Supraventricular tachyarrhythmias in Ebstein anomaly: management and outcome

Prenatal Cardiac Ultrasound Markers of Outcomes in Ebstein's Anomaly: An International Multicenter Case Series

This study aimed to analyze prenatal cardiac ultrasound markers of outcome in fetuses with Ebstein's anomaly (EA). From a retrospective database, 35 fetuses diagnosed with EA at fetal medicine centers in Brazil, Italy, and Poland were retrieved. The primary outcome was perinatal mortality. We analyzed prenatal cardiac ultrasound markers of outcomes and perinatal follow-up. Gestational age at diagnosis, extracardiac fetal anomalies, spontaneous fetal demise, and gestational age at each event were recorded. In postnatal survivors, data on cardiac surgery and short-term postoperative outcomes were collected. Our study included a cohort of 35 fetuses with EA (mean gestational age of 29.4 weeks), in which 6 fetuses were excluded due to termination of pregnancy (3), pregnancy still ongoing (2), and missed follow-up (1). Of the remaining 29 cases, severe tricuspid regurgitation and absence of anterograde pulmonary flow (pulmonary atresia) were observed in 88%. Significant cardiomegaly accounts for 58% of these data with a mean cardiothoracic ratio of 0.59. The cardiovascular profile (CVS) score ≤ 6 in six patients with one survival (4 fetal deaths, one stillbirth, and one survival). All fetuses with CVS score of 5 had intrauterine demise. Seventeen fetuses were born alive (53.1% of 29 cases). Of the remaining fetuses, one (1%) fetal was a stillbirth, six (20%) fetuses were neonatal deaths, and five (17%) fetuses were fetal deaths. Of the nineteen patients who underwent surgery to correct the cardiac defect, 17 survived after surgery. Among the survivors, biventricular cardiac repair was performed using the cone technique (da Silva's approach) in the majority of cases. We observed 2 abnormal karyotypes among in the remaining 29 fetuses. One of the patients with abnormal karyotype was a fetus with ascites and large for gestational age. The other patient with abnormal karyotype underwent cardiac surgery and progressed to neonatal death. Nine patients (25%) had extracardiac anomalies (genitourinary anomalies and single umbilical artery), being that 2 of them are alive and 4 died (2 had fetal and 2 neonatal death). Fetal EA is associated with high mortality. The most common prenatal marker associated with non-survival was CVP score ≤ 6. Fetuses that survived and underwent postnatal corrective surgery are significantly favorable outcomes.

Ebstein's anomaly: an electrophysiological perspective

Ebstein's anomaly of the tricuspid valve (EA) is an uncommon congenital cardiac malformation. It can present with atrioventricular tachycardia (AVRT), atrioventricular nodal re-entrant tachycardia (AVNRT), atrial arrhythmias, and rarely with ventricular tachycardia. The 12-lead electrocardiogram (ECG) is critically important and often diagnostic even prior to an electrophysiology study (EPS). Due to its complex anatomy, it poses particular challenges for mapping and ablation, even for an experienced electrophysiologist. In this review, we aim to provide insight into the electrophysiological perspective of EA and an in-depth analysis of the various arrhythmias encountered in diverse clinical scenarios.

A Twenty-Year Follow-Up of Adults with Ebstein Anomaly with Special Focus on Supraventricular Arrhythmias, Supraventricular Arrhythmias and Effectiveness of Catheter Ablation in 20-Year Follow-Up of Adults with Ebstein Anomaly

Background: Ebstein anomaly (EA) is a rare congenital heart disease characterized by the apical displacement of the tricuspid leaflets, creating an enlarged functional right atrium. Supraventricular arrhythmias (SVA) are common, and catheter ablation remains challenging. SVA is considered a risk factor for sudden cardiac death in this population. Still, there are very few real-life data on the impact of SVA treated invasively or conservatively on a patient's prognosis. We aimed to analyze the incidence of SVA in adults with EA, evaluate the effectiveness of catheter ablation, and analyze the impact of SVA and catheter ablation on survival in this population. Methods and results: 71 pts (median age 53 years; range 24-84 years) with EA were evaluated retrospectively from 1988 to 2020. Forty patients (56.3%) had SVA, and eighteen of them (45.0%) required at least one catheter ablation (35 procedures in total). Indications for ablation were mostly intra-atrial reentrant tachycardia (IART) and atrioventricular reentrant tachycardia (AVRT) (14 pts [77.8% and 9 pts [50.0%], respectively. IART and AVRT coexisted in nine pts. One patient suffered from persistent atrial fibrillation. Procedural effectiveness was reported in 28 (80%) cases; over a longer follow-up (mean 12.6 ± 5.4 years), only eight (44.4%) patients were completely free from SVA after the first ablation. In total, 10 patients (14%) died due to cardiovascular events. There was no difference in survival between patients with or without SVA (p = 0.9) and between ablated and non-ablated EA individuals (p = 0.89). Conclusions: Supraventricular arrhythmia is frequent in adults with Ebstein anomaly. Patients often require more than one catheter ablation but eventually become free from arrhythmias. The imaging parameters assessed by echocardiography or cardiac magnetic resonance do not seem to be associated with ablation outcomes. The impact of supraventricular arrhythmia itself or treatment with radiofrequency ablation is questionable and should be thoroughly investigated in this population.

Neurological, Extracardiac, and Cardiac Manifestations of Ebstein's Anomaly Along With its Genetics, Diagnostic Techniques, Treatment Updates, and the Future Ahead

Ebstein's anomaly is a congenital heart defect characterized by the displacement of the tricuspid valve, and its leaflets to be malformed. Due to the defect involving the tricuspid valve, there is a reverse flow of blood into the right-sided atrium, which may lead to cardiac hypertrophy and edema of the lower extremities. There is a decreased flow of blood out of the right heart due to reduced right ventricular contractility and tricuspid regurgitation. Children afflicted with this anomaly usually suffer from atrial septal defect and this is usually diagnosed before birth on a routine ultrasound scan. In neonates, cyanosis can be seen due to right-to-left atrial shunting or as a result of severe congestive heart failure. If the infant has pulmonary hypertension, cyanosis is markedly increased as there will be a limitation in pulmonary blood flow. In adults, arrhythmias, cyanosis, and heart failure are seen. The bundle of Kent leads to the formation of an electrical conduction abnormality between the right ventricle and atrium. This leads to a condition commonly known as Wolff- Parkinson-White syndrome in patients. An enlarged spherical heart is usually present on a chest X-ray. ECG changes of Ebstein's anomaly show taller than usual P waves, PR prolongation, and right bundle branch block. There can be certain neurological and extracardiac manifestations too such as hemiplegia, stroke, dysarthria, etc. During fetal life, specifically at 16 and 20 weeks of gestation, the anomaly can be diagnosed via echocardiography. Prostaglandin infusion (PGE1) is given to maintain pulmonary circulation in neonates if cyanosis is seen. In children and adults with congestive cardiac failure due to this anomaly, medical management includes digoxin, beta-blockers, diuretics, and angiotensin converting enzyme (ACE) inhibitors to improve heart failure. Surgical treatment includes valve reconstruction. In this article, we review the pathophysiology, genetics, diagnosis, management, and prognosis of Ebstein's Anomaly along with a comprehensive discussion on its genetics, neurological manifestations, extracardiac features, and current advancements in treatment.

Treating Supraventricular Tachycardia With Amiodarone in a Patient With Ebstein's Anomaly

Ebstein's anomaly is a congenital deformity marked by disease of the tricuspid valve and right cardiac hypertrophy. The severity, morphology, and appearance of Ebstein's anomaly cases might vary greatly. We discuss a case of an eight-year-old child with Ebstein's anomaly who presented with supraventricular tachycardia and was effectively treated with amiodarone after initial treatment with adenosine failed to reduce the heart rate.

Care of the Fetus With Congenital Cardiovascular Disease: From Diagnosis to Delivery

BACKGROUND

The majority of congenital cardiovascular disease including structural cardiac defects, abnormalities in cardiac function, and rhythm disturbances can be identified prenatally using screening obstetrical ultrasound with referral for fetal echocardiogram when indicated.

METHODS

Diagnosis of congenital heart disease in the fetus should prompt assessment for extracardiac abnormalities and associated genetic abnormalities once maternal consent is obtained. Pediatric cardiologists, in conjunction with maternal-fetal medicine, neonatology, and cardiothoracic surgery subspecialists, should counsel families about the details of the congenital heart defect as well as prenatal and postnatal management.

RESULTS

Prenatal diagnosis often leads to increased maternal depression and anxiety; however, it decreases morbidity and mortality for many congenital heart defects by allowing clinicians the opportunity to optimize prenatal care and plan delivery based on the specific lesion. Changes in prenatal care can include more frequent assessments through the remainder of the pregnancy, maternal medication administration, or, in selected cases, in utero cardiac catheter intervention or surgical procedures to optimize postnatal outcomes. Delivery planning may include changing the location, timing or mode of delivery to ensure that the neonate is delivered in the most appropriate hospital setting with the required level of hospital staff for immediate postnatal stabilization.

CONCLUSIONS

Based on the specific congenital heart defect, prenatal echocardiogram assessment in late gestation can often aid in predicting the severity of postnatal instability and guide the medical or interventional level of care needed for immediate postnatal intervention to optimize the transition to postnatal circulation.

Risk Factors for Atrial Arrhythmias in Adults With Ebstein Anomaly

Background

Atrial arrhythmias (AA) are common in Ebstein anomaly (EA), but risk factors associated with AA are not well understood.

Objectives

The purpose of this study was to determine the prevalence and risk factors for AA at baseline, incidence, and risk factors for AA during follow-up.

Methods

Adults with EA receiving care at Mayo Clinic, MN, between 2003 and 2020 were included. AA was defined as atrial fibrillation (AF) or atrial flutter/tachycardia (AFL). Clinical, echocardiographic, rhythm, surgical data were collected.

Results

Of 682 patients (aged 36 [24-49] years), 235 (34%) had AA at baseline (126 [18%] AF and 144 [21%] AFL), and the risk factors for AA were age, left and right atrial volume indexes, and reservoir strain. Among 447 patients without AA, 10-year cumulative incidence of AF and AFL was 16% and 22%, respectively. The risk factors for incident AF were older age and right atrial reservoir strain. The risk factors for incident AFL were atrial septal defect, left atrial volume index, and male sex. Among patients with baseline AA, 129 (40%) had recurrent episodes (AF 63 [20%], AFL 78 [24%]). The 5-year recurrence rate of AA was 34%, without significant difference for AF vs AFL (46% vs 27%, P = 0.081). Older age and right atrial reservoir strain were associated with recurrent AF.

Conclusions

Patients with EA are at risk for incident and recurrent AA. AF was almost as common as AFL despite relatively young ages. Echocardiographic indexes of atrial function can identify at-risk patients, hence be used to improve risk stratification and guide therapy.

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.

Narrative review of Ebstein's anomaly beyond childhood: Imaging, surgery, and future perspectives

Ebstein's anomaly is a rare congenital heart disease with malformation of the tricuspid valve and myopathy of the right ventricle. The septal and inferior leaflets adhere to the endocardium due to failure of delamination. This leads to apical displacement of their hinge points with a shift of the functional tricuspid valve annulus towards the right ventricular outflow tract with a possibly restrictive orifice. Frequently, a coaptation gap yields tricuspid valve regurgitation and over time the "atrialized" portion of the right ventricle may dilate. The highly variable anatomy determines the clinical presentation ranging from asymptomatic to very severe with need for early operation. Echocardiography and magnetic resonance imaging are the most important diagnostic modalities to assess the tricuspid valve as well as ventricular morphology and function. While medical management of asymptomatic patients can be effective for many years, surgical intervention is indicated before development of significant right ventricular dilatation or dysfunction. Onset of symptoms and arrhythmias are further indications for surgery. Modified cone reconstruction of the tricuspid valve is the state-of-the-art approach yielding the best results for most patients. Alternative procedures for select cases include tricuspid valve replacement and bidirectional cavopulmonary shunt depending on patient age and other individual characteristics. Long-term survival after surgery is favorable but rehospitalization and reoperation remain significant issues. Further studies are warranted to identify the optimal surgical strategy and timing before adverse right ventricular remodeling occurs. It is this article's objective to provide a comprehensive review of current literature and an overview on the management of Ebstein's Anomaly. It focuses on imaging, cardiac surgery, and outcome. Additionally, a brief insight into arrhythmias and their management is given. The "future perspectives" summarize open questions and fields of future research.

Accessory pathway ablation in Ebstein anomaly: A challenging substrate

BACKGROUND

Catheter ablation of accessory pathways (APs) in Ebstein anomaly (EA) has been associated with a high recurrence risk.

OBJECTIVE

The purpose of this study was to compare outcomes of AP ablation in EA in an early (1990-2004) vs a recent (2005-2019) era and identify variables associated with recurrence.

METHODS

A retrospective review of all catheter ablations for supraventricular tachycardia in EA at our institution was performed.

RESULTS

We identified 76 patients with median (25th-75th quartiles) age 9 (2.6-13.3) years. Of these patients, 52 had AP alone, 12 had atrial flutter, 3 had atrioventricular nodal reentrant tachycardia, and 9 had AP plus at least 1 additional arrhythmia. Of the 61 patients with APs, a total of 78 separate APs were identified: 40 right-sided, 37 septal, and 1 left-sided. Acute success for AP first procedure was 89% and did not differ between early and recent eras (89% vs 88%; P = .48). However, 19 patients (31%) required repeat procedures (average 1.4 per patient) due to AP recurrence or ablation failure at first attempt. In comparison to early era, recent era ablations had significantly lower recurrence rates at 1 year (62% vs 19%; P = .005). At median follow-up of 2.5 (0.2-7) years, ultimate AP elimination after all procedures was 93%. Younger age at time of electrophysiological study (<2 vs 12-47 years: hazard ratio [HR] 7.3; P = .003) and ablation era (early era vs recent era: HR 3.65; P = .009) predicted recurrence.

CONCLUSION

Outcomes for AP ablation in patients with EA have improved, but there is still a relatedly high recurrence risk requiring repeat procedures.

Therapy of supraventricular and ventricular arrhythmias in adults with congenital heart disease-narrative review

Arrhythmias are among the most common late complications in adults with congenital heart disease (ACHD) and a frequent reason for hospital admission. Both, supraventricular and ventricular arrhythmias, not only cause debilitating symptoms, but may be life-threatening by increasing risk of stroke, causing or worsening heart failure and being associated with sudden death. Substrate and risk for arrhythmia differs widely between congenital defects with specific arrhythmias being much more common in some patients than others. Atrial macroreentrant arrhythmias are particularly frequent in patients with atrial septal defects and repair that involves atrial incisions including patients with transposition of the great arteries (TGA) and atrial switch. Accessory pathways and related arrhythmias are often associated with Ebstein's anomaly and congenitally corrected TGA. Monomorphic ventricular arrhythmias occur in patients with ventricular incisions, namely patients with Tetralogy of Fallot. Changes in surgical repair techniques influence arrhythmia prevalence and substrate as well as anatomical access for catheter ablation procedures. In addition, epidemiologic changes associated with improved long-term survival will further increase the prevalence of atrial fibrillation in ACHD. This article summarizes current understanding of prevalence of specific arrhythmias, underlying mechanisms, medical and interventional treatment options and their outcome in ACHD.

Atrial Fibrillation in Congenital Heart Disease

The increasing prevalence of AF in a growing population of adults with congenital heart disease (CHD) poses new challenges to clinicians involved in the management of these patients. Distinctive underlying anatomies, unique physiological aspects, a high diversity of corrective surgeries and associated comorbidities can complicate clinical decision-making. In this review, the authors provide an overview of the current knowledge on epidemiology and pathophysiology, with a special focus on the differences to the non-CHD population and the clinical impact of AF in adults with CHD. Acute and long-term management strategies are summarised, including the use of antiarrhythmic drugs, catheter or surgical ablation and prophylaxis of thromboembolism. Finally, gaps of knowledge and potential areas of future research are highlighted.

Ebstein's Anomaly of the Tricuspid Valve: an Overview of Pathology and Management

PURPOSE OF REVIEW

Ebstein's anomaly (EA) is a rare, but complex form of congenital heart disease consisting of a right ventricular myopathy and morphologic tricuspid valve disease leading to a high incidence of right ventricular dysfunction and arrhythmias. This review offers an updated overview of the current understanding and management of patients with EA with a focus on the adult population.

RECENT FINDINGS

Increased understanding of anatomic accessory atrioventricular pathways in EA has resulted in an improvement in ablation techniques and long-term freedom of atrial arrhythmia recurrence. Despite an improvement in understanding and recognition of EA, significant disease heterogeneity and complex treatment options continue to challenge providers, with the best outcomes achieved at expert congenital heart disease centers.

Outcomes of Atrial Arrhythmia Surgery in Patients With Congenital Heart Disease: A Systematic Review

Background The improved life expectancy of patients with congenital heart disease is often accompanied by the development of atrial tachyarrhythmias. Similarly, the number of patients requiring redo operations is expected to continue to rise as these patients are aging. Consequently, the role of arrhythmia surgery in the treatment of atrial arrhythmias is likely to become more important in this population. Although atrial arrhythmia surgery is a well-established part of Fontan conversion procedures, evidence-based recommendations for arrhythmia surgery for macroreentrant atrial tachycardia and atrial fibrillation in other patients with congenital heart disease are still lacking. Methods and Results Twenty-eight studies were included in this systematic review. The median reported arrhythmia recurrence was 13% (interquartile range, 4%-26%) during follow-up ranging from 3 months to 15.2 years. A large variation in surgical techniques was observed. Based on the acquired data, biatrial lesions are more effective in the treatment of atrial fibrillation than exclusive right-sided lesions. Right-sided lesions may be more appropriate in the treatment of macroreentrant atrial tachycardia; evidence for the superiority of additional left-sided lesions is lacking. There are not enough data to support the use of exclusive left-sided lesions. Theoretically, prophylactic atrial arrhythmia surgery may be beneficial in this population, but evidence is currently limited. Conclusions To be able to provide recommendations for arrhythmia surgery in patients with congenital heart disease, future studies should report outcomes according to the type of preoperative arrhythmia, underlying congenital heart disease, lesion set, and energy source. This is essential for determining which surgical techniques should ideally be applied under which circumstances.

Ebstein Anomaly in the Adult Patient

Ebstein anomaly is a congenital malformation involving primarily the tricuspid valve, with failure of delamination from the underlying myocardium and right ventricular myopathy. Echocardiography is diagnostic in most patients and demonstrates apical displacement of the septal leaflet and variable tethering of leaflet tissue to the right ventricular myocardium. Operative intervention is considered for exertional symptoms, progressive right ventricular enlargement, or right ventricular dysfunction. Tricuspid valve cone repair is the preferred surgical approach. Tricuspid valve replacement and bidirectional cavopulmonary shunt also are considered in patients with advanced disease. Pregnancy generally is well tolerated. Patients with Ebstein anomaly require lifelong follow-up.

Ebstein's anomaly: contemporary management strategies

Ebstein’s anomaly (EA) is a rare congenital cardiac anomaly. It is a disease at a minimum of the tricuspid valve (TV) and the right ventricular myocardium. Presentation varies from a severe symptomatic form during the neonatal period to an incidental detection later in life due to the wide morphological variation of the condition. The neonatal presentation can be severe and every attempt should be made at medical management ideally into infancy and early childhood. Neonates not eligible or failing medical management should be surgically managed either with a single ventricle palliative approach or a more desirable biventricular repair with a neonatal TV valvuloplasty. Some neonates initially committed to a single ventricle pathway may be converted to a biventricular repair by a delayed TV valvuloplasty. The da Silva Cone repair has become the valvuloplasty of choice especially beyond the neonatal period and can be applied to a wide morphological variation of the condition with good long-term durability. If the chance of a successful TV valvuloplasty is high, it should be offered early in childhood to prevent further cardiac dilation. Adding a Bidirectional Glenn to a valvuloplasty may help salvage marginal risk patients or marginally repairable valves. If valve replacement is the only option, a bioprosthetic valve should be used as it is less thrombogenic especially with marginal right ventricular function. Heart transplantation should be considered in patients with associated left ventricular dysfunction.

Examination of pathologic features of the right atrioventricular groove in hearts with Ebstein anomaly and correlation with arrhythmias

BACKGROUND

Catheter ablation of accessory pathways (APs) in patients with Ebstein anomaly (EA) has a higher recurrence rate than in subjects with normal hearts. Anatomic features could account for suboptimal ablation outcomes.

OBJECTIVE

The purpose of this study was to examine the right atrioventricular (AV) groove in autopsy hearts with EA, correlate with clinical data, and identify features relevant for catheter ablation.

METHODS

Thirty-three specimens with EA from our Cardiac Registry were examined. The right AV groove was inspected for gross anatomic features. Limited microscopy was performed on selected specimens. Premortem clinical data were correlated with anatomic findings.

RESULTS

A prominent ridge along the right AV groove was seen in 15 of 33 specimens (45%). Ten specimens had a clinical history of AP (AP+). The extent of ventricular atrialization did not differ between AP+ and AP- groups (64 ± 63 mm/m² vs 76 ± 42 mm/m²; P = .61), nor did the presence of visible macroscopic AV tissue connections (45% vs 51%; P = .68). The single item that differed was the presence of an AV groove ridge itself, which was significantly more common in the AP+ group (70% vs 21%; P = .03). Microscopy of ridge tissue revealed a muscular bundle in 1 AP+ specimen penetrating deep into the fibrous AV annulus that was suggestive of an AP, although complete muscular continuity was not verified in the limited sections available for examination.

CONCLUSION

A prominent ridge along the inferior right AV groove is a common feature in EA and correlates with clinical history of AP. It presents a potential obstacle to catheter ablation and may contribute to recurrence rate.

Ebstein's anomaly with 'reversible' functional pulmonary atresia

We present the case of an infant with prenatal diagnosis, at 32 weeks gestation, of Ebstein's anomaly without anterograde flow from right ventricular to pulmonary atresia (PA)-functional PA with flow reversal in the ductus arteriosus. Prostaglandin E1 was started after birth. Chest X-ray showed severe cardiomegaly and echocardiogram confirmed Ebstein's anomaly with a thickened non-opening pulmonary valve without anterograde flow but with mild regurgitation. Multidisciplinary team decision was to progressively reduce prostaglandins and have an expectant attitude. Peripheral oxygen saturation above 85% was maintained and serial echocardiograms documented progressive reduction of the ductus arteriosus and the opening of the pulmonic valve cusps, with the development of anterograde flow. The newborn was discharged at day 19 of life without the need for any intervention, and at last follow-up remains asymptomatic, with anterograde normal flow in the pulmonary valve.

Delivery room emergencies in critical congenital heart diseases

Transition from fetal to postnatal life is a complex process. Even in the absence of congenital heart disease, about 4-10% of newborns require some form of assistance in the delivery room. Neonates with complex congenital heart disease should be expected to require significant intervention and thus the resuscitation team must be well prepared for such a delivery. Prenatal assessment including fetal and maternal health in general and detailed information on fetal heart structure, function and hemodynamics in particular are crucial for planning the delivery and resuscitation. In addition, understanding the impact of cardiac structural anomaly and associated altered blood flow on early postnatal transition is essential for success of resuscitation in the delivery room. In this article, we will briefly review transitional circulation focusing on altered hemodynamics of the complex congenital heart diseases and then discuss the process of preparing for these high-risk deliveries. Finally, we will review the pathophysiology resulting from the cardiac structural anomaly with resultant altered fetal circulation and discuss delivery room management of specific critical congenital heart diseases.

Ebstein's Anomaly

Ebstein's anomaly is a malformation of the tricuspid valve with myopathy of the right ventricle (RV) that presents with variable anatomic and pathophysiologic characteristics, leading to equally variable clinical scenarios. Medical management and observation is often recommended for asymptomatic patients and may be successful for many years. Tricuspid valve repair is the goal of operative intervention; repair also typically includes RV plication, right atrial reduction, and atrial septal closure or subtotal closure. Postoperative functional assessments generally demonstrate an improvement or relative stability related to degree of RV enlargement, RV dysfunction, RV fractional area change, and tricuspid valve regurgitation.

Cone Type Repair Has Become Our First Option in the Treatment of Adult Ebstein Anomaly

PURPOSE

Different surgical procedures were defined due to degree of Ebstein anomaly. In this study, we are reporting our surgical experience of adult patients with Ebstein anomaly.

METHODS

We analyzed the patients, who had operated with the diagnosis of Ebstein anomaly from March 2011 through February 2018, retrospectively. We evaluated patients in two groups: patients with cone type surgical repair were in Group 1 and patients with other surgical (Danielson, Carpentier) procedures were in Group 2.

RESULTS

There were 23 patients in the study; 9 (39%) were in Group 1 and 14 (61%) were in Group 2. In the comparison of preoperative data, groups were statistically similar. Aortic cross clamp and cardiopulmonary bypass (CPB) times, need for inotropic agents, intubation time, postoperative >2 tricuspid regurgitation incidence, intensive care unit, and hospital staying times were statistically significantly higher in Group 2. There was one mortality (4.3%) in Group 2 due to sepsis.

CONCLUSION

Cone type repair can safely be performed in the repair of Ebstein anomaly with acceptable results. Our results are encouraging to prefer this technique as one of the first-line treatment of Ebstein anomaly. However, further randomized controlled studies are recommended to evaluate the efficacy of this surgical procedure.

Risk of Atrial Fibrillation in Patients with Congenital Heart Disease: Results of a Propensity Score-Matched, Nationwide Cohort Study

Aim: The objective was to compare the rate of atrial fibrillation (AF) onset in patients with congenital heart disease (CHD) compared to controls.

Methods: Using a large number of samples extracted from nationwide cohort data in Taiwan, the authors used a propensity-matching procedure and multivariable Cox models to assess the risk of AF by CHD.

Results: A cohort of 19,439 CHD patients and a propensity-matched cohort of 19,439 control patients were included in this study. The cumulative incidence of AF was significantly higher in the CHD cohort than in the non-CHD cohort (p<0.001). After controlling for confounding factors, the adjusted hazard ratio (aHR) of AF was 4.23 (95% confidence interval [CI] 3.31－5.41) in the CHD cohort, compared to the non-CHD cohort.

Conclusion: A significant association between CHD and AF risk was found.

Outcomes of Ebstein's Anomaly Patients Treated with Tricuspid Valvuloplasty or Tricuspid Valve Replacement: Experience of a Single Center

Background:

The incidence of Ebstein's anomaly is extremely low, and except for the Mayo Clinic, no cardiac center has reported on a sufficient number of patients. The aim of our study was to report the outcomes of Ebstein's anomaly patients treated with tricuspid valvuloplasty (TVP) or tricuspid valve replacement (TVR).

Methods:

TVP or TVR was performed in 245 patients from July 2006 to April 2016. We reviewed patients' records and contacted patients via outpatient service and over the telephone.

Results:

The mean follow-up time was 43.6 ± 32.6 months, and 224 (91.4%) patients underwent follow-up. The mean operative age was 31.2 ± 15.7 years. TVR was performed in 23 patients, and TVP was performed in 201 patients. The 30-day mortality rate was 1.3%, and the overall survival rate was 97.9% at 5 and 10 years. The early mortality rate of the TVP group was lower than that of the TVR group (0.5% vs. 8.7%, P = 0.028), and the overall mortality rate of the TVP group was lower than that of the TVR group, without statistical significance (1.0% vs. 8.7%). After propensity score matching, the rates of mortality and New York Heart Association class ≥ III were lower in the TVP group than those in the TVR group without statistical significance. Seven patients with Type B Wolff-Parkinson-White (WPW) syndrome underwent one-stage surgery, and arrhythmias disappeared. Six patients suffered from episodes of left ventricular outflow tract obstruction (LVOTO) during surgery. Severe LVOTO could be treated with reoperation of the atrialized right ventricle.

Conclusions:

Ebstein's anomaly patients treated with TVP or TVR can experience optimal outcomes with midterm follow-up. However, TVP should be the first-choice treatment. Optimal outcomes can be obtained from one-stage operation in patients with Type B WPW syndrome. Severe LVOTO during surgery might be related to improper operation of the atrialized right ventricle.

Atrial Fibrillation Burden in Young Patients With Congenital Heart Disease

Background:

Patients with congenital heart disease (CHD) are assumed to be vulnerable to atrial fibrillation (AF) as a result of residual shunts, anomalous vessel anatomy, progressive valvulopathy, hypertension, and atrial scars from previous heart surgery. However, the risk of developing AF and the complications associated with AF in children and young adults with CHD have not been compared with those in control subjects.

Methods:

Data from the Swedish Patient and Cause of Death registers were used to identify all patients with a diagnosis of CHD who were born from 1970 to 1993. Each patient with CHD was matched by birth year, sex, and county with 10 control subjects from the Total Population Register in Sweden. Follow-up data were collected until 2011.

Results:

Among 21 982 patients (51.6% men) with CHD and 219 816 matched control subjects, 654 and 328 developed AF, respectively. The mean follow-up was 27 years. The risk of developing AF was 21.99 times higher (95% confidence interval, 19.26–25.12) in patients with CHD than control subjects. According to a hierarchical CHD classification, patients with conotruncal defects had the highest risk (hazard ratio, 84.27; 95% confidence interval, 56.86–124.89). At the age of 42 years, 8.3% of all patients with CHD had a recorded diagnosis of AF. Heart failure was the quantitatively most important complication in patients with CHD and AF, with a 10.7% (70 of 654) recorded diagnosis of heart failure.

Conclusions:

The risk of AF in children and young adults with CHD was 22 times higher than that in matched control subjects. Up to the age of 42 years, 1 of 12 patients with CHD had developed AF, and 1 of 10 patients with CHD with AF had developed heart failure. The patient groups with the most complex congenital defects carried the greatest risk of AF and could be considered for targeted monitoring.

Radiofrequency Ablation of Atrial Fibrillation in Patients with Ebstein's Anomaly: A Two-Case Report

Ebstein's anomaly (EA) is a rare congenital heart disease characterized by “atrialization” of the right ventricle, due to apical displacement of the tricuspid leaflets into the right ventricle. Patients with EA may develop all kinds of supraventricular arrhythmias requiring radiofrequency ablation. Atrial fibrillation (Afib) is a common arrhythmia in EA patients, and results in debilitating symptoms that often require surgical treatment. This is a follow-up report of 2 patients with EA undergoing radiofrequency ablation for Afib. The first patient underwent pulmonary vein isolation (PVI) and the ablation of a concomitant atrioventricular nodal reentrant tachycardia. The second patient was also treated with a PVI and a redo PVI 8 months later. Both patients remain in sinus rhythm 8 months on. Radiofrequency ablation is the therapy of choice for patients with pharmacological refractory Afib, but it is not common in patients with EA.

Cardiac Embryology and Molecular Mechanisms of Congenital Heart Disease: A Primer for Anesthesiologists

Congenital heart disease is diagnosed in 0.4% to 5% of live births and presents unique challenges to the pediatric anesthesiologist. Furthermore, advances in surgical management have led to improved survival of those patients, and many adult anesthesiologists now frequently take care of adolescents and adults who have previously undergone surgery to correct or palliate congenital heart lesions. Knowledge of abnormal heart development on the molecular and genetic level extends and improves the anesthesiologist's understanding of congenital heart disease. In this article, we aim to review current knowledge pertaining to genetic alterations and their cellular effects that are involved in the formation of congenital heart defects. Given that congenital heart disease can currently only occasionally be traced to a single genetic mutation, we highlight some of the difficulties that researchers face when trying to identify specific steps in the pathogenetic development of heart lesions.

Arrhythmia Surgery for Adults with Congenital Heart Disease

Patients with repaired or unrepaired congenital heart anomalies are at increased risk for arrhythmia development throughout their lives, often paralleling the need for reoperations for hemodynamic residua. The ability to incorporate arrhythmia surgery into reoperations can result in improvement in functional class and decreased need for antiarrhythmic medications. Every reoperation for congenital heart disease can be viewed as an opportunity to assess the electrical and arrhythmia substrates and to intervene to improve the arrhythmias and the hemodynamic condition of the patient. The authors review and summarize the operative techniques for arrhythmia surgery that are based on the arrhythmia mechanisms.

Supraventricular Arrhythmias in Patients with Adult Congenital Heart Disease

An increasing number of patients with congenital heart disease survive to adulthood; such prolonged survival is related to a rapid evolution of successful surgical repairs and modern diagnostic techniques. Despite these improvements, corrective atrial incisions performed at surgery still lead to subsequent myocardial scarring harbouring a potential substrate for macro-reentrant atrial tachycardia. Macroreentrant atrial tachycardias are the most common (75 %) type of supraventricular tachycardia (SVT) in patients with adult congenital heart disease (ACHD). Patients with ACHD, atrial tachycardias and impaired ventricular function - important risk factors for sudden cardiac death (SCD) - have a 2-9 % SCD risk per decade. Moreover, ACHD imposes certain considerations when choosing antiarrhythmic drugs from a safety aspect and also when considering catheter ablation procedures related to the inherent cardiac anatomical barriers and required expertise. Expert recommendations for physicians managing these patients are therefore mandatory. This review summarises current evidence-based developments in the field, focusing on advances in and general recommendations for the management of ACHD, including the recently published recommendations on management of SVT by the European Heart Rhythm Association.

Long-Term Results after Surgical Treatment of Ebstein's Anomaly: a 30-year Experience

BACKGROUND AND OBJECTIVES

The aim of the study is to evaluate the long-term results after a surgical repair of Ebstein's anomaly.

SUBJECTS AND METHODS

Forty-eight patients with Ebstein's anomaly who underwent open heart surgery between 1982 and 2013 were included. Median age at operation was 5.6 years (1 day-42.1 years). Forty-five patients (93.7%) demonstrated tricuspid valve (TV) regurgitation of less than moderate degree. When the patients were divided according to Carpentier's classification, types A, B, C, and D were 11, 21, 12, and 4 patients, respectively. Regarding the type of surgical treatment, bi-ventricular repair (n=38), one-and-a half ventricular repair (n=5), and single ventricle palliation (n=5) were performed. Of 38 patients who underwent a bi-ventricular repair, TV repairs were performed by Danielson's technique (n=20), Carpentier's technique (n=11), Cone repair (n=4), and TV annuloplasty (n=1). Two patients underwent TV replacement. Surgical treatment strategies were different according to Carpentier's types (p<0.001) and patient's age (p=0.022).

RESULTS

There were 2 in-hospital mortalities (4.2%; 1 neonate and 1 infant) and 2 late mortalities during follow-up. Freedom from recurrent TV regurgitation rates at 5, 10, and 15 years were 88.6%, 66.3%, 52.7%, respectively. TV regurgitation recurrence did not differ according to surgical method (p=0.800). Survival rates at 5, 10, and 20 years were 95.8%, 95.8%, and 85.6%, respectively, and freedom from reoperation rates at 5, 10, and 15 years were 85.9%, 68.0%, and 55.8%, respectively.

CONCLUSION

Surgical treatment strategies were decided according to Carpentier's type and patient's age. Overall survival and freedom from reoperation rates at 10 years were 95.8% and 68.0%, respectively. Approximately 25% of patients required a second operation for TV during the follow-up.

[Arrhythmia in adults with congenital heart defects : Atrial tachycardia]

Atrial arrhythmias are frequently encountered in patients with congenital heart disease (CHD) with or without corrective surgery and respond to pharmacological therapies with only limited success. This review describes the technologies currently available for performing successful ablation procedures in this very complex patient cohort. In addition to an understanding of the underlying anatomy, which can be supplemented by 3D imaging with the aid of magnetic resonance imaging (MRI) or computed tomography (CT), the choice between the different 3D mapping systems (sequential versus simultaneous) is presented. Finally, conventional manual navigation is compared with magnetic navigation and then discussed with regard to the respective arrhythmias encountered with the different forms of CHD.