Ebstein's anomaly: presentation and outcome from fetus to adult

Pericardial patch augmentation of anterior tricuspid leaflet in Ebstein's anomaly

Although refinement of tricuspid valvuloplasty and plication techniques has opened the way to a satisfactory outlook for the majority of patients with Ebstein's anomaly, paucity of tissue in the anterior tricuspid leaflet may preclude successful valve repair. In this particular circumstance, a modified Carpentier repair of the tricuspid valve with additional pericardial patch augmentation of the anterior leaflet may result in a well-functioning monocusp tricuspid valve.

Surgical management of isolated congenital tricuspid regurgitation

BACKGROUND

Isolated congenital tricuspid regurgitation without downward displacement of the leaflet is a rare clinical entity. Degenerative cusps and lack of chordae may preclude valvuloplasty and require valve replacement.

METHODS

Three consecutive patients with isolated congenital tricuspid regurgitation underwent surgical repair between May 1995 and April 1997. Their ages were 23, 15, and 8 years old. Tricuspid valvuloplasty was feasible in all of them, with use of a gathering suture of the anterior leaflet, artificial chordae implantation, and ring annuloplasty.

RESULTS

All 3 patients survived and recovered well after the operation. The cardiothoracic ratios on their chest roentgenograms decreased from 0.64 to 0.52 in patient 1, from 0.58 to 0.48 in patient 2, and from 0.60 to 0.44 in patient 3. Postoperative echocardiograms showed competent tricuspid valves and the disappearance of regurgitation in all cases.

CONCLUSIONS

Although malformation of the valve is extensive in isolated congenital tricuspid regurgitation, application of artificial chordae with conventional valvuloplasty technique can avoid the use of prosthetic valves by establishing the competence of the tricuspid valve.

Valvular heart disease in pregnancy. A contemporary perspective

Valvular heart disease may have a significant impact on the course and outcome of pregnancy with implications for fetal as well as maternal health. Optimally, serious symptomatic valvular heart disease should be detected and treated before pregnancy. Whether a pregnant woman is known to have valvular heart disease or is diagnosed during pregnancy, it is imperative that she is managed by an experienced multidisciplinary team. Although medical therapy may alleviate symptoms of heart failure in some patients, definitive intervention either with percutaneous balloon valvuloplasty or with surgical valve replacement may be necessary.

Factors affecting the prognosis of Ebstein's anomaly during fetal life

BACKGROUND

The echocardiographic criteria that have been used to evaluate severity of Ebstein's anomaly in utero are the same as those applied after birth.

OBJECTIVE

The objective of this study was to establish prognostic criteria that take into account the peculiarities of the fetal hemodynamics.

METHOD

The video recordings of eight fetuses with Ebstein's anomaly were retrospectively reviewed.

RESULTS

The following indexes had no prognostic significance either on fetal or neonatal outcome: the ratio of functional tricuspid opening over the diameter of the annulus, the degree of displacement of the tricuspid valve opening, and the degree of tricuspid regurgitation. The index of severity (based on the surfaces of right atrium + atrialized right ventricle) and the cardiothoracic ratio had a significant impact only on neonatal survival. The smallest fossa ovalis were found in two fetuses who had hydrops. Fetuses who reached term without problems had higher left ventricular outputs. A positive linear correlation was found between the z score of the left ventricular output and the size of the fossa ovalis (r = 0.81, p < 0.05).

CONCLUSION

The prognosis of Ebstein's anomaly during fetal life is not influenced by criteria described for postnatal life and may be related to factors that control the volume load of the left ventricle.

Outcome in cyanotic neonates with Ebstein's anomaly

Clinical, angiographic, radiographic, and echocardiographic data on 46 neonates with Ebstein's anomaly presenting with cyanosis between 1954 and 1996 were reviewed to determine possible risk factors for mortality. Most patients (67%) presented at birth with 3 cases diagnosed in utero. Mean systemic oxygen saturation was 62+/-12%. An atrial septal defect > or = 4 mm was noted in 20 patients (44%). The patent right ventricle to pulmonary artery connection was present in 10 (22%), and pulmonary atresia was functional in 25 (54%) and anatomic in 11 patients (24%). Fifteen patients (35%) underwent surgical interventions. Total mortality was 70% (vs 14% in acyanotic patients diagnosed during the same time period; p <0.0001) and was related to low cardiac output and hypoxia in 20 patients (62%), postoperative complications in 8 (25%), and sudden death in 4 (13%). Kaplan-Meier survival estimates were 61% at age 1 week (95% confidence interval [CI], 47% to 75%), 48% at age 1 month (95% CI, 34% to 62%), and 36% at both 1 and 5 years of age (95% CI, 22% to 50%). Mortality improved from 81% in 1954 to 1985 to 47% in 1986 to 1996 (p = 0.04). Significant independent predictors of mortality included an atrial septal defect > or = 4 mm (odds ratio [OR] 2.39; p = 0.04), reduced left ventricular function (OR 4.10; p = 0.002), and functional or anatomic pulmonary atresia (OR 2.44, p = 0.003; and OR 5.97, p = 0.004, respectively). An echocardiographic ratio of the combined right atrial and atrialized right ventricular area to the area of the functional right ventricle and left heart >1.0 was 100% predictive of mortality.

Conversion of complex neonatal Ebstein's anomaly into functional tricuspid or pulmonary atresia

BACKGROUND

Ebstein's anomaly, due to failure of delamination of one or more leaflets of the tricuspid valve (TV), is associated with varying degrees of tricuspid regurgitation (TR) and dysplasia of the right ventricle (RV). Although refinement of tricuspid valvuloplasty and plication techniques have opened the way to a satisfactory outlook for the majority of older children and adults, Ebstein's anomaly presenting at neonatal age, secondary to ineffective forward flow into the pulmonary and systemic circulation, has a reported mortality rate of as high as 75%. In order to improve the dismal outcome in neonatal Ebstein's anomaly, we have strived for early univentricular palliation.

PATIENTS AND METHODS

Univentricular repair was performed in five neonates (median age 5 days; range 2-14 days) with Ebstein's anomaly, ductal dependent pulmonary blood flow, severe TR, absence of forward flow across the pulmonary valve, and small left ventricular (LV) area due to right-to-left bowing of the ventricular septum and ineffective LV loading (median indexed LV area 10.5 cm2/m2). In addition, two neonates had moderate pulmonary regurgitation (PR), one with additional pulmonary stenosis. In all patients, the indexed area of the combined right atrium and atrialized RV was greater than that of the combined functional RV, left atrium, and left ventricle (median 22.0 and 20.8 cm2/m2, respectively). The median preoperative systemic oxygen tension was 35 mmHg and the median pH 7.28. Repair consisted of TV closure with a pericardial patch (with the coronary sinus draining into the RV) (n = 3) or, in the presence of PR, resection of the dysplastic TV and division and oversewing of the main pulmonary artery (n = 2), as well as excision of the atrial septum, resection of redundant right atrial wall, and construction of an aortopulmonary shunt (n = 5).

RESULTS

The median indexed LV area increased from 10.5 to 18.8 cm2/m2 as a result of more effective loading of the left ventricle. There was no intraoperative or late mortality. The patients were extubated at a median of 7 days postoperatively. At discharge, the median systemic oxygen tension was 46 mmHg. In all five patients, at 6, 7, 10, 12 and 16 weeks of age, a bidirectional cavopulmonary anastomosis has been constructed.

CONCLUSIONS

In neonates with Ebstein's anomaly and ductal dependent pulmonary blood flow, rational palliation consists of the surgical creation of tricuspid atresia or, in the additional presence of PR or pulmonary stenosis, the creation of pulmonary atresia. These procedures may result in effective LV decompression and more effective volume loading of the left ventricle with increase of systemic output and improved clinical outcome.

Right-sided maze procedure for right atrial arrhythmias in congenital heart disease

BACKGROUND

Atrial fibrillation and flutter, commonly associated with congenital heart anomalies that cause right atrial dilatation, may cause significant morbidity and reduction of quality of life, even after surgical repair of the anomalies.

METHODS

In an effort to reduce the incidence of atrial tachyarrhythmias after repair of right-sided congenital heart disease, we performed a concomitant right-sided maze procedure.

RESULTS

Eighteen patients with paroxysmal atrial fibrillation or flutter (n = 12) or chronic atrial fibrillation or flutter (n = 6) aged 10.9 to 68.4 years (mean 34.9 years) underwent a right-sided maze in association with repair of Ebstein's anomaly (n = 15), congenital tricuspid insufficiency (n = 2), and isolated atrial septal defect (n = 1). There were no early deaths, reoperations, or complete heart block. Discharge rhythm was sinus (n = 16) or junctional (n = 2). Follow-up was complete in all 18 patients and ranged from 3.1 to 17.2 months (mean 8.1 months); all are in New York Heart Association class I. Early postoperative arrhythmias developed in 3 patients (all were converted to sinus rhythm by antiarrhythmic drugs). There were no late deaths or reoperations.

CONCLUSIONS

The inclusion of a right-sided maze procedure with cardiac repair in patients having congenital heart anomalies that cause right atrial dilatation and associated atrial tachyarrhythmias is effective in eliminating or reducing the incidence of those arrhythmias.

Results after surgical repair of Ebstein's anomaly

BACKGROUND

Ebstein's anomaly of the tricuspid valve is a complex malformation. Various operations have been undertaken with varying results. Because valve replacement yielded poor results, surgical treatment has focused on valvuloplasties.

METHODS

Between April 1974 and February 1995, 60 patients with Ebstein's anomaly underwent surgical repair. Age ranged from 5 months to 54 years. In 56 patients (93.3%), tricuspid valvuloplasty was feasible, mainly by creating a monocusp valve with the single-stitch technique. The other 4 patients had valve replacement with a bioprosthesis. Six reoperations were necessary (10.0%): four valve replacements and two repeat valvuloplasties.

RESULTS

There were two hospital deaths (3.3%) and a late mortality rate of 10.0% (6 patients). Forty-nine (94.2%) of 52 survivors were followed for 5 months to 18.6 years (median follow-up, 5.0 years; mean follow-up, 6.9 years). The actuarial survival rate (Kaplan-Meier) was 96.5% +/- 2.4% at 1 year and 83.3% +/- 5.6% at 18 years. At follow-up evaluation, nearly all patients showed substantial improvement (93.9% were in functional class I or II) compared with their preoperative status. Doppler echocardiographic studies demonstrated good tricuspid valve function in most patients.

CONCLUSIONS

Valvuloplasty using the single-stitch technique is a rewarding operation. It yields good long-term results with substantial improvement in functional performance and clinical status.

Atrial compartment surgery for chronic atrial fibrillation associated with congenital heart defects

In three adult patients, two with atrial septal defect and one with Ebstein's anomaly, chronic atrial fibrillation was documented for 13, 21, and 3 years, respectively. Atrial compartment surgery was performed for ablation of the atrial fibrillation concomitant with repair of the cardiac defects. The operation was performed with traditional cardiopulmonary bypass and crystalloid cardioplegia myocardial protection. A U-shaped incision was made in the right atrium: a longitudinal incision 1 cm lateral and parallel to the sulcus terminalis, extending along the borders of the atrial septum to 3 cm (upper margin) and 1 cm (lower margin) distant to the tricuspid anulus. Cryolesions of the atrial isthmus between the upper incision margin and the tricuspid valve anulus were created at -60 degrees C for 180 seconds at a time. After the operation, all three patients had restored and maintained normal sinus rhythm during follow-up periods of 32, 16, and 3 months. Doppler echocardiography detected the recovery of atrial contractility in all three patients. Atrial compartment surgery is a simple and effective method for elimination of chronic atrial fibrillation associated with congenital heart defects.

Pediatric echocardiography: current role and a review of technical advances

Advances in echocardiography have enhanced our diagnostic imaging capabilities for congenital heart defects. In addition to improved resolution of two-dimensional images, cardiac hemodynamic assessment is possible with the use of Doppler, color Doppler, and stress echocardiography. Transesophageal echocardiography has allowed intraoperative assessment of cardiac repairs, and fetal echocardiography has allowed development of the field of fetal cardiology. The developing areas of intravascular ultrasonography and three-dimensional echocardiography show promise for the future. Echocardiography continues to revolutionize our ability to diagnose congenital heart defects accurately.