The epidemiology of CHD in Malta

BACKGROUND

CHD refers to structural cardiac abnormalities which comprise the commonest group of congenital malformations. Malta is a small island in the central Mediterranean with excellent diagnostic and therapeutic facilities. It is unique in the European population as termination of pregnancy is illegal. This study was carried out to ascertain patterns in CHD prevalence in comparison with EUROCAT data (European Surveillance of Congenital Anomalies).

METHODS

Anonymised data were obtained from the EUROCAT website for 1993-2020.

RESULTS

There were a total of 22,833,032 births from all EUROCAT Registries, of which 121,697 were from Malta. The prevalence rate for Malta CHD was 32.38/10,000 births (at the higher end of the range). Malta had a significant excess of commoner, comparatively non-severe CHDs. For most of the severe lesions analysed rates reported were higher than EUROCAT average, however, apart from Ebstein's anomaly, they all fell within the ranges reported from the different registries.

DISCUSSION

Wide variations in reported CHD prevalence are known, and the Malta rates may be higher for milder defects due to quicker pickup prior to spontaneous resolution. There may also be a higher pickup of milder forms of more severe conditions. For the more severe conditions, lack of termination may be the explanation. These factors may result in the higher neonatal mortality observed in Malta.

Atrial Fibrillation Ablation in Congenital Heart Disease: Therapeutic Challenges and Future Perspectives

The increasing prevalence of atrial fibrillation (AF) in adults with congenital heart disease raises significant questions regarding its management. The unique underlying anatomic and physiological background further adds to the difficulty in eliminating the AF burden in these patients. Herein, we provide an overview of the current knowledge on the pathophysiology and risk factors for AF in adult congenital heart disease, with a special focus on the existing challenges in AF ablation. Emerging imaging modalities and ablation techniques might have a role to play. Evidence regarding the safety and efficacy of AF ablation in adult congenital heart disease is summarized, especially for patients with an atrial septal defect, Ebstein anomaly of the tricuspid valve, tetralogy of Fallot, and Fontan circulation. Finally, any remaining gaps in knowledge and potential areas of future research are highlighted.

Ventricular Arrhythmias in Adults With Congenital Heart Disease, Part II: JACC State-of-the-Art Review

There are marked variations in the incidence of sudden cardiac death (SCD) and in the substrates for ventricular arrhythmias (VAs) across the gamut of congenital heart defects. In this 2-part review, patients with higher-risk forms of congenital heart disease (CHD) were conceptually categorized into those with discrete anatomic isthmuses for macro-reentrant ventricular tachycardia (VT) (Group A) and those with more diffuse or less well-defined substrates (Group B) that include patchy or extensive myocardial fibrosis. The latter category encompasses CHD lesions such as Ebstein anomaly, transposition of the great arteries with a systemic right ventricle (RV), and congenital aortic stenosis. For Group B patients, polymorphic VT and ventricular fibrillation account for a higher proportion of VA. The prognostic value of programmed ventricular stimulation is less well established, and catheter ablation plays a less prominent role. As cardiomyopathies evolve over time, pathophysiological mechanisms for VA among Groups A and B become increasingly blurred.

Atrial fibrillation in adult congenital heart disease and the general population

BACKGROUND

Atrial fibrillation (AF) in adult patients with congenital heart disease (ACHD) may appear early, depending on individual characteristics.

OBJECTIVES

The goals of this study were to investigate the epidemiological spectrum of AF in the entire cohort of ACHD and compare it with that in the general population.

METHODS

A retrospective study was performed in the nationwide cohort 2000-2014 with AF onset during 2003-2014.

RESULTS

In the cohort of ACHD, 2350 patients had AF; the incidence increased with age, plateauing around age 70. In patients aged 25-29, 45-49, 65-69, 75-79, and ≥80 years, the annual incidence was 1.3, 7.9, 20.6, 23.7, and 21.4/1000 per year, respectively. In the general population without CHD, 347,979 patients had AF; the annual incidence was <1/1000 per year in those aged <55 years but increased steadily with age (3.6, 8.6, and 14.2/1000 per year in aged 65-69, 75-79, and ≥80 years, respectively). Compared with individuals without ACHD, ACHD patients aged <50 years and those aged both 50-54 and 55-59 years exhibited a 20-fold and 10-fold higher incidence of AF, respectively. Patients with complex congenital heart disease and Ebstein's anomaly had the highest risk of AF (cumulative risk >10% by age 50 and >20% by age 60), followed by those with tetralogy of Fallot, tricuspid atresia, endocardial cushion defect, and secundum atrial septal defect (cumulative risk >5% by age 50 and >10% by age 60).

CONCLUSION

Compared with individuals without ACHD, AF in patients with ACHD likely appeared 30 years earlier, with a 10- to 20-fold higher incidence plateauing around age 70. Yet, incidence in individuals without ACHD continued to increase. AF burden in patients with ACHD is not expected to increase in a never-ending way.

Canadian Cardiovascular Society 2022 Guidelines for Cardiovascular Interventions in Adults With Congenital Heart Disease

Interventions in adults with congenital heart disease (ACHD) focus on surgical and percutaneous interventions in light of rapidly evolving ACHD clinical practice. To bring rigour to our process and amplify the cumulative nature of evidence ACHD care we used the ADAPTE process; we systematically adjudicated, updated, and adapted existing guidelines by Canadian, American, and European cardiac societies from 2010 to 2020. We applied this to interventions related to right and left ventricular outflow obstruction, tetralogy of Fallot, coarctation, aortopathy associated with bicuspid aortic valve, atrioventricular canal defects, Ebstein anomaly, complete and congenitally corrected transposition, and patients with the Fontan operation. In addition to tables indexed to evidence, clinical flow diagrams are included for each lesion to facilitate a practical approach to clinical decision-making. Excluded are recommendations for pacemakers, defibrillators, and arrhythmia-directed interventions covered in separate designated documents. Similarly, where overlap occurs with other guidelines for valvular interventions, reference is made to parallel publications. There is a paucity of high-level quality of evidence in the form of randomized clinical trials to support guidelines in ACHD. We accounted for this in the wording of the strength of recommendations put forth by our national and international experts. As data grow on long-term follow-up, we expect that the evidence driving clinical practice will become increasingly granular. These recommendations are meant to be used to guide dialogue between clinicians, interventional cardiologists, surgeons, and patients making complex decisions relative to ACHD interventions.

[Joint Cardiovascular Surgeries of Two Hospitals in Shizuoka for Adult Congenital Heart Disease (ACHD) Patients]

BACKGROUND

As for the medical management including surgery for the patients with adult congenital heart disease(ACHD), it may be difficult for most hospitals other than that have both adult/congenital cardiologists/cardiovascular surgeons. Between Shizuoka Prefectural General Hospital and Mt. Fuji Shizuoka Children's Hospital, medical stuff and information have been shared for these 4 years. And joint cardiovascular surgeries have started since 2015 autumn at Shizuoka Prefectural General Hospital.

PURPOSE

The contents and the results of these joint operations were evaluated.

PATIENTS AND METHODS

Thirteen joint operations were performed and median age at operation was 55 years old( male 3, female 10). The original diagnosis was tetralogy of Fallot/pulmonary atresia with ventricular septal defect 6, ventricular septal defect( VSD)±pulmonary stenosis 4, atrioventicular septal defect/two chamber right ventricle/Ebstein's anomaly 1 ( each). The procedures were pulmonary valve replacement/right ventricle out flow tract reconstruction 7, mitral valve plasty/tricuspid annuloplasty 4, Bentall 2, VSD closure 2 etc.(included multiple choices).

RESULTS

There was no early mortality. One late mortality was occurred 17 months after the surgery due to acute myeloid leukemia. General conditions in other patients have been feasible and most of them were followed in Shizuoka Prefectural General Hospital.

CONCLUSIONS

The results of the joint operations were feasible in the present study. Our joint project may become more important in the future.

[Surgical Repair of Ebstein's Anomaly in the Adult]

Ebstein's anomaly (EA) is a rare congenital cardiac malformation and this anomaly is a disorder of a tricuspid valve development in which the valve leaflets fail to delaminate properly from the ventricular wall. Clinical symptoms are age dependent and include cyanosis (size of inter-atrial communication), right-sided heart failure, arrhythmias, and general fatigue on exercise. Optimal timing of surgical intervention is often difficult and must be individualized. Patients have good long-term survival and functional outcomes after undergoing surgery for Ebstein's anomaly in adult population. Operation includes tricuspid valve repair or replacement, closure of any inter-atrial communications, and appropriate antiarrhythmia procedures.

Tuberculosis of the Sternoclavicular Joint: Report of Three cases

Ebstein's anomaly accounts for 0.3% to 0.7% of all cases of congenital heart disease. The condition is characterized by abnormal tricuspid valve and right ventricle with apical displacement of tricuspid valve leading to atrialization of right ventricle. There have been case reports of patients surviving up to ninth decade. It is unusual for these patients to be asymptomatic in adulthood for long duration. We describe a patient with Ebstein's anomaly in the ninth decade with coronary artery disease.

Hospitalization Trends and Health Resource Use for Adult Congenital Heart Disease-Related Heart Failure

Background This study assessed trends in heart failure ( HF) hospitalizations and health resource use in patients with adult congenital heart disease ( ACHD ). Methods and Results The Nationwide Inpatient Sample was used to compare ACHD with non- ACHD HF hospitalization and health resource trends. Health resource use was assessed using total hospital charges, hospital length of stay, and procedural burden. A total of 87 175±2676 ACHD -related HF hospitalizations occurred between 1998 and 2011. During this time, ACHD HF hospitalizations increased 91% (4620±438-8809±740, P<0.0001) versus a 21% increase in non- ACHD HF hospitalizations ( P=0.003). ACHD HF hospitalization was associated with longer length of stay ( ACHD HF versus non- ACHD HF, 7.2±0.09 versus 6.8±0.02 days; P<0.0001), greater procedural burden, and higher charges ($81 332±$1650 versus $52 050±$379; P<0.0001). ACHD HF hospitalization charges increased 258% during the study period ($26 533±$1816 in 1998 versus $94 887±$8310 in 2011; P=0.0002), more than double that for non- ACHD HF ( P=0.04). Patients with ACHD HF hospitalized in high-volume ACHD centers versus others were more likely to undergo invasive hemodynamic testing (30.2±0.6% versus 20.7±0.5%; P<0.0001) and to receive cardiac resynchronization/defibrillator devices (4.7±0.3% versus 1.8±0.2%; P<0.0001) and mechanical circulatory support (3.9±0.2% versus 2.4±0.2%; P<0.0001). Conclusions ACHD -related HF hospitalizations have increased dramatically in recent years and are associated with disproportionately higher costs, procedural burden, and health resource use.

Ebstein Anomaly

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.

Transcatheter Valve-in-Valve Implantation: Failing Tricuspid Bioprosthesis in a Patient with Ebstein’s Anomaly

Transcatheter valve-in-valve (VIV) implantation has been recently proposed as an alternative to surgical reoperative aortic valve replacement in patients with a failing aortic bioprosthesis. Experience with transcatheter VIV implantation at other valve positions is very limited. Herein is reported the case of an 18-year-old man with Ebstein's anomaly and severe tricuspid valve (TV) regurgitation status after bioprosthetic valve replacement, who developed new dyspnea on exertion three years after the initial valve replacement. Transesophageal echocardiography showed a severely dilated right atrium and new TV stenosis with an immobile leaflet. The patient underwent successful VIV implantation of a 29-mm SAPIEN XT bioprosthetic valve, with resolution of symptoms and no residual TV regurgitation or stenosis at the two-year follow up. Video 1: Degenerative bioprosthetic tricuspid valve. TEE showing the degenerative bioprosthetic tricuspid valve, and color Doppler during systole showing severe tricuspid regurgitation. Video 2: Degenerative bioprosthetic tricuspid valve. Three-dimensional TEE showing stenosis with an immobile leaflet creating a coaptation defect, viewed from the right atrium. Video 3: Transcatheter VIV replacement with a 29-mm Edwards SAPIEN XT deployed within the tricuspid valve prosthesis. Final result after valve implantation, demonstrating a patent valve orifice, and appropriate apposition of transcatheter valve within a pre-existing surgical Carpentier-Edwards bioprosthetic valve, viewed from the right ventricle. Video 4: Transcatheter VIV replacement with a 29-mm Edwards SAPIEN XT deployed within the tricuspid valve prosthesis. Final result after valve implantation, demonstrating a patent valve orifice, and appropriate apposition of transcatheter valve within a pre-existing surgical Carpentier-Edwards bioprosthetic valve, viewed from the right atrium.

[Ebstein's anomaly with refractory right-sided heart failure and leg ulcers: a case report]

Ebstein malformation is a congenital heart disease characterized pathologically by displacement of the septal leaflet of the tricuspid valve towards the apex of the right ventricle of the heart. Hypoplasia, dysfunction of the right ventricle and tricuspid regurgitation cause an increased volume load of the right heart and result in the clinical manifestations of chest tightness, shortness of breath and fatigue after activities, palpitation, cyanosis and heart failure. We report a case of Ebstein's anomaly with refractory right heart failure and leg ulcers.

Evidence-based case report for analgesic and anesthetic management of a parturient with Ebstein’s Anomaly and Wolff-Parkinson-White syndrome

The rare congenital heart defect of Ebstein's anomaly is characterized by downward displacement and elongation of the septal cusp of tricuspid valve. As a result, it is often associated with a thin-walled and poorly contractile right ventricle, an enlarged atrium, tricuspid regurgitation, atrial septal defect with intracardiac shunt, pulmonary hypertension and tachyarrhythmia. Published reports or studies on analgesic and/or anesthetic management of laboring parturients with Ebstein's anomaly are limited. We present an evidence-based case report of the successful management of an obese laboring parturient with Ebstein's anomaly and Wolff-Parkinson-White syndrome under epidural analgesia. We reviewed the literature and present the best evidence available or its lack of, and the reasoning in supporting the choice of the analgesic and anesthetic management.

THROMBIN GENERATION IN NORMAL SUBJECTS AND CARDIAC PATIENTS

A refined, reliable thrombin generation test with good sensitivity for both hypo- and hypercoagulability is described. When serial thrombin generation curves were obtained in cardiac patients subjected to standardized treadmill stress, fluctuations of the clotting system were observed in some and a marked tendency to hypercoagulability in others. The relationship of in vitro hypercoagulability as reflected by thrombin generation to an increased tendency to thrombosis remains to be determined.

Ebstein's anomaly: outcome of pregnancy

OBJECTIVES

The outcome of pregnancy in Ebstein's anomaly was studied in 72 such patients (44 women, 28 men) who had had pregnancies or fathered children.

BACKGROUND

Patients with Ebstein's anomaly often reach childbearing age. Reports of the outcome of pregnancy in Ebstein's anomaly are available; however, the number of patients is small.

METHODS

The medical and surgical data bases at the Mayo Clinic were reviewed, and 145 patients (62 men, 83 women) of childbearing age with Ebstein's anomaly were located. All patients were contacted, and 72 patients (44 women, 28 men) with offspring were identified and reviewed in detail to assess the outcome of pregnancy.

RESULTS

Forty-four women had 111 pregnancies resulting in 85 live births (76%). Seventy-six deliveries (89%) were vaginal, and nine (11%) were by cesarean section. Twenty-three deliveries were premature. There were 19 spontaneously unsuccessful pregnancies, 7 therapeutic abortions and 2 early neonatal deaths. The mean birth weight of the infants born to cyanotic women was 2.53 kg, which was significantly lower than the mean birth weight of infants born to acyanotic women (3.14 kg [p < 0.001]). The overall incidence of congenital heart disease in the 158 offspring of parents with Ebstein's anomaly was 4% (6 of 158). The incidence of congenital heart disease was 6% (5 of 83) in the offspring of women with Ebstein's anomaly and 1% (1 of 75) in that of men. There was a 0.6% (1 of 158) incidence of familial Ebstein's anomaly. There were no serious pregnancy-related maternal complications, which included maternal death, stroke, congestive heart failure, arrhythmias or endocarditis.

CONCLUSIONS

Pregnancy in women with Ebstein's anomaly is well tolerated. It is associated with an increased risk of prematurity, fetal loss and congenital heart disease in the offspring. In addition, a significantly lower birth weight is found in the offspring of cyanotic versus acyanotic women with Ebstein's anomaly. Paternal Ebstein's anomaly also seems to result in an increased risk of congenital heart disease in the offspring compared with the incidence in the general population.

Dental management of a child on anticoagulant therapy and the International Normalized Ratio: case report

A 7-year-old girl with a history of four prosthetic heart valve replacements and daily anticoagulant therapy was treated with modification of the anticoagulant regimen and hospitalization. Coagulation times now are being expressed using the International Normalized Ratio (INR), a move by the international medical community to standardized laboratory values worldwide. This report describes this new measure and its role in patient assessment.

[Anesthesia for cesarean section in a patient with Ebstein's anomaly]

A 30-year-old woman with Ebstein's anomaly was scheduled for Cesarean section at 38 week gestation because of latent fetal distress. After arterial and central venous catheters were inserted, general anesthesia was started. Anesthesia was induced smoothly and rapidly through intravenous route. Following induction, her hemodynamics was stable until post-operative period. The baby weighed 1564g and had an Apgar score of 8 at 1 minute. A patient with Ebstein's anomaly during pregnancy and anesthesia has potential for a variety of hemodynamic disturbances. This case illustrates the importance of careful attention to the preoperative findings and the perioperative hemodynamic parameters.

[Van der Hoeve's syndrome with Ebstein's anomaly, and prolapse of the mitral and aortic valves: a case report]

A hitherto unrecognized case of van der Hoeve's syndrome complicated by Ebstein's anomaly, and prolapse of the mitral and aortic valves was reported. A 46-year-old woman presented with blue sclera, osteogenesis imperfecta and a hearing loss, which are typical symptoms of this syndrome. The electrocardiogram showed a type B WPW syndrome. The phonocardiogram showed a loud and widely split first heart sound, an accentuated protodiastolic extrasound, a decrescendo regurgitant systolic murmur, and a presystolic murmur. The x descent of the jugular phlebogram was obliterated by a markedly increased c wave. Based on M-mode and two-dimensional echocardiograms, 1) the interventricular septal motion was paradoxical and the closure of the tricuspid valve was delayed, 2) the septal tricuspid leaflet was displaced toward the apex from its normal annular insertion on the apical four-chamber view, 3) the three leaflets of the tricuspid valve were abnormally elongated, 4) the anterior mitral leaflet and the non-coronary cusp of the aortic valve were elongated and prolapsed. Doppler echocardiography detected severe tricuspid and mild mitral regurgitations. We suggest that the development of Ebstein's anomaly is possibly related to that of osteogenesis imperfecta genetically and that not only Ebstein's anomaly but a connective tissue disorder contributes to the elongated and prolapsed leaflets.

Percutaneous gastrostomy in a child

A 2-year-old girl with cyanotic congenital heart disease needed to undergo gastrostomy. To avoid the use of general anesthesia, a percutaneous gastrostomy was performed as an interventional radiologic procedure with the patient under sedation and with the use of local anesthesia. The placement of a nasogastrocutaneous guide wire under fluoroscopic guidance provided a stable tract for placement of the gastrostomy tube.

Caesarean section under extradural analgesia in a patient with Ebstein's anomaly

Ebstein's anomaly is a rare congenital malformation of the tricuspid valve, often associated with an atrial septal defect. Death occurs usually from cardiac arrhythmias. The successful use of a two-catheter technique for elective Caesarean section with extradural analgesia is described and the hazards associated with Ebstein's anomaly in pregnancy and anaesthesia are discussed.

[Ebstein's disease. Study of 5 personal cases]

Ebstein's disease is a frequently cyanotic form of congenital heart disease. The lesions consist of low implantation in the right ventricle of the tricuspid valves, often associated with an atrial septal defect. Our five cases (two men and 3 women) had a variable clinical presentation depending on the degree of the variable clinical presentation depending on the degree of the lesions. A fairly exceptional fact should be emphasised, which is that 3 of our patients brought to term or almost to term 3 pregnancies and gave birth to live children. Ebstein's disease should be suspected when a large heart with a rugby football shape is discovered on X ray and E.C.G., together with right atrial hypertrophy, frequent elongation of the P-R interval, low voltage and complete right bundle branch block. The diagnosis can be confirmed by angiocardiography and catheterisation. Angiocardiography shows a large right atrium and a distal right ventricle in the form of a small chamber with thin walls. Catheterisation is essential and detects the atrial septal defect in 80% of cases and a pressure gradiant intermediate between atrial and ventricular pressures, revealing ventricular morphology. Surgical treatment will be either palliative (cavo-pulmonary anastomosis) or curative: Hunter's operation (Lillehei-Hardy) implantation of the tricuspid on the atrio-ventricular ring. The prognosis is then worse.

Ebstein's anomaly--anaesthetic problems. A case report

A patient with Ebstein's anomaly undergoing anaesthesia for the operation of hysterectomy is reported. The considerations relating to the risk of an increased right-to-left intracardiac shunt are discussed. The patient was anaesthetized successfully with a combination of nitrous oxide, droperidol and fentanyl.

Successful pregnancy in a patient with Ebstein's anomaly

A case is described of a successful pregnancy in a woman with Ebstein's anomaly. It is suggested that careful assessment should be made before advising against starting or terminating pregnancies, since successful outcomes are possible.

Ebstein's Malformation of the Tricuspid Valve

Two cases of complete correction of Ebstein's malformation are presented. The deformed tricuspid valve was excised. A ball-valve prosthesis was anchored at the true annulus. This procedure removes the obstruction to right ventricular outflow, eliminates tricuspid insufficiency, increases right ventricular diastolic capacity, and improves the pumping action of the right ventricle by increasing the size and effectiveness of the pump chamber. Preoperatively, both patients were cyanotic because of large right-to-left shunts at the atrial level.

No attempt was made to close the associated atrial septal defect in our first case. This patient continued to shunt right-to-left postoperatively but expired early in the postoperative period as a result of right-heart failure.

A flap-valve type closure of the large associated atrial septal defect in the second patient with Ebstein's malformation permitted right-to-left shunting until the right ventricle became competent to pump the entire venous return to the lungs. About two weeks after surgery the right-to-left shunting ceased in this patient.

Both patients developed complete heart block during the tricuspid valve prosthesis insertion. This complication was compensated for by a myocardial electrode and external pacemaker in the early postoperative interval.

The second patient was discharged in an asymptomatic condition following insertion of an implantable pacemaker. A possible method for avoiding heart block in these cases in the future is discussed.