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Eckerström F, Dellborg M, Hjortdal VE, Eriksson P, Mandalenakis Z. Mortality in Patients With Ebstein Anomaly. J Am Coll Cardiol 2023; 81:2420-2430. [PMID: 37344044 DOI: 10.1016/j.jacc.2023.04.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 04/14/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Low birth prevalence and referral bias constitute significant obstacles to elucidating the natural history of Ebstein anomaly (EA). OBJECTIVES An extensive 2-country register-based collaboration was performed to investigate the mortality in patients with EA. METHODS Patients born from 1970 to 2017 and diagnosed with EA were identified in Danish and Swedish nationwide medical registries. Each patient was matched by birth year and sex with 10 control subjects from the general population. Cumulative mortality and HR of mortality were computed using Kaplan-Meier failure function and Cox proportional regression model. RESULTS The study included 530 patients with EA and 5,300 matched control subjects with a median follow-up of 11 years. In the EA cohort, 43% (228) underwent cardiac surgery. Cumulative mortality was lower for patients diagnosed in the modern era (the year 2000 and later) than for those diagnosed in the prior era (P < 0.001). Patients with isolated lesion displayed lower cumulative mortality than patients with complex lesions did (P < 0.001). Patients with a presumed mild EA anatomy displayed a 35-year cumulative mortality of 11% (vs 4% for the matched control subjects; P < 0.001), yielding an HR for mortality of 6.0 (95% CI: 2.7-13.6), whereas patients with presumed severe EA demonstrated an HR of 36.2 (95% CI: 15.5-84.4) compared with control subjects and a cumulative mortality of 18% 35 years following diagnosis. CONCLUSIONS Mortality in patients with EA is high irrespective of presence of concomitant congenital cardiac malformations and time of diagnosis compared with the general population, but overall mortality has improved in the contemporary era.
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Affiliation(s)
- Filip Eckerström
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark.
| | - Mikael Dellborg
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Vibeke Elisabeth Hjortdal
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Peter Eriksson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Adult Congenital Heart Disease Unit, Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Zacharias Mandalenakis
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Adult Congenital Heart Disease Unit, Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
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2
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Martin de Miguel I, Madhavan M, Miranda WR, Connolly HM, Egbe AC. Prognostic implications of atrial fibrillation in adults with Ebstein anomaly. Heart 2023; 109:442-448. [PMID: 36368881 PMCID: PMC9975025 DOI: 10.1136/heartjnl-2022-321493] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 10/17/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Supraventricular arrhythmias are common in adults with Ebstein anomaly (EA). However, there are limited data about prognostic implications of atrial fibrillation (AF) in this population. Accordingly, our aim was to assess the clinical profile and burden of AF in adults with EA, and the relationship between AF and outcomes. METHODS AND RESULTS Six hundred eighty-two consecutive adults with a median age of 36 (24-49) years from Mayo Clinic, Minnesota, USA, between 2003 and 2020 were included. Sustained episodes of AF, clinical, echocardiographic, rhythm and surgical data were collected. Prevalence of AF at baseline was 18% (126 patients); the first episode occurred at a mean age of 43±17 years. Patients with AF were older, were more likely men, and had hypertension, renal dysfunction, cardiac devices, and more advanced right-sided and left-sided remodelling. During a median follow-up of 156 (81-240) months, 62 patients (11%) developed incident AF. At the last encounter, prevalence of AF was 28% (188 patients); of those, 63 (34%) had recurrent AF. Hospitalisation for heart failure (HF) occurred in 51 patients (7%). AF (HR 2.32, 95% CI 1.18 to 4.47; p=0.01) was independently associated with hospitalisation for HF. All-cause death occurred in 53 patients (8%); it was more frequent in those with AF in the univariable analysis, although it did not remain significant in the multivariable analysis. CONCLUSIONS AF in EA develops at relatively young ages with one-third of the cohort exhibiting a recurrent pattern. Patients with AF had a higher prevalence of comorbidities and worse right-sided and left-sided cardiac remodelling. AF was independently associated with HF hospitalisation.
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Affiliation(s)
| | - Malini Madhavan
- Department of Cardiovascular Medicine, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic Minnesota, Rochester, Minnesota, USA
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3
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Ebstein's Anomaly: From Fetus to Adult-Literature Review and Pathway for Patient Care. Pediatr Cardiol 2022; 43:1409-1428. [PMID: 35460366 DOI: 10.1007/s00246-022-02908-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 04/04/2022] [Indexed: 10/18/2022]
Abstract
Ebstein's anomaly, first described in 1866 by Dr William Ebstein, accounts for 0.3-0.5% of congenital heart defects and represents 40% of congenital tricuspid valve abnormalities. Ebstein's anomaly affects the development of the tricuspid valve with widely varying morphology and, therefore, clinical presentation. Associated congenital cardiac lesions tend to be found more often in younger patients and may even be the reason for presentation. Presentation can vary from the most extreme form in fetal life, to asymptomatic diagnosis late in adult life. The most symptomatic patients need intensive care support in the neonatal period. This article summarizes and analyzes the literature on Ebstein's anomaly and provides a framework for the investigation, management, and follow-up of these patients, whether they present via fetal detection or late in adult life. For each age group, the clinical presentation, required diagnostic investigations, natural history, and management are described. The surgical options available for patients with Ebstein's anomaly are detailed and analyzed, starting from the initial mono-leaflet repairs to the most recent cone repair and its modifications. The review also assesses the effects of pregnancy on the Ebstein's circulation, and vice versa, the effects of Ebstein's on pregnancy outcomes. Finally, two attached appendices are provided for a structured echocardiogram protocol and key information useful for comprehensive Multi-Disciplinary Team discussion.
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4
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Van Praagh R. Tricuspid Valve Anomalies. CONGENIT HEART DIS 2022. [DOI: 10.1016/b978-1-56053-368-9.00013-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Chowdhury UK, Singh S, George N, Sankhyan LK, Sharan S, Kapoor PM, Chauhan AS, Gharde P, B. SG, Sengupta S. Successful One and One-half Ventricular Circulation with Bioprosthetic Tricuspid Valve Replacement and Total Chordal Preservation in a Patient with Ebstein’s Anomaly: A Video Presentation. JOURNAL OF CARDIAC CRITICAL CARE TSS 2021. [DOI: 10.1055/s-0041-1723626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
AbstractEbstein’s anomaly is a rare congenital malformation of the right ventricle and tricuspid valve which is characterized by several features that can exhibit an infinite spectrum of malformation.The abnormalities include: i) adherence of the tricuspid leaflets to the underlying myocardium (failure of delamination); ii) anterior and apical rotational displacement of the functional tricuspid annulus (septal > posterior > anterior leaflet); iii) dilatation of the right atrioventricular junction (the true tricuspid annulus) with variable degrees of hypertrophy and thinning of the wall; iv) dilatation of the “atrialized” portion of the right ventricle; and v) redundancy, fenestration, and tethering of the anterior leaflet.
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Affiliation(s)
- Ujjwal K. Chowdhury
- Cardio-Thoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Sukhjeet Singh
- Cardio-Thoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Niwin George
- Cardio-Thoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | | | - Sandeep Sharan
- Cardio-Thoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Poonam Malhotra Kapoor
- Cardio-Thoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Abhinav Singh Chauhan
- Cardio-Thoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Parag Gharde
- Cardio-Thoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Sushama Gayatri B.
- Cardio-Thoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjoy Sengupta
- Cardio-Thoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
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Geerdink LM, Delhaas T, Helbing WA, du Marchie Sarvaas GJ, Heide HT, Rozendaal L, de Korte CL, Peer PGM, Kuipers IM, Kapusta L. Paediatric Ebstein's anomaly: how clinical presentation predicts mortality. Arch Dis Child 2018; 103:859-863. [PMID: 29567665 DOI: 10.1136/archdischild-2017-313482] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 02/20/2018] [Accepted: 02/24/2018] [Indexed: 01/20/2023]
Abstract
BACKGROUND Forecasting the prognosis of a child when diagnosed with Ebstein's anomaly is difficult. We, therefore, studied which factors at the time of diagnosis are associated with death during childhood. METHODS All consecutive patients (0-18 years) diagnosed with Ebstein's anomaly in the Netherlands between 1980 and 2014 were included. Survival curves were obtained using the Kaplan-Meier method. By using the Cox proportional hazard model, we analysed the factors (at diagnosis) that were associated with death. RESULTS We included 176 patients. Thirty-one patients (18%) died before the age of 18 years. The 1-year survival was 84% and remained stable at 82% from 35 months after diagnosis and onwards. Modified Ross Heart Failure Class 4 at the time of diagnosis was the most important risk factor for death during childhood (HR 12.5, 95% CI 4.4 to 35.9). Furthermore, diagnosis in the neonatal period (HR 4.2, 95% CI 1.5 to 12.0), severe tricuspid valve regurgitation (HR 2.4, 95% CI 1.2 to 5.0), severe right ventricular outflow tract obstruction (HR 3.7, 95% CI 1.8 to 7.7) and a patent ductus arteriosus (HR 2.8, 95% CI 1.3 to 6.0) at the time of diagnosis were univariately associated with death. Multivariable analysis showed that presentation with Heart Failure Class 4 and a ventricular septal defect is the strongest predictor of death in childhood and adolescence. CONCLUSION Patients with Ebstein's anomaly presenting with Heart Failure Class 4 and a ventricular septal defect have a high risk of death during childhood.
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Affiliation(s)
- Lianne M Geerdink
- Department of Paediatric Cardiology, Amalia Children's Hospital, Radboud University Medical Centre, Nijmegen, The Netherlands.,Department of Paediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Tammo Delhaas
- Department of Paediatric Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Willem A Helbing
- Department of Paediatric Cardiology, Sophia Children's Hospital, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Gideon J du Marchie Sarvaas
- Centre for Congenital Heart Diseases, Beatrix Children's Hospital, University Medical Centre Groningen, Groningen, The Netherlands
| | - Henriette Ter Heide
- Department of Paediatric Cardiology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Lieke Rozendaal
- Department of Paediatric Cardiology, Willem Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands
| | - Chris L de Korte
- Medical Ultrasound Imaging Centre, Department of Radiology and Nuclear Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Petronella G M Peer
- Department of Biostatistics, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Irene M Kuipers
- Department of Paediatric Cardiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Livia Kapusta
- Department of Paediatric Cardiology, Amalia Children's Hospital, Radboud University Medical Centre, Nijmegen, The Netherlands.,Department of Paediatrics, Paediatric Cardiology Unit, Tel Aviv Sourasky Medical Centre, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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7
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Cabrera R, Miranda-Fernández MC, Huertas-Quiñones VM, Carreño M, Pineda I, Restrepo CM, Silva CT, Quero R, Cano JD, Manrique DC, Camacho C, Tabares S, García A, Sandoval N, Moreno Medina KJ, Dennis Verano RJ. Identification of clinically relevant phenotypes in patients with Ebstein anomaly. Clin Cardiol 2018; 41:343-348. [PMID: 29569399 DOI: 10.1002/clc.22870] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 11/30/2017] [Accepted: 12/07/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ebstein anomaly (EA) is a heterogeneous congenital heart defect (CHD), frequently accompanied by diverse cardiac and extracardiac comorbidities, resulting in a wide range of clinical outcomes. HYPOTHESIS Phenotypic characterization of EA patients has the potential to identify variables that influence prognosis and subgroups with distinct contributing factors. METHODS A comprehensive cross-sectional phenotypic characterization of 147 EA patients from one of the main referral institutions for CHD in Colombia was carried out. The most prevalent comorbidities and distinct subgroups within the patient cohort were identified through cluster analysis. RESULTS The most prevalent cardiac comorbidities identified were atrial septal defect (61%), Wolff-Parkinson-White syndrome (WPW; 27%), and right ventricular outflow tract obstruction (25%). Cluster analysis showed that patients can be classified into 2 distinct subgroups with defined phenotypes that determine disease severity and survival. Patients in cluster 1 represented a particularly homogeneous subgroup with a milder spectrum of disease, including only patients with WPW and/or supraventricular tachycardia (SVT). Cluster 2 included patients with more diverse cardiovascular comorbidities. CONCLUSIONS This study represents one of the largest phenotypic characterizations of EA patients reported. The data show that EA is a heterogeneous disease, very frequently associated with cardiovascular and noncardiovascular comorbidities. Patients with WPW and SVT represent a homogeneous subgroup that presents with a less severe spectrum of disease and better survival when adequately managed. This should be considered when searching for genetic causes of EA and in the clinical setting.
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Affiliation(s)
- Rodrigo Cabrera
- Laboratorio de Biología Molecular y Pruebas Diagnósticas de Alta Complejidad, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Marta Catalina Miranda-Fernández
- Laboratorio de Biología Molecular y Pruebas Diagnósticas de Alta Complejidad, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Victor Manuel Huertas-Quiñones
- Instituto de Cardiopatías Congénitas, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia.,Facultad de Medicina, Universidad Nacional de Colombia, Bogotá, Colombia.,Facultad de Medicina, Universidad del Rosario, Bogotá, Colombia
| | - Marisol Carreño
- Departamento de Cirugía Cardiovascular, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Ivonne Pineda
- Departamento de Cirugía Cardiovascular, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Carlos M Restrepo
- Centro de Investigación en Genética y Genómica-CIGGUR, Grupo GENIUROS, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
| | - Claudia Tamar Silva
- Centro de Investigación en Genética y Genómica-CIGGUR, Grupo GENIUROS, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
| | - Rossi Quero
- Centro de Investigación en Genética y Genómica-CIGGUR, Grupo GENIUROS, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
| | - Juan David Cano
- Facultad de Medicina, Universidad Militar Nueva Granada, Bogotá, Colombia
| | | | - Camila Camacho
- Facultad de Medicina, Universidad Militar Nueva Granada, Bogotá, Colombia
| | - Sebastián Tabares
- Facultad de Medicina, Universidad Militar Nueva Granada, Bogotá, Colombia
| | - Alberto García
- Instituto de Cardiopatías Congénitas, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia.,Facultad de Medicina, Universidad del Rosario, Bogotá, Colombia.,Facultad de Medicina, Universidad Militar Nueva Granada, Bogotá, Colombia.,Facultad de Medicina, Universidad El Bosque, Bogotá, Colombia
| | - Néstor Sandoval
- Instituto de Cardiopatías Congénitas, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia.,Facultad de Medicina, Universidad del Rosario, Bogotá, Colombia
| | | | - Rodolfo José Dennis Verano
- Departamento de Investigaciones, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia.,Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá, Colombia
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8
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Li JS, Chen G, Ma J, Yan ZX, Cheng DM, Chang L, Zhang HC, Liu JY. The modified cone reconstruction in the treatment of Ebstein's anomaly: Case reports. Medicine (Baltimore) 2017; 96:e8727. [PMID: 29384893 PMCID: PMC6393128 DOI: 10.1097/md.0000000000008727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE To investigate the early and mid-term clinical outcomes of the modified cone reconstruction in the treatment of Ebstein's anomaly (EA) which provide appropriate surgical treatment for clinical and reduce the incidence of re-operation and valve replacement. PATIENT CONCERNS Clinical data of 18 consecutive patients with EA in our hospital between May 2008 and August 2015 were analyzed retrospectively. All patients were diagnosed by echocardiography. Among these patients, according to New York Heart Association functional grade, there were 12 patients with grade II cardiac function and 6 patients with grade III. All patients had severe tricuspid regurgitation grade. DIAGNOSES All patients were diagnosed EA. One case was with acute arterial embolism and amputation of left lower extremity caused by paradoxical embolism of combined secundum atrial septal defect. INTERVENTIONS The modified cone reconstruction in the treatment of EA of the tricuspid valve uses its own tissues to form not only central bloodstream, but also the coaption between 2 leaflets. For those patients whose anterior leaflet developed poor and smaller, the valve leaflet was widened by using autologous pericardial. For all patients, tricuspid annulus were reinforced by autologous pericardial. One case was combined with double-orifice technique due to postoperative poor closure of the tricuspid valve. OUTCOMES There were 2 cases with arrhythmia, and they returned to normal after medication. The rest patients recovered smoothly with no death. Review of echocardiography: 1 patient with moderate regurgitation, the rest of patients' leaflets coapted well and had no tricuspid stenosis. All cases were followed up postoperatively for 9 to 38 months, and there were 14 patients with grade I cardiac function and 4 patients with grade II. LESSONS The early and mid-term clinical outcomes of the modified cone reconstruction in the treatment of EA were which can make leaflets coapt and had a strong antiregurgitation ability, reducing the incidence of re-operation, valve replacement, and postoperative mortality.
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Affiliation(s)
- Jun-Sheng Li
- Department of Cardiothoracic Surgery, Taizhou Central Hospital (Taizhou University Hospital), Taizhou, Zhejiang
| | - Gang Chen
- The Secondary Ward of Thoracic Surgery, Shanxi Provincial Cancer Hospital
| | - Jie Ma
- Department of Cardiothoracic Surgery
| | | | | | | | | | - Jiang-Yan Liu
- Department of Ultrasound, Shanxi Medical University Second Hospital, Taiyuan, Shanxi, People's Republic of China
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Abstract
Ebstein anomaly is a rare form of congenital heart disease with a uniquely high prevalence of arrhythmias. The most prevalent arrhythmia mechanisms are intrinsic to the underlying embryologic defects and may manifest at any stage. Current electrophysiological and surgical strategies are well equipped to address these arrhythmia mechanisms, yet despite available technology and a robust understanding of the mechanisms, these cases remain challenging. Surgical techniques that render arrhythmia substrates unreachable mandate comprehensive presurgical electrophysiological assessment and potential ablation. As the population ages, the need to address atrial fibrillation management and risk stratification for sudden cardiac death becomes ever more pertinent.
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Affiliation(s)
- Elizabeth D Sherwin
- Division of Cardiology, Children's National Health System, 111 Michigan Avenue NW, Washington, DC 20010, USA
| | - Dominic J Abrams
- Division of Cardiac Electrophysiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
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10
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LI JS, Ma J, Yan ZX, Cheng DM, Chang L, Zhang HC, Liu JY. Acute arterial embolism of left lower extremity caused by paradoxical embolism in Ebstein's anomaly: A case report. Medicine (Baltimore) 2017; 96:e5901. [PMID: 28151866 PMCID: PMC5293429 DOI: 10.1097/md.0000000000005901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Ebstein's anomaly is a benign and stable congenital heart disease for asymptomatic patients. Despite a low incidence of Ebstein's anomaly (EA), patients' quality of life can be badly affected by EA without positive surgical intervention. Especially EA is associated with other congenital heart disease, such as the atrial septal defect, patent foramen ovale, and arterial embolism exclude other reasons, it is often considered to be the consequence of paradoxical embolism, and surgical intervention must be conducted. CASE REPORT An 11-year-old girl falling off the bed suffered pain from left lower extremity. Echocardiographic evaluation revealed an EA, severe tricuspid regurgitation, and secundum atrial septal defect. Both left leg amputation and cardiac surgery were conducted after recovery. Under the condition of anesthesia cardiopulmonary bypass extracorporeal circulation, atrial septal defect repair and Cone reconstruction of the tricuspid valve were performed. Patient recovered well and left hospital smoothly. DISCUSSION EA is a rare and complex congenital cardiac malformation. There are about 80% to 90% of EA patients with combined atrial septal defect and patent foramen ovale. Sudden arterial occlusion is very rare especially in childhood. When thoracic roentgenoscopy, arterial blood gas analysis, coagulation test, and echocardiographic of lower extremity deep venous system are all normal, one should consider the possibility of a paradoxical embolism. If patients have the paradoxical embolism or worsening tricuspid regurgitation, the most suitable therapeutic regimen should be chosen according to patients' condition. With surgical techniques and methods renewed continuously, cone reconstruction of the tricuspid valve has been confirmed in clinical trials, which can use its own tissues to form not only central bloodstream, but also the coaption between leaflet and leaflet.
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Affiliation(s)
| | - Jie Ma
- Department of Cardiothoracic Surgery
| | | | | | | | | | - Jiang-Yan Liu
- Department of Ultrasound, Shanxi Medical University Second Hospital, Taiyuan, Shanxi, P.R. China
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Kim HY, Jang SY, Moon JR, Kim EK, Chang SA, Song J, Huh J, Kang IS, Yang JH, Jun TG, Park SW. Natural Course of Adult Ebstein Anomaly When Treated according to Current Recommendation. J Korean Med Sci 2016; 31:1749-1754. [PMID: 27709852 PMCID: PMC5056206 DOI: 10.3346/jkms.2016.31.11.1749] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 07/16/2016] [Indexed: 11/20/2022] Open
Abstract
The objectives of this study were to assess the clinical outcomes of adults with Ebstein Anomaly (EA) according to their treatment modalities. All adult EA patients diagnosed between October 1994 and October 2014 were retrospectively evaluated by medical record review. Total 60 patients were categorized into 3 groups according to their treatment strategy, i.e. non-operative treatment (Group I, n = 23), immediate operative treatment (Group II, n = 27), and delayed operative treatment (Group III, n = 10). A composite of major adverse cardiac and cerebrovascular events (MACCE) and factors associated with MACCE were assessed in each treatment group. MACCE occurred in 13.0% patients in Group I, 55.6% patients in Group II and 50% in Group III (P = 0.006). Event free survivals at 5 years were 90% in Group I, 52.7% in Group II, 50.0% in Group III (P = 0.036). Post-operatively, most patients showed improvement on clinical symptoms. However, event free survival rate was lower in patients with operation compared to those with non-operative treatment (58.7% vs. 90.9%; P = 0.007). Major arrhythmic event occurred more frequently even after surgical ablation (50.0% vs. 20.0%; P = 0.034). Re-operation was more frequent in patients underwent delayed surgery compared to those with immediate surgery (50.0% vs. 18.5%; P = 0.001). Current guideline to decide patient's treatment strategy appeared to be appropriate in adult patients with EA. However, surgical ablation for arrhythmia was not enough so that concomitant medical treatment should be considered. Therefore, attentive risk stratification and cautious decision of treatment strategy by experienced cardiac surgeon are believed to improve clinical outcome.
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Affiliation(s)
- Hyung Yoon Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Shin Yi Jang
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ju Ryoung Moon
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun Kyoung Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung A Chang
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jinyoung Song
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - June Huh
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - I Seok Kang
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Hyuk Yang
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Gook Jun
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Woo Park
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Epidural anesthesia for cesarean section in a primigravida woman with Ebstein's anomaly with recurrent supraventricular tachycardia. ACTA ACUST UNITED AC 2014; 52:201-2. [PMID: 25446193 DOI: 10.1016/j.aat.2014.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 05/16/2014] [Accepted: 05/21/2014] [Indexed: 11/21/2022]
Abstract
Ebstein's anomaly is an uncommon congenital heart defect with an extremely variable natural history due to a wide spectrum of pathological features. We report on the anesthetic management of a 24-year-old primigravida woman with Ebstein's anomaly with recurrent supraventricular tachycardia for emergency cesarean section.
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Abstract
Ebstein's anomaly is a complex congenital disorder of the tricuspid valve. Presentation in neonatal life and (early) childhood is common. Disease severity and clinical features vary widely and require a patient-tailored treatment. In this review, we describe the natural history of children and adolescents with Ebstein's anomaly, including symptoms and signs presenting at diagnosis. Current classification strategies of Ebstein's anomaly are discussed. We report on diagnostic methods for establishing the severity of disease that might enhance decision on the timing of surgical intervention. Furthermore, we describe different surgical options for severely ill neonates and multiple surgical interventions after infancy. Only with ample knowledge and understanding of the above, this complex and diverse group of patients can be correctly treated in order to improve not only duration, but also quality of life.
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Abstract
Ebstein anomaly (EA) is a congenital defect of the tricuspid valve (TV) and the right ventricle (RV) in which the attachments of the septal and posterior valve leaflets are apically displaced. The latter creates 3 morphologic components inside the right heart, namely the right atrium proper, the atrialized RV, and the functional RV. This rare anomaly accounts for <1.5% of all congenital heart diseases. The current opinion among authors is that it is a genetically heterogeneous condition caused by failure of delamination of the TV leaflets from the underlying myocardium and the interventricular septum. Its characteristic electrocardiographic findings include tall, broad, right atrial P waves, prolonged PR intervals, and deep Q waves in the right precordial leads. Echocardiography is currently the best technique for diagnosing this anomaly, although cardiac magnetic resonance imaging is also gaining traction as an alternative modality. The management strategies for EA correlate with the age of the patient, severity of the heart disease, and/or associated cardiac abnormalities. TV repair, rather than valve replacement, is preferred because of its favorable long-term prognosis. Nevertheless, a large, randomized study is still needed to compare the different valve repair techniques used in patients with EA.
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Radojevic J, Inuzuka R, Alonso-Gonzalez R, Borgia F, Giannakoulas G, Prapa M, Liodakis E, Li W, Swan L, Diller GP, Dimopoulos K, Gatzoulis MA. Peak oxygen uptake correlates with disease severity and predicts outcome in adult patients with Ebstein's anomaly of the tricuspid valve. Int J Cardiol 2013; 163:305-308. [DOI: 10.1016/j.ijcard.2011.06.047] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Accepted: 06/06/2011] [Indexed: 10/18/2022]
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Kipps AK, Graham DA, Lewis E, Marx GR, Banka P, Rhodes J. Natural history of exercise function in patients with Ebstein anomaly: A serial study. Am Heart J 2012; 163:486-91. [PMID: 22424021 DOI: 10.1016/j.ahj.2011.12.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Accepted: 12/14/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND The clinical manifestations of Ebstein anomaly (EA) vary greatly; criteria for surgical intervention remain undefined. Decisions regarding surgical intervention in asymptomatic/mildly symptomatic patients would be helpfully informed by a detailed, quantitative understanding of the natural history of exercise intolerance in these patients. However, past studies of exercise function in EA have been of a cross-sectional, rather than a serial, nature. We, therefore, analyzed serial cardiopulmonary exercise (CPX) tests from patients with unrepaired EA to better appreciate the natural history of their exercise function. METHODS All patients with EA who had had at least 2 CPX tests, separated by at least 6 months, between November 2002 and October 2010 were identified. Patients with prior tricuspid valve surgery were excluded from the study. RESULTS Cardiopulmonary exercise data from 23 patients (64 CPX tests; 2.8 ± 1.0 tests/patient) were analyzed. The median time interval between the first and last CPX tests was 3.3 (range, 0.6-7.3) years. The percentage of predicted peak oxygen consumption declined slowly (1.87 ± 8.04 percentage points/y) during the follow-up period. The decline was more pronounced (3.04 ± 6.78 percentage points/y) in patients <18 years old. On multivariate modeling, only the change in oxygen pulse at peak exercise (a surrogate for forward stroke volume) and the change in peak heart rate over time emerged as statistically significant correlates of the change in percentage of predicted peak oxygen consumption. CONCLUSION The exercise function of patients with EA tends to deteriorate over time. This deterioration appears to be related to a progressive decline in their ability to augment their forward stroke volume and heart rate during exercise.
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Silversides CK, Kiess M, Beauchesne L, Bradley T, Connelly M, Niwa K, Mulder B, Webb G, Colman J, Therrien J. Canadian Cardiovascular Society 2009 Consensus Conference on the management of adults with congenital heart disease: outflow tract obstruction, coarctation of the aorta, tetralogy of Fallot, Ebstein anomaly and Marfan's syndrome. Can J Cardiol 2010; 26:e80-97. [PMID: 20352138 DOI: 10.1016/s0828-282x(10)70355-x] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
With advances in pediatric cardiology and cardiac surgery, the population of adults with congenital heart disease (CHD) has increased. In the current era, there are more adults with CHD than children. This population has many unique issues and needs. Since the 2001 Canadian Cardiovascular Society Consensus Conference report on the management of adults with CHD, there have been significant advances in the field of adult CHD. Therefore, new clinical guidelines have been written by Canadian adult CHD physicians in collaboration with an international panel of experts in the field. Part II of the guidelines includes recommendations for the care of patients with left ventricular outflow tract obstruction and bicuspid aortic valve disease, coarctation of the aorta, right ventricular outflow tract obstruction, tetralogy of Fallot, Ebstein anomaly and Marfan's syndrome. Topics addressed include genetics, clinical outcomes, recommended diagnostic workup, surgical and interventional options, treatment of arrhythmias, assessment of pregnancy risk and follow-up requirements. The complete document consists of four manuscripts that are published online in the present issue of The Canadian Journal of Cardiology. The complete document and references can also be found at www.ccs.ca or www.cachnet.org.
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Management and long-term outcome of neonatal Ebstein anomaly. J Thorac Cardiovasc Surg 2010; 139:354-8. [DOI: 10.1016/j.jtcvs.2009.07.062] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2009] [Revised: 04/08/2009] [Accepted: 07/23/2009] [Indexed: 11/22/2022]
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Delhaas T, du Marchie Sarvaas GJ, Rijlaarsdam ME, Strengers JL, Eveleigh RM, Poulino SE, de Korte CL, Kapusta L. A multicenter, long-term study on arrhythmias in children with Ebstein anomaly. Pediatr Cardiol 2010; 31:229-33. [PMID: 19937010 PMCID: PMC2817085 DOI: 10.1007/s00246-009-9590-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2009] [Accepted: 10/30/2009] [Indexed: 11/28/2022]
Abstract
To assess the prevalence, history, and treatment of arrhythmias, in particular preexcitation and Wolff-Parkinson-White (WPW) syndrome, in patients with Ebstein anomaly (EA) during childhood and adolescence, we performed a multicenter retrospective study of all consecutive live-born patients with EA, diagnosed, and followed by pediatric cardiologists between 1980 and 2005 in The Netherlands. During a follow-up after EA diagnosis of 13 years 3 months (range: 6 days to 28 years 2 months), 16 (17%) of the 93 pediatric EA patients exhibited rhythm disturbances. Nine patients showed arrhythmic events starting as of the neonatal period. Supraventricular tachycardia was noted in 11 patients. One patient died in the neonatal period due to intractable supraventricular tachycardia resulting in heart failure and one patient died at 5 weeks of age most probably due to an arrhythmic event. The 14 surviving patients all show preexcitation, albeit 4 of them intermittently, and all have a right-sided accessory pathway location. Nine patients underwent catheter ablation of an accessory pathway. Only four patients are currently on antiarrhythmic drugs. The 17% prevalence of rhythm disturbances in pediatric EA patients, most commonly supraventricular arrhythmias, is significantly lower than in adult EA patients. Life-threatening rhythm disturbances are not frequent early in life. Symptomatic patients are well treated with radiofrequency catheter ablation.
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Affiliation(s)
- Tammo Delhaas
- Department of Pediatrics, Maastricht University Medical Center, Maastricht, The Netherlands.
| | | | - Marry E. Rijlaarsdam
- Center for Congenital Anomalies of the Heart Amsterdam/Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | - Jan L. Strengers
- Department of Pediatric Cardiology, Network for Congenital Heart Disease Utrecht-Rotterdam, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rhona M. Eveleigh
- Children’s Heart Center, Radboud University, Nijmegen Medical Center, Radboud, The Netherlands
| | - Sumayah E. Poulino
- Children’s Heart Center, Radboud University, Nijmegen Medical Center, Radboud, The Netherlands
| | - Chris L. de Korte
- Children’s Heart Center, Radboud University, Nijmegen Medical Center, Radboud, The Netherlands
| | - Livia Kapusta
- Children’s Heart Center, Radboud University, Nijmegen Medical Center, Radboud, The Netherlands
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Echocardiographic Assessment of Ebstein's Anomaly in a 60-Year-Old Man. Case Rep Med 2009; 2009:653741. [PMID: 19707481 PMCID: PMC2729450 DOI: 10.1155/2009/653741] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Accepted: 04/26/2009] [Indexed: 11/17/2022] Open
Abstract
We present an echocardiographic evaluation of an elderly man affected with Ebstein's anomaly. In the natural history of this congenital disease only 5% of patients survive beyond the fifth decade. The patient presented severe right heart failure and he was refered to our institution for heart transplantation.
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Chauvaud S, Carpentier A. Ebstein's anomaly: the Broussais approach. Multimed Man Cardiothorac Surg 2008; 2008:mmcts.2007.003038. [PMID: 24415583 DOI: 10.1510/mmcts.2007.003038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Ebstein's anomaly is rare, but it is the most frequent cause of congenital tricuspid valve anomaly. For many years valve replacement was performed. Conservative techniques are now preferred due to improvement of the results. The goals of surgery are to restore a normal tricuspid valve function, to preserve the right ventricular contractility and to decrease the risk of rhythm disturbances. Basically, the technique is based on mobilization of the anterior leaflet and longitudinal plication of the right ventricle. A bidirectional cavo pulmonary shunt is used in severe cases. Results are correlated with the severity of the disease, the expertise of the surgical team and also with the perioperative management.
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Affiliation(s)
- Sylvain Chauvaud
- Department of Cardiac Surgery, Hopital Européen Georges Pompidou, 20-40, rue Leblanc, 75015 Paris, France
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Abstract
Ebstein's anomaly of the tricuspid valve is a rare lesion comprising less than 1% of patients with congenital heart disease. Among congenital heart lesions, Ebstein's anomaly is one of the most diverse in presentation, severity, and management. In its most severe form, it is also one of the most lethal. In this article we present a case of a patient who developed cardiac symptoms in adulthood. We follow this with a review of the pathology, clinical presentation, evaluation, and management of Ebstein's anomaly.
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Affiliation(s)
- Michelle Gurvitz
- Division of Cardiology, University of Washington, Box 356422, 1959 NE Pacific, Seattle, WA 98105, USA.
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da Silva JP, Baumgratz JF, da Fonseca L, Franchi SM, Lopes LM, Tavares GMP, Soares AM, Moreira LF, Barbero-Marcial M. The cone reconstruction of the tricuspid valve in Ebstein’s anomaly. The operation: early and midterm results. J Thorac Cardiovasc Surg 2007; 133:215-23. [PMID: 17198815 DOI: 10.1016/j.jtcvs.2006.09.018] [Citation(s) in RCA: 155] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2006] [Revised: 08/06/2006] [Accepted: 09/06/2006] [Indexed: 11/23/2022]
Abstract
OBJECTIVES We sought to describe a new technique for tricuspid valve repair in Ebstein's anomaly and to report early echocardiographic results, as well as early and midterm clinical outcomes. METHODS From November 1993 through August 2005, 40 consecutive patients with Ebstein's anomaly (mean age, 16.8 +/- 12.3 years) underwent a new surgical repair modified from Carpentier's procedure, the principal details of which are as follows. The anterior and posterior tricuspid valve leaflets are mobilized from their anomalous attachments in the right ventricle, and the free edge of this complex is rotated clockwise to be sutured to the septal border of the anterior leaflet, thus creating a cone the vertex of which remains fixed at the right ventricular apex and the base of which is sutured to the true tricuspid valve annulus level. Additionally, the septal leaflet is incorporated into the cone wall whenever possible, and the atrial septal defect is closed in a valved fashion. RESULTS There was 1 (2.5%) hospital death and 1 late death. Early postoperative echocardiograms have shown good right ventricular morphology and reduction in tricuspid regurgitation grade from 3.6 +/- 0.5 to 1.2 +/- 0.5 (P < .0001). After mean follow-up of 4 years, the functional class (New York Heart Association) improved from 2.6 +/- 0.7 to 1.2 +/- 0.4 (P < .0001). Two patients required late tricuspid valve re-repair, and there was neither atrioventricular block nor tricuspid valve replacement at any time. CONCLUSIONS This surgical technique for Ebstein's anomaly can be performed with low mortality and morbidity. Early echocardiograms showed significant reduction of tricuspid insufficiency, and the follow-up showed improvement in patients' clinical status and low incidence of reoperation.
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Wald RM, Adatia I, Van Arsdell GS, Hornberger LK. Relation of limiting ductal patency to survival in neonatal Ebstein's anomaly. Am J Cardiol 2005; 96:851-6. [PMID: 16169376 DOI: 10.1016/j.amjcard.2005.05.035] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2005] [Revised: 05/02/2005] [Accepted: 05/02/2005] [Indexed: 11/19/2022]
Abstract
Fetal and neonatal Ebstein's anomaly has a poor prognosis, and there are few contemporary reviews of management and outcomes. This study retrospectively reviewed a management algorithm promoting early ductal closure after anatomic pulmonary obstruction had been excluded or relieved in neonatal Ebstein's anomaly from 1995 to 2004. Twenty-eight patients with Ebstein's anomaly were identified, 9 prenatally (8 with hydrops) and 19 postnatally, at a median age of <24 hours. Celermajer index scores predicted a mortality rate of 35%. Prostaglandins were administered to 24 of 28 patients. Prostaglandins were continued for obstructive lesions in 9 until the relief of pulmonary outflow obstructions or aortic coarctation repair. In 8 of 9 patients, prostaglandins were discontinued after intervention. One patient continued receiving prostaglandins until a Blalock-Taussig shunt was performed 3 weeks after surgical valvotomy. Prostaglandins were discontinued in 17 of 24 patients with uneventful ductal constrictions. The ductus arteriosus persisted in 5 patients with hemodynamic instability, of whom 4 underwent ductal ligation, with immediate improvement. In 1 of 24 patients, unrecognized right ventricular outflow tract obstructions became apparent when prostaglandins were discontinued. Prostaglandins were restarted until a primary superior cavopulmonary anastomosis was performed at 7 weeks. The median follow-up period of 26 survivors was 34 months (range 3 to 106), 4 after bidirectional superior cavopulmonary anastomoses and 1 after a Fontan procedure. In conclusion, in neonatal Ebstein's anomaly of the tricuspid valve, prolonged patency of the ductus arteriosus in patients without anatomic outflow tract obstructions is deleterious. "Circular shunts" may develop in patients with pulmonary and tricuspid insufficiency. The ligation or spontaneous constriction of the ductus arteriosus may result in hemodynamic improvement. This approach to neonatal Ebstein's anomaly of the tricuspid valve has yielded a substantial reduction in mortality to 7% in a high-risk cohort.
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Affiliation(s)
- Rachel M Wald
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
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Affiliation(s)
- J Boullin
- Centre for Developmental Origins of Health and Disease, University of Southampton, Southampton SO16 5YA, UK.
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Di Russo GB, Gaynor JW. Ebstein's anomaly: Indications for repair and surgical technique. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2001; 2:35-50. [PMID: 11486224 DOI: 10.1016/s1092-9126(99)70004-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Ebstein's anomaly of the tricuspid valve is characterized by a regurgitant tricuspid valve with a large anterior leaflet and septal and tricuspid leaflets displaced into the right ventricle. Associated anomalies are common, especially atrial septal communication and right ventricular outflow tract obstruction. Clinical presentation includes a spectrum from minimal hemodynamic derangement and mild exercise intolerance to severe cardiopulmonary abnormalities and grave illness. The natural history of the disease is extremely variable; the worst prognosis is in the youngest patients, who often have associated cardiac abnormalities. Operative procedures range from ligation of a patent ductus arteriosus to cardiac transplantation. Tricuspid valvuloplasty has been advanced by several investigators and can be considered in nearly all cases. Repairs are based on the creation of a monocuspid or bicuspid valve with reduction of the enlarged annulus. While tricuspid valve repair or replacement is indicated for symptomatic children and adults, the management of the symptomatic neonate is difficult. Patients are stratified according to clinical status and morphology, then treated with observation, valve repair, conversion to single ventricle, or transplantation. We review the anatomy and pathophysiology of Ebstein's anomaly, the indications for surgery, and the appropriate timing of surgical intervention. Current techniques of tricuspid valvuloplasty are described and unresolved issues are discussed, including the role for superior cavopulmonary anastomosis, the management of symptomatic infants, and the necessity of ventricular plication in valve repair. Copyright 1999 by W.B. Saunders Company
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Affiliation(s)
- Gregory B. Di Russo
- Division of Pediatric Cardiothoracic Surgery, The Cardiac Center at the Children's Hospital of Philadelphia, Philadelphia, PA
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Daniels CJ, Chan DP. Evaluation of syncope in adult congenital heart disease. PROGRESS IN PEDIATRIC CARDIOLOGY 2001; 13:83-90. [PMID: 11457677 DOI: 10.1016/s1058-9813(01)00091-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Approximately one million adults in the United States have congenital heart disease. The practitioner who sees one of these patients presenting with syncope must have a thorough understanding of: the underlying disease process; the associated congenital heart abnormalities; the type of surgery performed; the potential surgical residua; and the natural and unnatural history of this type of heart disease. Several types of congenital heart disease including: atrial septal defects; ventricular septal defects; left-sided obstructive lesions; Ebstein Anomaly; tetralogy of Fallot; and transposition of the great arteries are reviewed.
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Affiliation(s)
- C J. Daniels
- The Ohio State University College of Medicine and Public Health, Division of Pediatric Cardiology, Columbus Children's Hospital, 700 Children's Drive, 43205, Columbus, OH, USA
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Abstract
OBJECTIVE To predict the growth in demand for long term follow up of adults with congenital heart disease. DESIGN Observed diagnoses of congenital heart disease in infancy and childhood were adjusted for observed infant survival, predicted further survival to age 16 years, underascertainment in older childhood, and predicted need for long term follow up. SETTING The resident population of one health region in the UK. PATIENTS All confirmed cardiovascular malformations diagnosed in 1985 to 1999 in children born in 1985 to 1994. RESULTS 1942 cases of congenital heart disease were diagnosed in infancy in a population of 377 310 live births (5.2/1000). 1588 (82%) survived to 1 year and 1514 were predicted to survive to age 16. 605 further diagnoses were made in childhood-678 when adjusted for underascertainment. Thus, 2192 children were predicted to reach age 16, of whom 784 would require long term follow up in adult life. The adult population would comprise 28% complex, 54% significant, and 18% minor congenital heart disease. These figures predict the need for adult follow up of congenital heart disease of over 200 extra cases per 100 000 live births each year or over 1600 extra cases a year every year in the UK. CONCLUSIONS The need for follow up of congenital heart disease in adult life is likely to grow linearly, with increasing complexity and increasing need for reinvestigation and reintervention with time. Appropriate provision should be made for adequate manpower, resources, and facilities for care of these patients.
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Affiliation(s)
- C Wren
- Department of Paediatric Cardiology, Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK.
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Garrido Martín A, Oliver Ruiz JM, Domínguez Melcón FJ, González AE, Sobrino Daza JA. [Congenital dysplasia of tricuspid valve (Ebstein like) in a 73-year-old male with severe tricuspid insufficiency]. Rev Esp Cardiol 2000; 53:1008-10. [PMID: 10944999 DOI: 10.1016/s0300-8932(00)75186-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Multiple congenital abnormalities in the structure of the tricuspid valve have been described and, the majority of cases could be considered as variations of Ebstein's anomaly. The onset of the symptoms and the diagnosis depend on the severity of the valve dysfunction and the right ventricular function and size. The age at diagnosis ranges from birth to adulthood, but a delayed diagnosis is rare when tricuspid regurgitation is severe. We cite as an example the case of a 73 year-old male classified as class I of the NYHA up to 5 months before, since then he developed progressive ascitis and edema on his legs. The physical examination suggested severe tricuspid regurgitation. We performed a transtoracic and transesophageal ecocardiogram that showed severe dysplasia in the tricuspid leaflets, severe regurgitation because of lack of adequate joining, dilatation of right chambers and right ventricular systolic dysfunction.
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Therrien J, Henein MY, Li W, Somerville J, Rigby M. Right ventricular long axis function in adults and children with Ebstein's malformation. Int J Cardiol 2000; 73:243-9. [PMID: 10841966 DOI: 10.1016/s0167-5273(00)00230-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To assess right ventricular function in adults and children with Ebstein's anomaly. DESIGN Prospective study. SETTING Tertiary referral centre. SUBJECTS Fifteen patients (8 adults and 7 children) with Ebstein's anomaly and 14 healthy controls. INTERVENTIONS Transthoracic echocardiography was performed in all. Right ventricular function was assessed from long axis M-mode recordings of the right atrio-ventricular free wall. Total systolic excursion as well as peak shortening and lenghtening rates of the right ventricle were measured. RESULTS Children and adult patients with Ebstein's anomaly differed in terms of age at diagnosis, the adult group having been diagnosed later 19.8+/-15.8 vs. 5.9+/-6.2 years, P<0.05. Measures of right ventricular long axis function in children with Ebstein's anomaly showed a significantly reduced systolic excursion 1.4+/-0.4 vs. 2.4+/-0.53 cm, P<0.05 and peak lenghtening rate; early 8.04+/-4.3 vs. 11.8+/-2.4 cm/s and late 6.14+/-3.6 vs. 10.6+/-4.3 cm/s, P=0.05 compared to controls. In contrast, measurements of right ventricular long axis function in adults with Ebstein's anomaly showed no significant difference when compared to the control group. Transtricuspid Doppler flow velocities were not different between patient's groups and corresponding controls. CONCLUSION The right ventricle assessed by this simple, non-invasive technique reveals a significantly reduced systolic and diastolic function in children with Ebstein's malformation compared to controls but a 'normal' right ventricular function comparable to controls in adult patients. Significant right ventricular dysfunction in children with Ebstein's anomaly could account for their earlier presentation. Long term follow up of the right ventricular abnormalities is needed in such children to discover more about the natural history of the disease.
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Affiliation(s)
- J Therrien
- Cardiac Department, Royal Brompton and Harefield Trust and National Heart and Lung Institute, Imperial College, London, UK
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Knott-Craig CJ, Overholt ED, Ward KE, Razook JD. Neonatal repair of Ebstein's anomaly: indications, surgical technique, and medium-term follow-up. Ann Thorac Surg 2000; 69:1505-10. [PMID: 10881831 DOI: 10.1016/s0003-4975(00)01138-3] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Ebstein's anomaly in the severely symptomatic neonate is usually fatal. Because the mortality for various surgical interventions has been prohibitively high, the indications for operation in these critically ill neonates are unclear. METHODS We reviewed our results with biventricular repair of three consecutive severely symptomatic neonates (2.8 to 3.2 kg) at our institution since 1994. Each had associated complex cardiac pathology, including multiple muscular ventricular septal defects (n = 1), pulmonary stenosis with functional pulmonary atresia (n = 1), and anatomic pulmonary atresia (n = 1). Preoperatively, all infants had severe tricuspid regurgitation, Great Ormond Street Ebstein echocardiogram scores greater than 1.3:1 (grade 3 or 4) and cardiothoracic ratio greater than 0.85. Two patients were severely cyanotic. Hepatic and renal insufficiency with diffuse coagulopathy was present preoperatively in two patients. Surgical repair consisted of (1) reconstruction of a competent monocuspid tricuspid valve, (2) right ventriculorrhaphy, (3) subtotal closure of atrial septal defect (ASD), (4) aggressive reduction atrioplasty, and (5) repair of all associated cardiac defects. RESULTS There were no early or late deaths. All patients are currently asymptomatic, without medications, and in sinus rhythm. At 5-year follow-up, trivial tricuspid regurgitation is present in 1 and mild regurgitation in 2 patients. On the basis of these results and review of the current literature, we propose new indications for surgical repair in the neonate with Ebstein's anomaly. CONCLUSIONS Biventricular repair of Ebstein's anomaly in the critically ill neonate is feasible and medium-term durability of the repair is excellent. Therefore, conventional management of these patients should be revised and early surgical repair encouraged.
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Affiliation(s)
- C J Knott-Craig
- Section of Thoracic and Cardiovascular Surgery, University of Oklahoma Health Sciences Center, Oklahoma City 73190, USA.
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Attie F, Rosas M, Rijlaarsdam M, Buendia A, Zabal C, Kuri J, Granados N. The adult patient with Ebstein anomaly. Outcome in 72 unoperated patients. Medicine (Baltimore) 2000; 79:27-36. [PMID: 10670407 DOI: 10.1097/00005792-200001000-00003] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Knowledge of the long-term outcome in unoperated adult patients with Ebstein anomaly is limited, and the therapeutic approach is still controversial. We studied unoperated adult patients with Ebstein anomaly to define the patterns of presentation, anatomic characteristics, outcome, and predictive factors for survival. Seventy-two unoperated survivors of Ebstein anomaly aged over 25 years attended from 1972 to 1997 were reviewed and followed-up from 1.6 to 22.0 years. Patients were classified in 3 groups of severity according to the echocardiographic appearance of the septal leaflet attachment of tricuspid valve. The mean age at diagnosis was 23.9 +/- 10.4 years, and the most common clinical presentation was an arrhythmic event (51.4%). There were 30 (42%) deaths, including 6 from arrhythmia, 12 related to heart failure, 7 sudden, 2 unrelated, and 3 unascertained. According to Cox regression analysis, predictors of cardiac-related death included age at diagnosis (hazard ratio 0.89 for each year of age, 95% confidence intervals CI[ 0.84-0.94), male sex (3.93, 95% CI, 1.50-10.29), degree of echocardiographic severity (3.34, 95% CI, 1.78-6.24), and cardiothoracic ratio > or = 0.65 (3.57, 95% CI, 1.15-11.03). During follow-up, morbidity was mainly related to arrhythmia and refractory late hemodynamic deterioration. The magnitude of tricuspid regurgitation, cyanosis, and the New York Heart Association (NYHA) functional class at time zero were significant risk factors according to the univariate analysis, but not after multivariable confrontation. The results of this study suggest that pattern of presentation, clinical course, and prognosis of unoperated adult patients with Ebstein anomaly are influenced by several factors. Although the initial symptoms are usually mild and commonly related to supraventricular arrhythmias, these are not associated with the long-term outcome. The severity of the morbid anatomy was the main determinant of survival only in extreme cases, but not in those with mild or moderate deformations, which are more common in adults. Other independent risk factors such as cardiothoracic ratio, sex, age at diagnosis, and the echocardiographic evaluation may help to determine the therapeutic approach. Adult patients with Ebstein anomaly should not be considered as a simple low-risk group.
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Affiliation(s)
- F Attie
- Instituto Nacional de Cardiología Ignacio Chavez, Mexico D.F., Mexico
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Geggel RL. Ebstein's anomaly associated with severe valvar pulmonary stenosis: successful palliation with balloon pulmonary valvuloplasty in an adult. Catheter Cardiovasc Interv 1999; 46:441-4. [PMID: 10216011 DOI: 10.1002/(sici)1522-726x(199904)46:4<441::aid-ccd11>3.0.co;2-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We report a 52-year-old adult with Ebstein's anomaly associated with severe valvar pulmonary stenosis, secundum atrial septal defect, polycythemia, hypoxemia, and severe exertional limitations. Balloon pulmonary valvuloplasty relieved the valvar obstruction, reduced the degree of tricuspid regurgitation and polycythemia, and improved systemic oxygenation and exercise abilities. Use of this technique in patients with this combination of lesions can postpone the need for surgical intervention.
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Affiliation(s)
- R L Geggel
- Department of Cardiology, Children's Hospital, Boston, Massachusetts 02115, USA.
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Abstract
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.
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Affiliation(s)
- A T Yetman
- Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Ontario, Canada
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Augustin N, Schmidt-Habelmann P, Wottke M, Meisner H, Sebening F. Results after surgical repair of Ebstein's anomaly. Ann Thorac Surg 1997; 63:1650-6. [PMID: 9205163 DOI: 10.1016/s0003-4975(97)00090-8] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- N Augustin
- Department of Cardiovascular Surgery, German Heart Center Munich.
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Jaiswal PK, Balakrishnan KG, Saha A, Venkitachalam CG, Tharakan J, Titus T. Clinical profile and natural history of Ebstein's anomaly of tricuspid valve. Int J Cardiol 1994; 46:113-9. [PMID: 7814159 DOI: 10.1016/0167-5273(94)90031-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
There were 63 patients of Ebstein's anomaly of tricuspid valve encountered from 1976 to 1991; 28 (44.4%) were male and 35 (55.6%) female. Their age at presentation ranged from 3 months to 51 years. Five (7.9%) patients were asymptomatic, 48 (76.2%) had class II-III exertional dyspnoea, palpitation or both. Thirty patients (47.6%) had cyanosis. Electrocardiogram showed paroxysmal atrial fibrillation in two, chronic atrial fibrillation in four (6.3%), paroxysmal supraventricular tachycardia in seven, atrial or ventricular ectopic beats in five (7.9%), 2:1 atrioventricular block in one (1.6%), complete atrioventricular block in two (3.2%) and type B WPW syndrome in nine patients (14.3%). Chest X-ray showed diminished vascularity in 22 (34.9%). Diagnosis was established by cardiac catheterization and or echocardiography. Atrialized right ventricular chamber was demonstrated in 51 (80.9%) by angiography and in 40 (63.5%) by electrophysiology. Patients were followed up for 1-172 months. Seventeen patients (26.9%) required surgery. Three patients (4.8%) died during medical follow-up, and five (7.9%) died following surgery. Survival probability for 46 medical patients was 88.9% at 172 months. Factors affecting survival were pulmonary blood flow, cyanosis, clubbing and systemic arterial oxygen saturation.
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Affiliation(s)
- P K Jaiswal
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
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Correa-Villaseñor A, Ferencz C, Neill CA, Wilson PD, Boughman JA. Ebstein's malformation of the tricuspid valve: genetic and environmental factors. The Baltimore-Washington Infant Study Group. TERATOLOGY 1994; 50:137-47. [PMID: 7801301 DOI: 10.1002/tera.1420500208] [Citation(s) in RCA: 105] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Ebstein's anomaly is a specific structural deformity of the tricuspid valve, and its rarity has hampered etiologic evaluation. Cases of Ebstein's anomaly registered in the Baltimore Washington Infant Study (BWIS), a regional case-control study of cardiovascular malformations (CVM) in infancy, are reviewed. Between 1981 and 1989 a total of 4,390 CVM cases, including 47 Ebstein cases, and 3,572 controls were registered. The prevalence of Ebstein's anomaly was 5.2 per 100,000 livebirths. Additional cardiac anomalies were present in 38.3% of Ebstein cases. Non-cardiac malformations were present in 19.1% of Ebstein cases vs. 25.5% of other CVM, and 1.7% of controls. Case-fatality by 1 year of age was 23.4% in Ebstein vs. 18.1% in other CVM. Interviews of parents of Ebstein cases, other CVM, and controls (n = 44, 3,335, and 3,572, respectively) elicited information on family history of malformations, maternal illnesses, reproductive history, therapeutic drugs, parental lifestyle, and environmental exposures during the periconceptional period. Case-control analyses suggest genetic, reproductive, and environmental risk factors: twins [odds ratio (OR) 8.2, 95% confidence interval (CI) 2.6-25.3]; family history of CVM (OR 6.4, 95% CI 1.8-22.2); white race (OR 2.9 with non-whites as reference, 95% CI 1.2-7.0); previous miscarriages (OR 2.0, 95% CI 1.2-3.3); maternal exposure to benzodiazepines (OR 5.4, 95% CI 1.5-19.1); and varnishing (OR 3.4, 95% CI 1.3-9.1). Additional multicenter investigations are warranted to elucidate the role of genetic, reproductive, and environmental factors in the etiology of this anomaly.
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Affiliation(s)
- A Correa-Villaseñor
- Department of Epidemiology, Johns Hopkins Health Institutions, Baltimore, Maryland 21205
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Kocheril AG, Rosenfeld LE. Radiofrequency ablation of an accessory pathway in a patient with corrected Ebstein's anomaly. Pacing Clin Electrophysiol 1994; 17:986-90. [PMID: 7517536 DOI: 10.1111/j.1540-8159.1994.tb01444.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Ebstein's anomaly of the tricuspid valve has a known association with the Wolff-Parkinson-White syndrome. Radiofrequency ablation has become the treatment of choice for the latter, but there have been no reports of the feasibility of this procedure after tricuspid valve replacement. We present a patient who first exhibited evidence of intermittent preexcitation and associated symptomatic arrhythmia 9 years after tricuspid valve replacement for Ebstein's anomaly, and describe the challenges posed by this case.
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Affiliation(s)
- A G Kocheril
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut 06510
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Affiliation(s)
- R A Hurwitz
- Department of Pediatrics and Radiology, Indiana University Medical Center, Indianapolis
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Celermajer DS, Bull C, Till JA, Cullen S, Vassillikos VP, Sullivan ID, Allan L, Nihoyannopoulos P, Somerville J, Deanfield JE. Ebstein's anomaly: presentation and outcome from fetus to adult. J Am Coll Cardiol 1994; 23:170-6. [PMID: 8277076 DOI: 10.1016/0735-1097(94)90516-9] [Citation(s) in RCA: 247] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES This study was conducted to investigate the presentation and outcome of patients with Ebstein's anomaly of the tricuspid valve. BACKGROUND Ebstin's anomaly may present at any age and has a highly variable clinical course. Previous natural history studies have been based on clinical and angiographic diagnosis and have included mainly older children and adults. Echocardiography, however, has facilitated fetal and neonatal diagnosis so that the natural history needs to be redefined. METHODS We reviewed 220 cases of Ebstein's anomaly presenting from fetal to adult life between 1958 and 1991, with 1 to 34 years of follow-up. RESULTS The most common presentation in each age group was abnormal routine prenatal scan for fetuses (86%), cyanosis for neonates (74%), heart failure for infants (43%), incidental murmur for children (63%) and arrhythmia for adolescents and adults (42%). Early presentation was frequently associated with other cardiac lesions, usually pulmonary stenosis or atresia. Surgery was undertaken at some stage in 86 (39%) of the 220 patients. Actuarial survival for all liveborn patients was 67% at 1 year and 59% at 10 years. There were 58 deaths, including 26 from heart failure, 19 perioperative and 8 sudden. Predictors of death included echocardiographic grade of severity at presentation (relative risk 2.7 for each increase in grade, 95% confidence limits 1.6 to 4.6), fetal presentation (6.9, confidence limits 1.6 to 16.5) and right ventricular outflow tract obstruction (2.1, confidence limits 1.1 to 4.4). Morbidity was mainly related to arrhythmias and late hemodynamic deterioration. Of 155 survivors, 129 (83%) were in functional class 1 and 104 (67%) were receiving no medical therapy. CONCLUSIONS In Ebstein's anomaly, fetal and neonatal presentation is associated with a poor outcome and can be predicted by the echocardiographic appearance and presence of associated lesions. In older children and adults, incidental findings and arrhythmia are common and the long-term outcome is superior.
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Affiliation(s)
- D S Celermajer
- Cardiothoracic Unit, Hospital for Sick Children, London, England
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Ivy D, Loehr J, Schaffer M. Usefulness of prolonged prostaglandin infusion in neonates with Ebstein's anomaly. Am J Cardiol 1993; 72:1327-9. [PMID: 8256717 DOI: 10.1016/0002-9149(93)90310-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- D Ivy
- Division of Pediatric Cardiology, Children's Hospital, University of Colorado, Denver 80218
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