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Gupta A, Prabhu MA, Anderson RD, Prasad SB, Campbell T, Turnbull S, Lee G, Skinner JR, Kalman J, Kumar S. Ebstein's anomaly: an electrophysiological perspective. J Interv Card Electrophysiol 2024; 67:887-900. [PMID: 38289561 PMCID: PMC11166840 DOI: 10.1007/s10840-024-01744-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 01/07/2024] [Indexed: 06/12/2024]
Abstract
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.
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Affiliation(s)
- Anunay Gupta
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Darcy Road, Westmead, Sydney, New South Wales, 2145, Australia
- Department of Cardiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Mukund A Prabhu
- Department of Cardiology, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Robert D Anderson
- Department of Cardiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Srinivas Bv Prasad
- Department of Cardiology, Fortis Hospital, Bannerghatta, Bengaluru, India
| | - Timothy Campbell
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Darcy Road, Westmead, Sydney, New South Wales, 2145, Australia
| | - Samual Turnbull
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Darcy Road, Westmead, Sydney, New South Wales, 2145, Australia
| | - Geoffrey Lee
- Department of Cardiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Jonathan R Skinner
- Department of Cardiology, Children's Hospital Westmead, Westmead, New South Wales, Australia
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Darcy Road, Westmead, Sydney, New South Wales, 2145, Australia.
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Baroutidou A, Otountzidis N, Papazoglou AS, Moysidis DV, Kartas A, Mantziari L, Kamperidis V, Ziakas A, Giannakoulas G. Atrial Fibrillation Ablation in Congenital Heart Disease: Therapeutic Challenges and Future Perspectives. J Am Heart Assoc 2024; 13:e032102. [PMID: 38193287 PMCID: PMC10926799 DOI: 10.1161/jaha.123.032102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 12/06/2023] [Indexed: 01/10/2024]
Abstract
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.
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Affiliation(s)
- Amalia Baroutidou
- First Department of CardiologyAHEPA University Hospital, Aristotle University of ThessalonikiThessalonikiGreece
| | - Nikolaos Otountzidis
- First Department of CardiologyAHEPA University Hospital, Aristotle University of ThessalonikiThessalonikiGreece
| | | | | | - Anastasios Kartas
- First Department of CardiologyAHEPA University Hospital, Aristotle University of ThessalonikiThessalonikiGreece
| | | | - Vasileios Kamperidis
- First Department of CardiologyAHEPA University Hospital, Aristotle University of ThessalonikiThessalonikiGreece
| | - Antonios Ziakas
- First Department of CardiologyAHEPA University Hospital, Aristotle University of ThessalonikiThessalonikiGreece
| | - George Giannakoulas
- First Department of CardiologyAHEPA University Hospital, Aristotle University of ThessalonikiThessalonikiGreece
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Chaloupecký V, Gebauer R, Kovanda J, Koubský K, Sus I, Janoušek J. Electrophysiology and surgery intertwined in complex treatment of Ebstein's anomaly in childhood. HeartRhythm Case Rep 2022; 9:17-22. [PMID: 36685680 PMCID: PMC9845553 DOI: 10.1016/j.hrcr.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Affiliation(s)
- Václav Chaloupecký
- Children’s Heart Centre, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic,Address reprint requests and correspondence: Dr Václav Chaloupecký Jr, Children’s Heart Centre, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Hošťálkova 605/58, Prague 169 00, Czech Republic.
| | - Roman Gebauer
- Children’s Heart Centre, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Jan Kovanda
- Children’s Heart Centre, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Karel Koubský
- Children’s Heart Centre, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Ioana Sus
- Emergency Institute for Cardiovascular Disease and Transplantation, Tirgu Mures, Romania
| | - Jan Janoušek
- Children’s Heart Centre, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
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Nikoo MH, Khorshidifar M, Nasrollahi E, Bahramvand Y, Nouri F, Attar A. Ventricular versus atrial side ablation for treatment of atrioventricular accessory pathways: a randomized controlled clinical trial. J Interv Card Electrophysiol 2022; 64:103-110. [PMID: 35013893 DOI: 10.1007/s10840-021-01100-0] [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: 07/29/2021] [Accepted: 11/29/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The earliest atrial (A)/ventricular (V) activation potentials, or fused A/V potentials, are commonly used as ablation targets for atrioventricular (AV) accessory pathways (APs). However, these targets can be achieved in a relatively wide area of the heart around AV rings at both atrial and ventricular sides. The aim of this study is to analyze the height of intracardiac A and V waves and their correlation to find the most appropriate side for successful delivery of radiofrequency energy, atrial or ventricular edge. METHODS Ninety patients diagnosed with orthodromic AV re-entrant tachycardia (AVRT) or Wolff-Parkinson-White syndrome were enrolled. Local atrial/ventricular (A/V) amplitude potentials with the earliest activation or fused AV potentials were measured. Patients were randomly assigned into two groups with a 2:1 ratio. In group 1, ablation was done at the site where A was greater than V. In group 2, V was greater than A. Primary endpoint was success at first attempt, achieving antegrade AP conduction block, AV block during right ventricle pacing, or AVRT termination with no AP conduction. RESULTS Fifty-one patients (56.7%) were male. Thirty patients had an ablation at an atrial site (A > V) and 60 at a ventricular site (V > A). Ablation was more successful at the ventricular site (87% vs 100%, P = 0.011). All 30 patients in the atrial arm and 71% of the ventricular group underwent ablation via the antegrade method. CONCLUSIONS Success of catheter ablation of APs is higher where V > A (ventricular site of AP), indicating the priority of the ventricular edge of the mitral ring for a better outcome.
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Affiliation(s)
- Mohammad Hossein Nikoo
- Department of Cardiovascular Medicine, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.,Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Non-Communicable Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Meghdad Khorshidifar
- Students' Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Elham Nasrollahi
- School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Yaser Bahramvand
- School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fatemeh Nouri
- Students' Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Armin Attar
- Department of Cardiovascular Medicine, TAHA Clinical Trial Group, School of Medicine, Shiraz University of Medical Sciences, 71344-1864, Shiraz, Iran.
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He BJ, Merriman AF, Cakulev I, Stambler BS, Srivastava D, Scheinman MM. Ebstein's Anomaly: Review of Arrhythmia Types and Morphogenesis of the Anomaly. JACC Clin Electrophysiol 2021; 7:1198-1206. [PMID: 34454887 DOI: 10.1016/j.jacep.2021.05.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 05/07/2021] [Accepted: 05/17/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Beixin Julie He
- Cardiology, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA; Cardiology, Section of Cardiac Electrophysiology, University of Washington, Seattle, Washington, USA.
| | | | - Ivan Cakulev
- Department of Medicine, University Hospitals of Cleveland Medical Center, Cleveland, Ohio, USA
| | | | - Deepak Srivastava
- Gladstone Institute of Cardiovascular Disease, San Francisco, California, USA; Department of Pediatrics, University of California-San Francisco, San Francisco, California, USA; Department of Biochemistry and Biophysics, University of California-San Francisco, San Francisco, California, USA
| | - Melvin M Scheinman
- Cardiology, Section of Cardiac Electrophysiology, University of California-San Francisco, San Francisco, California, USA
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Walsh EP. Ebstein’s Anomaly of the Tricuspid Valve. JACC Clin Electrophysiol 2018; 4:1271-1288. [DOI: 10.1016/j.jacep.2018.05.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 05/31/2018] [Indexed: 01/29/2023]
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Joung B. Markers for Catheter Ablation of Atrioventricular Accessory Pathways. Korean Circ J 2017; 47:442-443. [PMID: 28765733 PMCID: PMC5537143 DOI: 10.4070/kcj.2017.0113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 06/07/2017] [Indexed: 11/11/2022] Open
Affiliation(s)
- Boyoung Joung
- Division of Cardiology, Yonsei University College of Medicine, Seoul, Korea
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Janson CM, Shah MJ. Supraventricular Tachycardia in Adult Congenital Heart Disease: Mechanisms, Diagnosis, and Clinical Aspects. Card Electrophysiol Clin 2017; 9:189-211. [PMID: 28457235 DOI: 10.1016/j.ccep.2017.02.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Supraventricular arrhythmias represent a major source of morbidity in adults with congenital heart disease (ACHD). Anatomic variants and post-operative changes contribute to a unique electrophysiologic milieu ripe for the development of supraventricular tachycardia. Intra-atrial reentrant tachycardia is the most prevalent mechanism. Atrioventricular reciprocating tachycardia is common in lesions associated with accessory pathways. Abnormal anatomy complicates the management of atrioventricular nodal reentrant tachycardia. Tachycardia mediated by twin atrioventricular nodes is rare. Focal tachycardias are considerations in the ACHD population. Each of these tachycardia mechanisms is reviewed, focusing on the inherent diagnostic and therapeutic challenges.
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Affiliation(s)
- Christopher M Janson
- Division of Cardiology, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, 3415 Bainbridge Avenue, R1, Bronx, NY 10467, USA.
| | - Maully J Shah
- Division of Cardiology, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 34th & Civic Center Boulevard, Philadelphia, PA 19104, USA
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Kim KH, Kim DK, Im HJ, Seo JS, Jin HY, Jang JS, Yang TH, Kim DS, Jeong SY, Song YS, Kim DK, Song PS, Seol SH, Kim DIL. Local Atrial/Ventricular Ratio as an Adjuvant Marker for Catheter Ablation of Atrioventricular Accessory Pathways. Korean Circ J 2017; 47:462-468. [PMID: 28765737 PMCID: PMC5537147 DOI: 10.4070/kcj.2016.0371] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 01/06/2017] [Accepted: 01/29/2017] [Indexed: 11/24/2022] Open
Abstract
Background and Objectives The earliest atrial (A)/ventricular (V) activation potential, or accessory pathway (AP) potential are commonly used as ablation targets for atrioventricular (AV) APs. However, these targets are sometimes ambiguous. Subjects and Methods We reviewed 119 catheter ablation cases in 112 patients diagnosed with orthodromic atrioventricular reentrant tachycardia (AVRT) or Wolff-Parkinson-White (WPW) syndrome. Local A/V amplitude potentials with the earliest activation or AP potential were measured shortly before achieving antegrade AP conduction block, ventriculoatrial block during right ventricle (RV) pacing, or AVRT termination with no AP conduction. Results APs were located in the left lateral (55.5%), left posterior (17.6%), left posteroseptal (10.1%), midseptal (1.7%), right posteroseptal (7.6%), right posterior (1.7%), and right lateral (5.9%) regions. The mean earliest activation time was 16.7±15.5 ms, mean A/V potential was 1.1±0.9/1.0±0.9 mV, and mean A/V ratio was 1.7±2.0. There was no statistically significant difference between the activation methods (antegrade vs. RV pacing vs. orthodromic AVRT) or AP locations (left vs. right atrium). However, when the local A/V ratio was divided into 3 groups (≤0.6, 1.0±0.3, and ≥1.4), the antegrade approach resulted in an A/V ratio greater than 1.0±0.3 (86.7%, p=0.007), and the orthodromic AVRT state resulted in a ratio of less than 1.0±0.3 (87.5%, p<0.001). Conclusion The mean local A/V potential and ratio did not differ by activation method or AP location. However, a different A/V ratio based on activation method (≥1.0±0.3, antegrade approach; and ≤1.0±0.3, orthodromic AVRT state) could be a good adjuvant marker for targeting AV APs.
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Affiliation(s)
- Ki-Hun Kim
- Department of Internal Medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Dae-Kyeong Kim
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Paik Hospital, Busan, Korea
| | - Hyun-Ji Im
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Paik Hospital, Busan, Korea
| | - Jeong-Sook Seo
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Paik Hospital, Busan, Korea
| | - Han-Young Jin
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Paik Hospital, Busan, Korea
| | - Jae-Sik Jang
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Paik Hospital, Busan, Korea
| | - Tae-Hyun Yang
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Paik Hospital, Busan, Korea
| | - Dong-Soo Kim
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Paik Hospital, Busan, Korea
| | - So-Young Jeong
- Department of Internal Medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Yun Seok Song
- Department of Internal Medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Dong-Kie Kim
- Department of Internal Medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Pil-Sang Song
- Department of Internal Medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Sang-Hoon Seol
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Paik Hospital, Busan, Korea
| | - Doo-IL Kim
- Department of Internal Medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
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