABf/kx9Fp03IHlOpb92t8Dt4aUaAL6RD9uQ3egXAASP+N6KCRIfrgyCOPLO0F1Pzt3/5tcdiDt/X74lpdDu+he0KXwxLyp8/0H8A/hsBNWzBFyahn6Dh9j4N87bXXlrbmlKmDuoTjEe/tE6CsI5Qi6YPkOgAlHsQcS7aqBpTBS3zWhr2IUAI0gGHMSQmjygBYmh9KH6A0h8HQFSZA1p5j0ClKRsAigOjAKu8exTAo8hMNvdI/E1DOTQIYYp1Kp2S4GXBOjk5HSZJJUSBDHwCN6xQU42LIhOGgiEz4N8mbQRcFZOhj3kpdoj4AyigPxUHpikQa4lB+SlSkEoijmAFFEQPKHj/0VcNG5jfjBa8fMcYMCg/WRO8Y7op3tT8pdMAHGMVH+oFxF/EFzg1PGn4CNil0kTfKULQAWCXn3qUtlEkbGRGJKGf9vqUEKOlNfMFLSl2bMIYAM/CH73iEb8Cia+oXbaI98Q4BTXRoGNiaJ/F9uQPKqKdPcygDPJBp9gcIITN4DOiItiPyLjoMmAeJoHGEpA0ChLRDm1YCoKzrrC/SneSTnRYMAsLoApF0PBJBBNbwHSDDSzzXnz1bLwKhUwWnItJev6vrO31m3qu2M0oU76Fb9AvloZfpEvpNcErZ6Dg622/yoQ8Cm+YTcqp9r9vc+/sEKJUznB94apBc06OIvo4+4Hc96lMS/MVRACb1lzZNNEJJuWsozEaGz2ISrA5sJVKsfNVAFKNw9e67716Musa1d5qwq2vtoQShaVFN4DJpMAcSUA7my0xXARjbgpj7G9EchjaGQoDNTTbZpAy1iKKR00MPPbTZbLPNmnvd615l31QRDPJ+n/vcp6SlnAZRnwCl8gEj+tqmm246tdBN9ED9EQWkjiIHog0AOC/eNX1VvRElLQ98pNSGIQZbPrb8oQ8YdpFdIB6fDz744HKfIUfeZa84z8TiCm235557Nptvvnn5C++7fv9SApTKDdTc+973LrwMp0RUMhbWqGPwTQQF7+zd65q5rNoJia5HRKbmR/19JQFKgQqyG9EXfZScARnkiK2iPzlXQD25wT/ABxDitGgPIENbxNQWst+mlQYo1R+QJIOmXCD9mLMIlHNu2Hr60SgIIqf0imfogppE1GCJuQBKzwO05rHTRdoJwRFAJgKUop8EjiAH9Hu95Q4Z0Ad32WWXqcXAJYO//OsToIyRCnLN8aQv6VJyLdDBLoVcaxvpOfyCfQIjAgocK4EUgRNR3WOOOaY46nWdfZ8ooGy/PH9PngMJKCfP87m8sW+Aci5lX6pplxqgnCSfVxKgxFeOiPnTZ511VglMADvAjIgYgMNhcV/kEYmkb7fddsXZBHCQiDigwQHtAuwrEVAW5qyQf30ClFhuWha5FREWYW3LtVX07keggNNvJbu9KwUBOFMikq4ZSeZgDaIElIO4soyvJaDsd+MmoJx8+ySg7Ob5SgOU3ZwY750ElOPlZ99y6xugnBR/FgxQ1svxJ1WZfM/sHDDvJIZtZ0+dKSbNAcMPMd9l0u9eqe8z7GOOluHhpOkcMLxlbnDSeDkgimlx1aA5veN9U+a2GBww33uYueKLUbaFfKdh8pjSMMx7hj560Qotc8nMdci/fvDAYiWrkM0J4UFlu/SjXaIdtI+5POYaWSgR1/Nz4dpJPzDZ39GD5lcl3//Ka7yxbYpRjdTlf+XLqP0RX82vtCDK2oHUxePj7ahtM47n6RDznM399rlS2pf9Mr8exhiWhgKUJn06mcHKTiug8q8fPDCR/IEPfGDz4Ac/uHgR2S79aJdoB+1jw39zsnTKuJ6fC9dOvGmK32IAWxxZCJj8/j9+480+++xT5gOmLh+fDOKrjbEtFDMn0++UufHxd7F5SXdbGU6nmJu4UtqX/bInq89haShAKQJmtZytLfKvPzwwnGq1p6GWbJf+tEu0hfahfBiZuJafC99OFmIceOCBZaFF8ns6vw3bAT9kM3kznTej8MM0AjJ38cUXJ1+XIU6Agfbff/8yGjiKnCy1Zx1QM3ZAaSuR2MpjWKSa6SbDAXsq5sbvk+H1fN5iC4ucszYfzs3/mZjPZp+6pOkcYNC6VipPT5m/5sIBQ6v2THVSSdLy44DtpkRKV9q8bNtnCYoMS0NFKAFKm5Qm9Y8Ducq7f21SlyhXedfcmMz3XOXdzedc5d3Nm1Hu5CrvUbjX/2fNmzzzzDNX3KKrBVvlnYCyn0KfgLKf7RKlSkAZnJjcZwLKbl4noOzmzSh3ElCOwr3+P5uAcrg2WpIRSicZWMGZ1JQVm3FCQPKjfxxIQDn5NklA2c3zBJTdvBnlTgLKUbjX/2cTUA7XRiMBSkcZWQFlFev2229fjjyybYKj6+zejhzPaEKrsXirLiOtvfns7XTIIYc02267bbkeB8dbqu5s0CDL9uNYJvt8OfPX0U6G4h0r5Cgyx5M5+inImeCUp3Ms7Q7vvY4mMgfCFkjK672Oh3S8nHlXJvPH8UzmXym37SD6TBmhnHvrmO/khID111+/yGqdg7kyVrbd5S53aTbccMOpucPOjd5ggw3KEV8hm2TFvBpnqXZRHwGl81wtzBg0H0j/sjJd/eN4NOkczeUaeQuyUM81Cz30odnIXrbS2zFCn67J+bSOtnTfyQ1x/6STTirX8Nk7HCHmGEzpTBYfNE9yqQFKzvFOO+1U6hRH19a8cZyd+tZHxdF9rm211VbN9ddfX/hgBapr/sytHkQJKAdxZfRrKx1Q2vv1EY94RPPJT35yGjPpjqOPPnpKLu9617s2l112WbG3bDJZjTnm5p9a2OSaIxr19dnIueA777xzs956661xdHM860hSp8PQC+iFL3xhecd+++1Xjh90zbG73utY2hpHRB4JKIMTM3+OBCgJCwNDmHQoe78BjgCfcyIRw+A3wCatT4LiWQ3nrG7A0r5ozplkrB1/5XD5IItOTCRnPCjPiy66qOQBAMa5qoCj8ziDgEGC5Po111xT0seZtxQ0oKgcgKhyEWabhBMcxLAqgwPm+0zKnhHK4VuIo0PmKDWyaV5MKBq5aH9y4Cgq8sEhcu38888vsksWX/CCFzQ//vGPy/FXZITxDgeqXZK+AUpAhPyTG8d11aR/vexlLyuK2T11R+oIiLim36KYV+0ah2424mgC3vhGecuzBoNGHRgW+emL7nEw8d35vsoM1MvH2cDy4SDac7JNSwlQhlOiHt/5znfK9iQcnqCbbrqpnCONB+edd145Mo0zTebw4MorryzySl+5/5WvfGVaO0U+8bmSACUZIlNrr712CR7UfMUP9/XPu9/97mVLGMEJ9kX6tdZaq5ztTP87U/6ggw4q1zhRtdwGX1cyoOQQcSo5qvRqm/CP/HLWn/e85xUZdTa64wDJN7vvKEyBJE6ntFYXa5uZiC6ii6+66qpipzmY+kZNdJjgFYCqfen8d73rXeUd7IB9gpXLomPvFQxzrGGb+gQoyR/cQkaB8rZcK6vtwdyPoIA9JW0v6BqeycMfvMaBH6RH8WCicyg1KOOrkShGSk4HfPWrX93wHBChYTwYZw0YQNM9gJIBC6Cn8AQJQ3xqaMQAWZ2IGBVbXhAUzCKQiIC+973vLd8ZJfkSUsIRoLPcbJoSoYxrDkm3Ok+nIMyxYtp9gDXKFs/27TMB5dxaROcjGzoYouAAlCCyh6e33nprUTA6HXBJzskVOaE4yaZ70pHrpQIolVm/I/PqU5O+KxKoP+un6oQfovjAjmv6ubobmdDHXQvgWefV/q7f2lIFec7+kNG/XQMoOX/yA1BFI/3+3Oc+V56hA/C9joTqn4NOiVpKgDLagn7UNrYAG1QnTBC9fPe7311ANYCN71/96leLPgMoySHnGV9rPhUG/uXfSgKUnA/yjLeXX3556cM1X/DOCta6H9D/7BfSHogMCkBId9xxxxUelxvVv5UMKLEBrwR6BgHKYBM9CvQJHgXhKUeI7hEEoieQANKgaH0851PfcSIWB5ReoqPbwRX94TWveU3Rd3R1TTBFnAAYbS2YJZ9aTjxDD/ZlUQ5MRa7VG7/xry4vWQeeYZsA6/gCKwneAdfagp6kh+nVLp0zcUApfHzdddeVwjLOOq/IQgiW7wAg8ElZ6sQEwW+fjDsPBoleUoqAoCFuaTU0NG6H+hBaXjhjVwNKBk9eruvcvhMywiQMz3NRNmTIO4CohmC4HJROmcTiI54/Ae87JaCcWwvpSCLmvFFEzhjpINd1OEMovD+dF/HAKcMLLrhgahjc9aUGKJX59ttvHwgo9QlDUuruj0KXdpNNNinX11133QIKRcZMGTFE5A8/a4VWGNb6JxIQEQdg3kbBtWetv22xxRYlP3xmaCi6cPwoPIqTg8cgMRTahIJs01IClHScetJViHyFUW3Xi5Hl/OA1kC8t4+ca3Wh6gGkchsGNzgyilQQobdkV+lw/tZl7LS/AhAgmMBMgR6RGJN01zk2bBDpEMdu00gElfswGKDmUcQwtO83+i0oahfAbCALYyb/TxWr90Oa338CfaFvoHnadfAe5LuKoTemo0CUcLoGBs88+e0q/xzNwQAzBxzWffQKUAKMRIoQH5JpObpP6q3fYMPddE0zA6yABP1HeQTRRQEkJGnYyh2H16tUFyCmUhuPlue9T4wGQ5vjssssuJfQqjUhIDSh1aukZHMqAYFEAvHFg0H0KglFpRyhFNShXzwKQIVjyX7VqVbPrrrsWoKt8NaD0m9AxaECndwG4hD+ilYMY3ZdrCShnbwnyAixxRHQubRzRMVHtLgOu4zIgZI3DYmiAHAEs4dH2HVCSZZEa9Q/HrQtQShd7jqkv0IJnPhGP1zxo6Shj+el3dABnEFFYjCujSwkH1YAS7+M4yrgfn/jKSeVR0wUUJlIOEUmA37DjPe95z7JxeTiJ8bzPpQQo8bIGlHRRjMbUdcJLgJqOoldFec1FPfjggwv4qdOa+sPQRnvX91YSoMRLgAUBJ4AiuQ4SvOBAkSVz9/AYwOfYbLzxxs2JJ544xUMAk40Q0RkENFcaoGS79XH8DF04E6Bk/zlAzoZGAJAhWOsbOD/ucyK12ZZbbllstN9B0nufgADwidqAko6p+04dWAJa6QWknNpcgItOCwoMQQba1CdAaXg+6in4Rq5D/9blpisF+cg+vWxqoiDBueeeOzVNSdv1BlASAgZXw4tIBmo2/ALIaXAAkEGm+AG+egi5HaFUYQxgcChanoLoZ4BD32ODdY1fRygxEgiEtEUWKQAkQgnQ1lQDSsIJYFjEI09Gi0A581ZIue+UgHL2FqJIzCkRcRQt1/4RoaTkeKWDiPzqrKLjOqFnXDP0EZGOvgNKQJJDBXyEhz4ToCRPSB/WX3mowIk+rL8DNa5FP5XWtchbHzrrrLNKlKzeQFvfjEV33m+oKkB9m/f6rOiRT7wycPFwAAAIxElEQVRHFu3EfKBIr6zvec974ufU51IClPgWoykqAES3h5/wno4K3ecZ8kh3cXoBfm0TRK8aEmNs2rTcAaW6688cEDIXhhcgEa2p59iRr1hgJ23Yr+CZKVwCG8gUDws7tIG+0aaVBiiNGoqEk8OQvZkAJRssbejN4J9njVaw7dpAHojuARCDTInxPqeOBdDkVIm2AUuAEf1QLwoyV1Lfcs1zZD9GAuQrkECPIc8bqWL/A7DGu332FVDiZ1uuo9xGLoy+IrjLGhcBPX0iHPHeAUoNT3FpZI0L8WtggEyHNLcRBaCsvWadHzOCdFZoGYlGusf4R8gWOA1ly3AJn9dgkXIlIIBoCB2lwaupSZ7AKwIQRGViTp0yUN6EcSlQAsq5tRJQKAJG9pC2JzcMjT9yE46E6/jLgwaakA5IzgE1xDPk/XZR3xblKCeDqD76KcILdTcMcuqpp5Zr+gMwrZ4UkX7rj1EAaKSLYUJD1AzqTMQwh3ITQROhVA5GQZvUkQI6JYZ1fCLGRX8HRvV9xCDURqdcXGIRSgaBDOIB2RL55dByiEUWXCNDoilBnHdTNVAAeG0XRkKbaadBkbTlDijJhFEEIJtTEk6MSBq5qocG2YYY6gMs2w4LZ6W9QEPfj7n60R4+VxqgrOse3wVyAqCTS3IcYJPMRv8H2OpIsQi9EQm2P+ZM+81Ok/8uon/IOT0iT99FMekyekK080EPelABUSLOVpvTNyEDggHRrwDa0EmD3tcnQFmPqtETbblWfvU0mlTzOerF2Yx1A/jbqwilBtGACsYbiILyKPbYY48pMMhIGxrTaXV08xoYspNPPrl4JQAoZRqRDsZO57VFiEgGhI1xGhYRVJETwxY8S6uV5Pfwhz98SnClE0FlPL2TUBN0z7juGiGsFYRhjb322qtzDlI0Sl8+E1DOrSXIKYdDFI0McHoAJZEhHUsHBRB5qoZWKUidktEXzcRv0QpDPowR0LV69eri3YYTU5eob4BSP1EHw/dACeXqU/31KeAQ4Nb38Imi9ltEUb+h5F3zSTHhn+sB8uq619/1TUbeeyg6BoNBMGlcFBLg5MjRIcrHSBgeox8YfnwWedSHKX7to6zq06alFKEkjwwq3oSuovvoLAaabrXFlXlSdCe+AYz4gQccaPfUWZu4Rrbp30G03AFlXWejTuHshRMDZAMP+ir5DodEdAq/66iugAZAireixOiSSy6ZihTX71rJgJIzJNhjuzX9Fa/J7eGHH17sNf1KVwRYpGfwnt7Qt+lWOpZsSkeGObGDRh9qnusnAD89AAtoa+1Ex4TDFen1LWWq+45+o31hk3333bdEMTmtdHZbn/UJUApw0BlI0IM+DLnmVNLp9ANdERS4ym8jRxG591tbDNKj7k10DiXDYiiK8kc6qsnySOQGYIvIg1Czzgs0mkxPWAiixqcAXTPMXRODYnUnpSuiSGC8E7nGG/Uswx8rvykGXkoQgEhI5U/hYrioqWueFZGsSWRG2D2Aa32vj98TUM69VQAZMmMvRp4c0nHIG2UH2Nh30WeQTnzssceWeVUhX+T7sY99bFGiOnV4vvGMz74BSv3ExHeKX58A9NQnto3Qh92nkCJSK/qlnvpu1JHhPf7444uTSFEPQ0AjHurz+q/8lYeOoPAYEUNToQf0dSDeMxGp1HYAvfbpMjhLCVDim2gK/nK4fUecFREeQIXBxWt1ZrgRYO23SLH6IhEg14DRempRufmXfysJUHL6yJSgAVk39Ck4YfGSfu8Pv4By9sBoF9tgniSwQd4Zan2Y4yMdvSGy1aaVDCj1SbJrzql1Euwy2w586+O+s8uhT/DOyCDZ1bcBfwR4AobaBACki2cjOIODSp9F36HL6/2j6Ro4hTwgOiX6iXvwCxmhe+LddVk90ydAaeSilmtBD3JKro3G0hGbb755CQrQBfQDZ0kbCQByXgVOtJsgnQCadsC3Nk0UULZfvpC/Ta5mfJKmcyAB5XR+9O1X3wBl3/izEOVZaoByIXjQledKApR4AEgAk5w/JPIkyBCBDoZWYCHm3gElDK5nOFeIseZgSVdHdsrNv/xbyYCy5sNy/d4nQInHbbnmQJJr4Fjwg0NEhkVvRWUFyiKIFpFLdeKs+nMvrtdtuGwBJSMRSqCu8Er/noCy3xKQgHLy7ZOAspvnKw1QdnNivHcSUI6Xn33LrW+AclL8WTBAyZNL6h8HDA3EcGX/SpclMlRrjkrS5DhgPpahnVh0NLk39/9NRnrq1ff9L/HSKKEpIOYdx8KopVHqLOWwHBD5E7luz60c9vmlms7cShHMYWnooxfNLzCf0VyI/OsHD8xRcb6vuT6+Z7v0o12iHbQJJeTYNgu/4np+Llw74bOJ/rZJMmfbPMvk9//xG2/MN3vMYx5TFkAkX8Yjh/hqIcnq1avLwqnUxePha1/kkw6xyMdcQ4t2VoouJ8fWBhgOH5aGApTmjRxxxBFlUrK5JPnXDx6YJO6AeyvbNXy2Sz/aJdpBlMwuBfZPy/aZTNvgs8n+Nke2uMLq9GiPlf6JNwcccEDZUFo0baXzY1z1x1fzK7fddtuy0E+/H1femc9k9MZMfKZDgKrddtut6JaVosvV00KrenHqbMByKEBp9ZVJneYwWuWZf/3ggfaw4stftk0/2qTuG9rEykIrEbN9JtM++Gz1Ip5ri+T7X/mOF3SF4dnky1/5UvfZ+XzHS/uJ2u0g7eT4+DqftliIZ6KvWLBFt8TvhXhXn/JUT/XtOoBiELgcClAOejCvJQeSA8mB5EByIDmQHEgOJAdwIAFlykFyIDmQHEgOJAeSA8mB5MBIHEhAORL78uHkQHIgOZAcSA4kB5IDyYEElCkDyYHkQHIgOZAcSA4kB5IDI3EgAeVI7MuHkwPJgeRAciA5kBxIDiQHElCmDCQHkgPJgeRAciA5kBxIDozEgQSUI7EvH04OJAeSA8mB5EByIDmQHEhAmTKQHEgOJAeSA8mB5EByIDkwEgf+P8AxpucGdGFEAAAAAElFTkSuQmCC\" width=\"660\" height=\"130\"\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003ePerioperative management:\u003c/h2\u003e \u003cp\u003eEA patients with preoperative LV dysfunction had longer CPB time (163 +/- 42 vs 142 +/-38 min, p\u0026thinsp;=\u0026thinsp;0.17) and longer aortic cross clamp time (125 +/-26 vs 100 +/-34 min, p\u0026thinsp;=\u0026thinsp;0.09) as compared to those with normal LV function. The duration of milrinone use was comparable in the two groups (50.1 +/-21.5 vs 47.3 +/-45.9, p\u0026thinsp;=\u0026thinsp;0.85), but there was longer use of epinephrine in the immediate postoperative period in the group with pre-operative LV dysfunction (23.5 +/- 22 vs 11.2 +/- 22.3 hrs, p\u0026thinsp;=\u0026thinsp;0.20) as compared to those with normal LV function.\u003c/p\u003e \u003cp\u003eThere were no significant differences in cardiopulmonary bypass times or aortic cross-clamp times related to LV trabeculation indices.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe classic description of EA focuses on the tricuspid valve morphology and dysfunction with resultant right heart dilation and dysfunction (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). This study is consistent in that the EA patients at baseline had markedly dilated RV and lower RVEF as compared to the healthy subjects(Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). To the best of our knowledge, this is the largest study using CMR to assess left ventricular structure and function with respect to EA disease severity and management. Our findings revealed that, LV dysfunction was common in preoperative EA patients (40%) which is consistent with prior literature(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Many cases exhibited reduced LVEF likely due to RV dilatation, paradoxical septal motion, and ventricular interdependence which is consistent with prior studies. (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)There has been accumulation of evidence for more than coincidental occurrence of EA and LVNC (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e)There has also been literature describing a genetic underpinning of EA with LVNC (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e), (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). The reported prevalence of LVNC has been variable (4.8\u0026ndash;29%) in patients with EA (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e),(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Of note these studies used echocardiography as the main tool to diagnose LVNC in these patients which is inherently difficult with poor reproducibility.. Based on the most commonly referenced MRI Peterson criteria (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), only 1 patient (2.8%) met the diagnosis of LVNC in our study population. However, there was a trend toward higher LVNC ratio in the EA population compared to control in our cohort.\u003c/p\u003e \u003cp\u003eInterestingly, transthoracic echocardiogram underestimated patients with LV dysfunction, detecting only two (14%) out of fourteen diagnosed to have dysfunction on CMR in the cohort. Most of the patients with mild LV dysfunction on CMR were not detected by echocardiography. This highlights the challenges of quantitative echocardiographic assessment of LV function in the setting of dyskinetic septal motion. LV dysfunction in EA has been thought to be a consequence of compression caused by a dilated RV and abnormal septal motion. The prevalence of LV hypertrabeculation provides another perspective of underlying intrinsic myocardial abnormalities. Though our study was underpowered to show correlation between hypertrabeculation and LV dysfunction, there was a trend toward increased LV NC/C ratio in the EA population compared to normal controls. A recent study found myocardial fibrosis in EA was associated with worse LV function suggesting a propensity toward myocardial fibrosis and providing support for further study of LV myocardium in EA(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhile LVEF is the main criterion of systolic function in clinical practice, myocardial strain imaging techniques have been proven to identify occult myocardial dysfunction before clinically decreased LVEF (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). We postulated that myocardial strain may help to risk stratify the preoperative EA patient. In our study, the global circumferential and longitudinal strain on CMR of EA patients with normal LVEF were comparable to the control group. However, the global peak circumferential and longitudinal strain was lower in the reduced LVEF group than the strain measured in preserved LVEF groups suggesting CMR strain may have value in the pre-operative evaluation of EA\u003c/p\u003e \u003cp\u003eIt is no surprise that the most extreme forms of EA have associated LV dysfunction, but our study lends further support to specific measures of disease. RVEDV, the ratio of RVEDV/LVEDV and TV DI were used as indirect markers of severity of EA. LV dysfunction had negative correlation to increasing DI and RVEDV. This validates the ventricular interdependence mechanism as the cause of LV dysfunction whereby patients with more severe displacement of the TV hinge point had larger atrialized right ventricular chambers and thus greater impingement on left atrial and left ventricular filling. A previous study by Liu et al, reported negative correlation of LVEF to TV regurgitation but no studies thus far have reported an association with TV DI (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the current study, we also compared the impact of preoperative LV dysfunction to immediate postoperative stay clinical outcomes and found that there was a trend towards longer operative times (cardiopulmonary bypass and aortic cross clamp times). The correlation of more severe displacement in patients with preoperative LV dysfunction can explain the longer cross-clamp time as higher complexity surgical maneuvers are needed during the TV repair. There was also longer use of epinephrine in the immediate postop period in the ICU in those who had LV dysfunction as compared to those with normal LV function. Prior studies have reported LV dysfunction independently predictive of increased late mortality in EA(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), however we conclude that LV function also has implications in the perioperative period.\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eLimitations:\u003c/h2\u003e \u003cp\u003eOur study has several limitations. The retrospective study design led to a variable timing of the preoperative CMR in relation to the timing of surgery. We included a minority of CMR studies performed at referral centers which introduces variation in the CMR acquisition parameters. Since our institute is an international referral center for Ebstein anomaly, our study includes a significant referral bias that may include better surgical candidates, however many patients were referred following attempted prior palliation which complicates their surgical management Furthermore, many patients returned to their home centers immediately following surgery, therefore while the LV dysfunction seemed to impact the immediate perioperative period, we do not have longer term follow up to assess ventricular remodeling following the Da Silva Cone operation. Though this is the largest reported dataset of EA patients with CMR, overall, the study is limited by relatively small cohort size. The number of patients in each subgroup was small, limiting the statistical power of these findings. Larger, multi-center studies are needed to validate our results.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eTrue LVNC is rare in this population, but our data supports increased trabeculation of the LV in EA. There is negative correlation of LV function with right heart volume and tricuspid valve displacement index, all markers of EA disease severity. No correlation was found between the degree of LV trabeculation and LV dysfunction. However, the presence of LV dysfunction is under-recognized by echocardiogram and quality CMR assessment of the LV is relevant to perioperative management of EA. Further studies with a long-term follow up are necessary.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eCompeting interests:\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAG collected the data and wrote the manuscript. CDC collected data and LW analyzed the data. LDS, JDS , CD, LO, TA, AC formulated the hypothesis, analyzed the results and reviewed the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAttenhofer Jost CH, Connolly HM, Edwards WD, Hayes D, Warnes CA, Danielson GK. Ebstein\u0026apos;s anomaly - review of a multifaceted congenital cardiac condition. Swiss Med Wkly. 2005;135(19-20):269-81.\u003c/li\u003e\n\u003cli\u003eDearani JA, Mora BN, Nelson TJ, Haile DT, O\u0026apos;Leary PW. Ebstein anomaly review: what\u0026apos;s now, what\u0026apos;s next? Expert Rev Cardiovasc Ther. 2015;13(10):1101-9.\u003c/li\u003e\n\u003cli\u003eLee CM, Sheehan FH, Bouzas B, Chen SS, Gatzoulis MA, Kilner PJ. The shape and function of the right ventricle in Ebstein\u0026apos;s anomaly. Int J Cardiol. 2013;167(3):704-10.\u003c/li\u003e\n\u003cli\u003eTobler D, Yalonetsky S, Crean AM, Granton JT, Burchill L, Silversides CK, et al. Right heart characteristics and exercise parameters in adults with Ebstein anomaly: new perspectives from cardiac magnetic resonance imaging studies. Int J Cardiol. 2013;165(1):146-50.\u003c/li\u003e\n\u003cli\u003e\u0026lt;lv geomety and function in adults wuth ebstein of TV- 1987, UCLA.pdf\u0026gt;.\u003c/li\u003e\n\u003cli\u003eYang D, Sun J, Wan K, Luo Y, Liu H, Cheng W, et al. LV geometric and substrate remodelling in patient with Ebstein anomaly - a deep insight from MRI T1 mapping fibrosis imaging. Journal of Cardiovascular Magnetic Resonance. 2016;18(S1).\u003c/li\u003e\n\u003cli\u003eGoleski PJ, Sheehan FH, Chen SS, Kilner PJ, Gatzoulis MA. The shape and function of the left ventricle in Ebstein\u0026apos;s anomaly. Int J Cardiol. 2014;171(3):404-12.\u003c/li\u003e\n\u003cli\u003eAttenhofer Jost CH, Connolly HM, O\u0026apos;Leary PW, Warnes CA, Tajik AJ, Seward JB. Left heart lesions in patients with Ebstein anomaly. Mayo Clin Proc. 2005;80(3):361-8.\u003c/li\u003e\n\u003cli\u003eBenson LN, Child JS, Schwaiger M, Perloff JK, Schelbert HR. Left ventricular geometry and function in adults with Ebstein\u0026apos;s anomaly of the tricuspid valve. Circulation. 1987;75(2):353-9.\u003c/li\u003e\n\u003cli\u003eBrown ML, Dearani JA, Danielson GK, Cetta F, Connolly HM, Warnes CA, et al. Effect of operation for Ebstein anomaly on left ventricular function. Am J Cardiol. 2008;102(12):1724-7.\u003c/li\u003e\n\u003cli\u003eLi X, Wang SM, Schreiber C, Cheng W, Lin K, Sun JY, et al. More than valve repair: Effect of cone reconstruction on right ventricular geometry and function in patients with Ebstein anomaly. Int J Cardiol. 2016;206:131-7.\u003c/li\u003e\n\u003cli\u003eLange R, Burri M, Eschenbach LK, Badiu CC, da Silva JP, Nagdyman N, et al. Da Silva\u0026apos;s cone repair for Ebstein\u0026apos;s anomaly: effect on right ventricular size and function. Eur J Cardiothorac Surg. 2015;48(2):316-20; discussion 20-1.\u003c/li\u003e\n\u003cli\u003eBrown ML, Dearani JA, Danielson GK, Cetta F, Connolly HM, Warnes CA, et al. Functional status after operation for Ebstein anomaly: the Mayo Clinic experience. J Am Coll Cardiol. 2008;52(6):460-6.\u003c/li\u003e\n\u003cli\u003eNeijenhuis RML, Tsang VT, Marek J, Issitt R, Bonello B, Von Klemperer K, et al. Cone reconstruction for Ebstein anomaly: Late biventricular function and possible remodeling. J Thorac Cardiovasc Surg. 2021;161(3):1097-108.\u003c/li\u003e\n\u003cli\u003eBeroukhim RS, Jing L, Harrild DM, Fornwalt BK, Mejia-Spiegeler A, Rhodes J, et al. Impact of the cone operation on left ventricular size, function, and dyssynchrony in Ebstein anomaly: a cardiovascular magnetic resonance study. J Cardiovasc Magn Reson. 2018;20(1):32.\u003c/li\u003e\n\u003cli\u003eFratz S, Chung T, Greil GF, Samyn MM, Taylor AM, Valsangiacomo Buechel ER, et al. Guidelines and protocols for cardiovascular magnetic resonance in children and adults with congenital heart disease: SCMR expert consensus group on congenital heart disease. J Cardiovasc Magn Reson. 2013;15(1):51.\u003c/li\u003e\n\u003cli\u003eLeung MP, Baker EJ, Anderson RH, Zuberbuhler JR. Cineangiographic spectrum of Ebstein\u0026apos;s malformation: its relevance to clinical presentation and outcome. J Am Coll Cardiol. 1988;11(1):154-61.\u003c/li\u003e\n\u003cli\u003eAlsaied T, Castrillon CD, Christopher A, Da Silva J, Morell VO, Lanford L, et al. Cardiac MRI predictors of right ventricular dysfunction after the Da Silva cone operation for Ebstein\u0026apos;s anomaly. International Journal of Cardiology Congenital Heart Disease. 2022;7.\u003c/li\u003e\n\u003cli\u003ePetersen SE, Selvanayagam JB, Wiesmann F, Robson MD, Francis JM, Anderson RH, et al. Left ventricular non-compaction: insights from cardiovascular magnetic resonance imaging. J Am Coll Cardiol. 2005;46(1):101-5.\u003c/li\u003e\n\u003cli\u003eGrothoff M, Pachowsky M, Hoffmann J, Posch M, Klaassen S, Lehmkuhl L, et al. Value of cardiovascular MR in diagnosing left ventricular non-compaction cardiomyopathy and in discriminating between other cardiomyopathies. Eur Radiol. 2012;22(12):2699-709.\u003c/li\u003e\n\u003cli\u003eDawson DK, Maceira AM, Raj VJ, Graham C, Pennell DJ, Kilner PJ. Regional thicknesses and thickening of compacted and trabeculated myocardial layers of the normal left ventricle studied by cardiovascular magnetic resonance. Circ Cardiovasc Imaging. 2011;4(2):139-46.\u003c/li\u003e\n\u003cli\u003eFratz S, Janello C, Muller D, Seligmann M, Meierhofer C, Schuster T, et al. The functional right ventricle and tricuspid regurgitation in Ebstein\u0026apos;s anomaly. Int J Cardiol. 2013;167(1):258-61.\u003c/li\u003e\n\u003cli\u003eDaliento L, Angelini A, Ho SY, Frescura C, Turrini P, Baratella MC, et al. Angiographic and morphologic features of the left ventricle in Ebstein\u0026apos;s malformation. Am J Cardiol. 1997;80(8):1051-9.\u003c/li\u003e\n\u003cli\u003eHurwitz RA. Left ventricular function in infants and children with symptomatic Ebstein\u0026apos;s anomaly. Am J Cardiol. 1994;73(9):716-8.\u003c/li\u003e\n\u003cli\u003eChauvaud S, Berrebi A, d\u0026apos;Attellis N, Mousseaux E, Hernigou A, Carpentier A. Ebstein\u0026apos;s anomaly: repair based on functional analysis. Eur J Cardiothorac Surg. 2003;23(4):525-31.\u003c/li\u003e\n\u003cli\u003eLouie EK, Lin SS, Reynertson SI, Brundage BH, Levitsky S, Rich S. Pressure and volume loading of the right ventricle have opposite effects on left ventricular ejection fraction. Circulation. 1995;92(4):819-24.\u003c/li\u003e\n\u003cli\u003eBonow RO, Borer JS, Rosing DR, Bacharach SL, Green MV, Kent KM. Left ventricular functional reserve in adult patients with atrial septal defect: pre- and postoperative studies. Circulation. 1981;63(6):1315-22.\u003c/li\u003e\n\u003cli\u003eKelly DT, Spotnitz HM, Beiser GD, Pierce JE, Epstein SE. Effects of chronic right ventricular volume and pressure loading on left ventricular performance. Circulation. 1971;44(3):403-12.\u003c/li\u003e\n\u003cli\u003eThareja SK, Frommelt MA, Lincoln J, Lough JW, Mitchell ME, Tomita-Mitchell A. A Systematic Review of Ebstein\u0026apos;s Anomaly with Left Ventricular Noncompaction. J Cardiovasc Dev Dis. 2022;9(4).\u003c/li\u003e\n\u003cli\u003eVermeer AM, van Engelen K, Postma AV, Baars MJ, Christiaans I, De Haij S, et al. Ebstein anomaly associated with left ventricular noncompaction: an autosomal dominant condition that can be caused by mutations in MYH7. Am J Med Genet C Semin Med Genet. 2013;163C(3):178-84.\u003c/li\u003e\n\u003cli\u003eKlaassen S, Probst S, Oechslin E, Gerull B, Krings G, Schuler P, et al. Mutations in sarcomere protein genes in left ventricular noncompaction. Circulation. 2008;117(22):2893-901.\u003c/li\u003e\n\u003cli\u003evan Engelen K, Postma AV, van de Meerakker JB, Roos-Hesselink JW, Helderman-van den Enden AT, Vliegen HW, et al. Ebstein\u0026apos;s anomaly may be caused by mutations in the sarcomere protein gene MYH7. Neth Heart J. 2013;21(3):113-7.\u003c/li\u003e\n\u003cli\u003ePignatelli RH, Texter KM, Denfield SW, Grenier MA, Altman CA, Ayres NA, et al. LV Noncompaction in Ebstein\u0026apos;s anomaly in infants and outcomes. JACC Cardiovasc Imaging. 2014;7(2):207-9.\u003c/li\u003e\n\u003cli\u003eKumor M, Lipczynska M, Biernacka EK, Klisiewicz A, Wojcik A, Konka M, et al. Cardiac arrest and ventricular arrhythmia in adults with Ebstein anomaly and left ventricular non-compaction. J Cardiol. 2018;71(5):484-7.\u003c/li\u003e\n\u003cli\u003eYang D, Sun J, Luo Y, Liu H, Wan K, Zhang T, et al. Feature tracking (FT) and extracelluar volume (ECV) by cardiac magnetic resonance segmentally analyze change of LV in Ebstein:a novel perspective in myocardial remodeling. Journal of Cardiovascular Magnetic Resonance. 2016;18(Suppl 1).\u003c/li\u003e\n\u003cli\u003eSmiseth OA, Torp H, Opdahl A, Haugaa KH, Urheim S. Myocardial strain imaging: how useful is it in clinical decision making? Eur Heart J. 2016;37(15):1196-207.\u003c/li\u003e\n\u003cli\u003eAletras AH, Tilak GS, Hsu LY, Arai AE. Heterogeneity of intramural function in hypertrophic cardiomyopathy: mechanistic insights from MRI late gadolinium enhancement and high-resolution displacement encoding with stimulated echoes strain maps. Circ Cardiovasc Imaging. 2011;4(4):425-34.\u003c/li\u003e\n\u003cli\u003eLiu X, Zhang Q, Yang ZG, Guo YK, Shi K, Xu HY, et al. Morphologic and functional abnormalities in patients with Ebstein\u0026apos;s anomaly with cardiac magnetic resonance imaging: Correlation with tricuspid regurgitation. Eur J Radiol. 2016;85(9):1601-6.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"pediatric-cardiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pedc","sideBox":"Learn more about [Pediatric Cardiology](http://link.springer.com/journal/246)","snPcode":"246","submissionUrl":"https://submission.nature.com/new-submission/246/3","title":"Pediatric Cardiology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4219470/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4219470/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Ebstein Anomaly (EA) is a malformation of the right heart, but there is data to suggest that the left ventricle (LV) can suffer from intrinsic structural and functional abnormalities which affect surgical outcomes.\u003c/p\u003e\n\u003cp\u003eHypothesis: The LV in patients with EA is hypertrabeculated with abnormalities in LV function and strain.\u003c/p\u003e\n\u003cp\u003eMethods: In this retrospective single-center study, patients with EA who underwent pre-operative cardiac MRI (CMR) between the period of 2014-2023 were included along with a group of healthy-age-matched controls. Left ventricular and right ventricular volume, function and strain analyses were performed on standard SSFP imaging. LV noncompacted:compacted (NC/C) ratio and the displacement index of the tricuspid valve were measured.\u003c/p\u003e\n\u003cp\u003eResults: Thirty-five EA patients were included with mean age of 21.0 +/- 16.4 years. Thirteen EA patients (37%) had mild pre-operative LV dysfunction on CMR and 1 (3%) had moderate LV dysfunction. The global circumferential and longitudinal strain were significantly lower in the reduced LVEF group compared to those with preserved LVEF (-15% vs. -16.8%, p =0.01 and −11.8% vs. −16.1%; p =0.04; respectively). A single EA patient (3%) met criteria for LVNC with a maximal NC/C ratio \u0026gt; 2.3. There was no statistically significant difference in NC/C ratio in the EA population (1.33 +/- 0.5) vs. controls (1.11 +/- 0.2), p = 0.16. There was an inverse correlation of LV ejection fraction (EF) with right ventricular end-diastolic volume and displacement index (DI). All patients underwent the Da Silva Cone procedure at our center. Patients with preoperative LV dysfunction had longer bypass time (163 +/- 42 vs 142 +/-38 min, p=0.17) and duration of postoperative epinephrine support (23.5 +/- 22 vs 11.2 +/- 22.3 hours, p=0.20).\u003c/p\u003e\n\u003cp\u003eConclusions: This is the largest study to date to evaluate preoperative LV structure and function in EA patients by CMR. In this cohort of 35 patients, LV non-compaction was rare, though there was a trend toward increased trabeculation. Pre-operative LV dysfunction is common and associated with more severe EA with larger RV size. The presence of LV dysfunction is relevant to perioperative management and further study with larger cohorts and longer follow up are necessary.\u003c/p\u003e","manuscriptTitle":"Assessing left ventricular pathology in patients with Ebstein anomaly using Cardiovascular magnetic resonance: Looking past the right heart","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-11 17:29:35","doi":"10.21203/rs.3.rs-4219470/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2024-04-30T00:11:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-09T21:17:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"14456842-3bb7-4f23-8807-3d2b576290e1","date":"2024-04-08T20:50:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"4f22443a-1b46-43c1-84c1-1d6274742a7f","date":"2024-04-08T19:38:42+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-04-08T19:11:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-06T07:43:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-06T07:43:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"Pediatric Cardiology","date":"2024-04-04T18:57:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"pediatric-cardiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pedc","sideBox":"Learn more about [Pediatric Cardiology](http://link.springer.com/journal/246)","snPcode":"246","submissionUrl":"https://submission.nature.com/new-submission/246/3","title":"Pediatric Cardiology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"b5c58c3b-0ead-4fc0-bf61-45ffc6c66ca4","owner":[],"postedDate":"April 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-07-21T00:27:28+00:00","versionOfRecord":{"articleIdentity":"rs-4219470","link":"https://doi.org/10.1007/s00246-024-03585-8","journal":{"identity":"pediatric-cardiology","isVorOnly":false,"title":"Pediatric Cardiology"},"publishedOn":"2024-07-20 00:27:28","publishedOnDateReadable":"July 20th, 2024"},"versionCreatedAt":"2024-04-11 17:29:35","video":"","vorDoi":"10.1007/s00246-024-03585-8","vorDoiUrl":"https://doi.org/10.1007/s00246-024-03585-8","workflowStages":[]},"version":"v1","identity":"rs-4219470","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4219470","identity":"rs-4219470","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}