Late (5 to 132 months) clinical and hemodynamic results after either tricuspid valve replacement or anuloplasty for Ebstein's anomaly of the tricuspid valve

Cardiac Catheterization in Adults with Ebstein Anomaly: Pathophysiologic Insights Regarding Surgical Repair and Prognosis

The underlying invasive hemodynamics and physiology in Ebstein anomaly (EA) are poorly understood. Moreover, the hemodynamic impact of tricuspid valve intervention in EA has not been well studied. Retrospective cohort of 52 adults with repaired and 36 with unrepaired EA undergoing right heart catheterization at Mayo Clinic, MN between 1993 and 2021. "Repaired" EA was defined as prior tricuspid valve repair and/or replacement (83% post-tricuspid valve replacement). Repaired patients were younger than those with unrepaired EA (41.3 ± 16.0 versus 50.6 ± 15.6 years, p = 0.008) and had a lower prevalence of ≥ moderate native or prosthetic tricuspid regurgitation (67% versus 81%, p = 0.01). Right atrial (RA) pressure was higher among patients with repaired EA than in unrepaired disease [13 (11; 18) versus 10 (8; 15) mmHg; p = 0.02], but these differences were no longer present when adjusting for ≥ moderate right ventricular systolic dysfunction and ≥ moderate tricuspid regurgitation. Cardiac index (Qs) was lower among those with unrepaired EA than in repaired EA (1.9 ± 0.7 versus 2.3 ± 0.6 l/min/m2, p = 0.01), even after adjusting for similar confounders. During a follow-up of 8.6 (3.2-13.3) years, 16 (18%) patients died. Systolic pulmonary artery pressure was independently associated with all-cause mortality. In summary, higher cardiac indices were found in those with repaired EA compared to those with unrepaired disease. RA hypertension was prevalent in both groups and no differences in right filling pressures were found between groups after adjusting for potential confounders. Elevation in pulmonary pressures was independently associated with survival. The use of pulmonary vasomodulators in EA requires further investigation.

Right ventricular long axis function in adults and children with Ebstein's malformation

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.

Thrombosed tricuspid valves presenting some 20 years after the surgical correction of Ebstein's anomaly: report of two cases

We present herein the cases of two patients who were diagnosed as having thrombosed tricuspid valves by electrocardiography after undergoing valve replacement with Starr-Edwards caged ball valves for Ebstein's anomaly 19 and 27 years earlier. In both patients, the valves were found to be attached to the right ventricular septum and covered with massive thrombus, the balls being completely jammed in a half-open position in the cages. Re-replacement of the valves was successfully performed with Hancock II porcine heterograft prostheses and both patients are now classified as being in Functional Class I or II.

Ebstein's anomaly: a long-term study of survival

This study examines data regarding the survival of patients with Ebstein's malformation. Of 61 patients studied at the University of Minnesota, 31 are currently alive, with the average survival being 15 years. Several factors adversely affected survival: NYHA functional classification, hemoglobin level, right atrial pressure, symptoms during the neonatal period, and cardiac surgery. Data from a multi-institutional study collected during the past decade adds information regarding survival. Of 18,281 patients in the study, 71 (0.4%) had Ebstein's malformation. Sixteen of these were among 7235 infants, and of these seven died during the first year of life. In contrast, among 55 patients over the age of 1 year, four died, each after cardiac surgery. The data help our understanding of the course of patients with Ebstein's malformation and decisions regarding surgical treatment.

Failure of mechanical valves in Ebstein's malformation

Five patients with Ebstein's malformation were operated on with closure of the atrial septal defect and implantation of a mechanical prosthesis at the right atrioventricular junction. The 4 patients who survived showed an excellent early recovery. Three of the patients noticed the disappearance of the valve clicks 6 months after the operation. At re-examination using echophonocardiography, peripheral dye dilution curves and catheterization, these valves were found to be stuck in the open position in 2 patients and in the closed position in 1 patient. The last patient had a paravalvar channel supplying blood into the right ventricle. One patient who had a St. Jude prosthesis was doing excellently 4 years postoperatively and the valve was functioning well. Two years after the operation, the other patient with a St. Jude valve again noticed valve clicks after over 1 year of silence. Examination revealed the prosthesis to be functioning normally. The totally occluded Björk-Shiley prosthesis (10 years postoperatively) was excised at re-operation and replaced by an Ionescu-Shiley bioprosthesis. The patient with a jammed Björk-Shiley prosthesis (10 years postoperatively) declined a re-operation and is doing well, albeit under close observation.