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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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Krawczyk-Ożóg A, Hołda MK, Batko J, Jaśkiewicz K, Dziewierz A, Zdzierak B, Zasada W, Gil K, Hołda J. Description and prevalence of ventricular mitral annular disjunction: variation of normality or pathological variant? REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024:S1885-5857(24)00129-4. [PMID: 38641167 DOI: 10.1016/j.rec.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 04/03/2024] [Indexed: 04/21/2024]
Abstract
INTRODUCTION AND OBJECTIVES The aim of this study was to investigate a new variation of the atrial wall-mitral annulus-ventricular wall junction along the mural mitral leaflet and commissures: the ventricular mitral annular disjunction (v-MAD). This new variant is characterized by spatial displacement of the mitral leaflet hinge line by more than 2mm toward the left ventricle. METHODS We examined a cohort of autopsied human hearts (n=224, 21.9% females, 47.9±17.6 years) from patients without known cardiovascular disease to identify the presence of v-MAD. RESULTS More than half (57.1%) of the hearts showed no signs of MAD in the mural mitral leaflet or mitral commissures. However, v-MAD was found in 23.6% of cases, located within 20.1% of mural leaflets, 2.2% in superolateral commissures, and 1.3% in inferoseptal commissures. V-MAD was not uniformly distributed along the mitral annulus circumference, with the most frequent site being the P2 scallop (19.6% of hearts). The v-MAD height was significantly greater in mural leaflets than in commissures (4.4 mm±1.2 mm vs 2.1 mm±0.1 mm; P<.001). No specific variations in mitral valve morphology or anthropometrical features of donors were associated with the presence or distribution of v-MADs. Microscopic examinations revealed the overlap of the thin layer of atrial myocardium over ventricular myocardium in areas of v-MAD. CONCLUSIONS Our study is the first to present a detailed definition and morphometric description of v-MAD. Further studies should focus on the clinical significance of v-MAD to elucidate whether it represents a benign anatomical variant or a significant clinical anomaly.
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Affiliation(s)
- Agata Krawczyk-Ożóg
- Department of Anatomy, Heart Embryology and Anatomy Research Team (HEART), Jagiellonian University Medical College, Krakow, Poland; Clinical Department of Cardiology and Cardiovascular Interventions, Krakow University Hospital, Krakow, Poland.
| | - Mateusz K Hołda
- Department of Anatomy, Heart Embryology and Anatomy Research Team (HEART), Jagiellonian University Medical College, Krakow, Poland; Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
| | - Jakub Batko
- Department of Anatomy, Heart Embryology and Anatomy Research Team (HEART), Jagiellonian University Medical College, Krakow, Poland
| | - Kacper Jaśkiewicz
- Department of Anatomy, Heart Embryology and Anatomy Research Team (HEART), Jagiellonian University Medical College, Krakow, Poland
| | - Artur Dziewierz
- Clinical Department of Cardiology and Cardiovascular Interventions, Krakow University Hospital, Krakow, Poland; 2nd Department of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Barbara Zdzierak
- Clinical Department of Cardiology and Cardiovascular Interventions, Krakow University Hospital, Krakow, Poland
| | - Wojciech Zasada
- Clinical Department of Cardiology and Cardiovascular Interventions, Krakow University Hospital, Krakow, Poland
| | - Krzysztof Gil
- Department of Pathophysiology, Jagiellonian University Medical College, Krakow, Poland
| | - Jakub Hołda
- Department of Anatomy, Heart Embryology and Anatomy Research Team (HEART), Jagiellonian University Medical College, Krakow, Poland. https://twitter.com/@Jakub_Batko_
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Akazawa Y, Fujioka T, Yazaki K, Strbad M, Hörer J, Kühn A, Hui W, Slorach C, Roehlig C, Mertens L, Bijnens BH, Vogt M, Friedberg MK. Right Ventricular Electromechanical Dyssynchrony and Its Relation to Right Ventricular Remodeling, Dysfunction, and Exercise Capacity in Ebstein Anomaly. J Am Soc Echocardiogr 2023:S0894-7317(23)00096-2. [PMID: 36841267 DOI: 10.1016/j.echo.2023.02.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 01/21/2023] [Accepted: 02/08/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND Abnormal atrioventricular and intraventricular electrical conduction and dysfunction of the functional right ventricle (fRV) are common in Ebstein anomaly (EA). However, fRV mechanical dyssynchrony and its relation to fRV function are poorly characterized. We evaluated fRV mechanical dyssynchrony in EA patients in relation to fRV remodeling, dysfunction, and exercise intolerance. METHODS We retrospectively analyzed data from nonoperated EA patients and age-matched controls who underwent echocardiography, cardiovascular magnetic resonance imaging, and cardiopulmonary exercise testing to quantify right ventricular (RV) remodeling, dysfunction, and exercise capacity. The relation of these to fRV dyssynchrony was retrospectively investigated. Right ventricular mechanical dyssynchrony was defined by early fRV septal activation (right-sided septal flash), RV lateral wall prestretch/late contraction, postsystolic shortening, and intra-RV delay using two-dimensional strain echocardiography. The SD of time to peak shortening among the fRV segments was calculated as a parameter of mechanical dispersion. RESULTS Thirty-five EA patients (10 of whom were <18 years of age) and 35 age-matched controls were studied. Ebstein anomaly patients had worse RV function and increased intra-RV dyssynchrony versus controls. Nineteen of 35 (54%) EA patients had early septal activation with simultaneous stretch and consequent late activation and postsystolic shortening of RV lateral segments. Intra-fRV mechanical delay correlated with fRV end-diastolic volume index (r = 0.43, P < .05) and fRV end-systolic volume index (r = 0.63, P < .001). The fRV ejection fraction was lower in EA with versus without right-sided septal flash (44.9 ± 11.0 vs 54.2 ± 8.2, P = .012). The fRV mechanical dispersion correlated with the percentage of predicted peak VO2 (r = -0.35, P < .05). CONCLUSIONS In EA, fRV mechanical dyssynchrony is associated with fRV remodeling, dysfunction, and impaired exercise capacity. Mechanical dyssynchrony as a therapeutic target in selected EA patients warrants further study.
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Affiliation(s)
- Yohei Akazawa
- Department of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Tao Fujioka
- Department of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kana Yazaki
- Department of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Martina Strbad
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Jürgen Hörer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Andreas Kühn
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technische Universituät München, München, Germany
| | - Wei Hui
- Department of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Cameron Slorach
- Department of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Christoph Roehlig
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technische Universituät München, München, Germany
| | - Luc Mertens
- Department of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Bart H Bijnens
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; ICREA, Passeig de Lluís Companys, Barcelona, Spain
| | - Manfred Vogt
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technische Universituät München, München, Germany; Kinderherz-Praxis München, München, Germany
| | - Mark K Friedberg
- Department of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada.
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Albertini L, HA AC, Nair K. Ebstein's Anomaly: How to Identify Intracardiac Structures When Electrical Signals Do Not Match the Anatomy. J Innov Card Rhythm Manag 2022; 13:5181-5182. [PMID: 36196236 PMCID: PMC9521723 DOI: 10.19102/icrm.2022.130906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 05/05/2022] [Indexed: 11/20/2022] Open
Abstract
In patients with Ebstein's anomaly, the distorted anatomy with discordance between the true atrioventricular (AV) groove and the tricuspid valve poses many challenges to the electrophysiologist. Intracardiac echocardiography is a recent tool that allows visualization of the displaced tricuspid valve, the true AV groove, and the atrialized right ventricle. We present a 3-dimensional electroanatomic map built using intracardiac echocardiography and the CARTOSOUND® module (Biosense Webster, Diamond Bar, CA, USA) in one such patient who underwent ablation of a right-sided mid-septal accessory pathway.
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Affiliation(s)
- Lisa Albertini
- Division of Cardiology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - Andrew C.T. HA
- Division of Cardiology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - Krishnakumar Nair
- Division of Cardiology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada,Address correspondence to: Krishnakumar Nair, MD, 3 Floor, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, 200 Elizabeth Street, Toronto, M5G 2C4, Canada.
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Thareja SK, Frommelt MA, Lincoln J, Lough JW, Mitchell ME, Tomita-Mitchell A. A Systematic Review of Ebstein’s Anomaly with Left Ventricular Noncompaction. J Cardiovasc Dev Dis 2022; 9:jcdd9040115. [PMID: 35448091 PMCID: PMC9031964 DOI: 10.3390/jcdd9040115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 03/31/2022] [Accepted: 04/07/2022] [Indexed: 11/16/2022] Open
Abstract
Traditional definitions of Ebstein’s anomaly (EA) and left ventricular noncompaction (LVNC), two rare congenital heart defects (CHDs), confine disease to either the right or left heart, respectively. Around 15–29% of patients with EA, which has a prevalence of 1 in 20,000 live births, commonly manifest with LVNC. While individual EA or LVNC literature is extensive, relatively little discussion is devoted to the joint appearance of EA and LVNC (EA/LVNC), which poses a higher risk of poor clinical outcomes. We queried PubMed, Medline, and Web of Science for all peer-reviewed publications from inception to February 2022 that discuss EA/LVNC and found 58 unique articles written in English. Here, we summarize and extrapolate commonalities in clinical and genetic understanding of EA/LVNC to date. We additionally postulate involvement of shared developmental pathways that may lead to this combined disease. Anatomical variation in EA/LVNC encompasses characteristics of both CHDs, including tricuspid valve displacement, right heart dilatation, and left ventricular trabeculation, and dictates clinical presentation in both age and severity. Disease treatment is non-specific, ranging from symptomatic management to invasive surgery. Apart from a few variant associations, mainly in sarcomeric genes MYH7 and TPM1, the genetic etiology and pathogenesis of EA/LVNC remain largely unknown.
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Affiliation(s)
- Suma K. Thareja
- Department of Cell Biology, Neurobiology, and Anatomy, Medical College of Wisconsin, Milwaukee, WI 53226, USA; (S.K.T.); (J.W.L.)
- Department of Surgery, Division of Congenital Heart Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA;
| | - Michele A. Frommelt
- Department of Pediatrics, Division of Pediatric Cardiology, Children’s Wisconsin, Milwaukee, WI 53226, USA; (M.A.F.); (J.L.)
- Herma Heart Institute, Children’s Wisconsin, Milwaukee, WI 53226, USA
| | - Joy Lincoln
- Department of Pediatrics, Division of Pediatric Cardiology, Children’s Wisconsin, Milwaukee, WI 53226, USA; (M.A.F.); (J.L.)
- Herma Heart Institute, Children’s Wisconsin, Milwaukee, WI 53226, USA
| | - John W. Lough
- Department of Cell Biology, Neurobiology, and Anatomy, Medical College of Wisconsin, Milwaukee, WI 53226, USA; (S.K.T.); (J.W.L.)
| | - Michael E. Mitchell
- Department of Surgery, Division of Congenital Heart Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA;
- Department of Pediatrics, Division of Pediatric Cardiology, Children’s Wisconsin, Milwaukee, WI 53226, USA; (M.A.F.); (J.L.)
- Herma Heart Institute, Children’s Wisconsin, Milwaukee, WI 53226, USA
| | - Aoy Tomita-Mitchell
- Department of Surgery, Division of Congenital Heart Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA;
- Department of Pediatrics, Division of Pediatric Cardiology, Children’s Wisconsin, Milwaukee, WI 53226, USA; (M.A.F.); (J.L.)
- Herma Heart Institute, Children’s Wisconsin, Milwaukee, WI 53226, USA
- Correspondence:
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Van Praagh R. Tricuspid Valve Anomalies. CONGENIT HEART DIS 2022. [DOI: 10.1016/b978-1-56053-368-9.00013-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Neumann S, Rüffer A, Sachweh J, Biermann D, Herrmann J, Jerosch-Herold M, Hazekamp M, Sinning C, Zengin E, Blankenberg S, Girdauskas E, Reichenspurner H, Kehl T, Müller G, Kozlik-Feldmann R, Rickers C. Narrative review of Ebstein's anomaly beyond childhood: Imaging, surgery, and future perspectives. Cardiovasc Diagn Ther 2021; 11:1310-1323. [PMID: 35070800 PMCID: PMC8748487 DOI: 10.21037/cdt-20-771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 12/22/2020] [Indexed: 11/29/2023]
Abstract
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.
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Affiliation(s)
- Stephan Neumann
- Department of Pediatric Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - André Rüffer
- Surgery for Congenital Heart Disease, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Jörg Sachweh
- Surgery for Congenital Heart Disease, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Daniel Biermann
- Surgery for Congenital Heart Disease, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Jochen Herrmann
- Department of Pediatric Radiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Mark Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Christoph Sinning
- Department of Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Elvin Zengin
- Department of Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Stefan Blankenberg
- Department of Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Evaldas Girdauskas
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Torben Kehl
- Department of Pediatric Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Götz Müller
- Department of Pediatric Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Rainer Kozlik-Feldmann
- Department of Pediatric Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Carsten Rickers
- Adult Congenital Heart Disease Section, University Heart & Vascular Center Hamburg, Hamburg, Germany
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Knott-Craig CJ, Boston US. Current surgical techniques in the management of the symptomatic neonate with severe Ebstein anomaly: Too much, too little, or just enough? JTCVS Tech 2021; 9:128-134. [PMID: 34647081 PMCID: PMC8501262 DOI: 10.1016/j.xjtc.2021.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 05/11/2021] [Indexed: 12/03/2022] Open
Abstract
The management of severely symptomatic neonates with Ebstein anomaly is challenging during the early neonatal period. Initial management goals should focus on mitigating a central shunt; providing respiratory mechanical support; providing an adequate but not excessive source of pulmonary blood flow; and minimizing pulmonary vascular resistance. For most patients thus stabilized, definitive repair should be prudently deferred until it is safe for a bailout bidirectional Glenn anastomosis to be added, usually at age 3 to 4 months. For those who remain critical, initial ligation of the large ductus and placing a more peripheral aortopulmonary shunt, or ligating the main pulmonary artery, should be weighed against a primary biventricular repair (Knott-Craig repair), or the Starnes' single-ventricle palliation. The Da Silva cone biventricular repair should generally be avoided during the early neonatal period. An initial Starnes' repair can be potentially converted to a biventricular repair in later infancy.
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Affiliation(s)
- Christopher J. Knott-Craig
- Address for reprints: Christopher J. Knott-Craig, MD, FACS, Division of Pediatric Cardiovascular Surgery, Le Bonheur Children's Hospital and the University of Tennessee Health Sciences Center, Suite 332 Physician office Building, 50 N Dunlap, Memphis, TN 38105.
| | - Umar S. Boston
- Division of Pediatric Cardiovascular Surgery, Le Bonheur Children's Hospital, Memphis, Tenn
- University of Tennessee Health Sciences Center, Memphis, Tenn
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Saef JM, Ghobrial J. Valvular heart disease in congenital heart disease: a narrative review. Cardiovasc Diagn Ther 2021; 11:818-839. [PMID: 34295708 DOI: 10.21037/cdt-19-693-b] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 01/29/2021] [Indexed: 12/29/2022]
Abstract
Patients with congenital heart disease (CHD) are one of the fastest growing populations in cardiology, and valvular pathology is at the center of many congenital lesions. Derangements in valvular embryology lead to several anomalies prone to dysfunction, each with hemodynamic effects that require appropriate surveillance and management. Surgical innovation has provided new treatments that have improved survival in this population, though has also contributed to esotericism in patients who already have unique anatomic and physiologic considerations. Conduit and prosthesis durability are often monitored collaboratively with general and specialized congenital-focused cardiologists. As such, general cardiologists must become familiar with valvular disease with CHD for appropriate care and referral practices. In this review, we summarize the embryology of the semilunar and atrioventricular (AV) valves as a foundation for understanding the origins of valvular CHD and describe the mechanisms that account for heterogeneity in disease. We then highlight the categories of pathology from the simple (e.g., bicuspid aortic valve, isolated pulmonic stenosis) to the more complex (e.g., Ebstein's anomaly, AV valvular disease in single ventricle circulations) with details on natural history, diagnosis, and contemporary therapeutic approaches. Care for CHD patients requires collaborative effort between providers, both CHD-specialized and not, to achieve optimal patient outcomes.
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Affiliation(s)
- Joshua M Saef
- Division of Cardiology, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Joanna Ghobrial
- Division of Cardiology, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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Saoussen A, Sana O, Kaouther H, Hela M, Fatma O. Electocardiographic features in Ebstein's disease. LA TUNISIE MEDICALE 2021; 99:614-622. [PMID: 35244913 PMCID: PMC8795996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Ebstein's disease (ED) is a rare and heterogeneous congenital heart disease affecting the tricuspid valve and the right ventricle. Few studies have analyzed the electrocardiographic features of this disease. AIM To describe the electrocardiographic features observed in Ebstein's disease. METHODS We conducted a retrospective descriptive study that enrolled 26 patients followed for ED. RESULTS The mean age of discovery of the ME was 103.5±99 months [0-31 years]. The diagnosis of ME is most often made between 5 and 10 years. We noted right atrial hypertrophy in 11 patients (42%), right ventricular hypertrophy in half of the patients. Right axial deviation was noted in 11 patients (42%). Eight patients (30%) had wide QRS≥ 120 ms. Seven of these 8 patients (27%) had a fragmented QRS appearance. A right bandle block was noted in 22 patients (84%), it was a complete block in 7 cases (27%). A preexcitation was found in 6 patients (23%). The localization of accessory pathway was right postero-septal in all cases. Rhythmic disorders were noted in 9 patients (34%). It was a junctional tachycardia in 3 patients (11%), atrial flutter in 4 patients (15%) and atrial fibrillation in 2 patients (7%). A second degree atriventricular block was observed in one patient, it was Mobitz I type. Two cases of postoperative rhythm disturbances were recorded: paroxysmal atrial fibrillation and junctional tachycardia related to Wolf Parkinson White (WPW) syndrome. CONCLUSION Surface ECG in the ED is often pathological with prevalence of rhythm disturbances related to WPW syndrome.
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Abstract
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.
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Affiliation(s)
- Margaret M Fuchs
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
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Moore JP, Shivkumar K. Ebstein's anomaly: Structural insights for the interventional electrophysiologist. Heart Rhythm 2020; 17:1099-1100. [PMID: 32380287 DOI: 10.1016/j.hrthm.2020.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 04/20/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Jeremy P Moore
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, Los Angeles, California; Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, California; Division of Pediatric Cardiology, David Geffen School of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Kalyanam Shivkumar
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, Los Angeles, California; Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, California.
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Sánchez-Quintana D, Cabrera JA, Picazo-Angelin B, Cabrera A, Anderson RH. Histological examination of the potential arrhythmic substrates in the setting of Ebstein's malformation. J Anat 2020; 237:155-165. [PMID: 32115720 DOI: 10.1111/joa.13179] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 02/13/2020] [Accepted: 02/14/2020] [Indexed: 11/29/2022] Open
Abstract
Cardiac arrhythmias, notably Wolff-Parkinson-White syndrome, are known to represent a major issue in patients with Ebstein's malformation of the tricuspid valve. Abnormal conducting circuits, however, can also be produced by pathways extending either from the atrioventricular node or the ventricular components of the atrioventricular conduction axis, direct to the crest of the muscular ventricular septum. We hoped to provide further information on the potential presence of such pathways by investigations of six autopsied examples of Ebstein's malformation. All were studied by histological sectioning on the full extent of the atrioventricular conduction axis, with limited sectioning of the right atrioventricular junction supporting the inferior and antero-superior leaflets of the deformed tricuspid valve. We used the criteria established by Aschoff (Verhandlungen der Deutschen Gesellschaft für Pathologie, 14, 1910, 3) and Mönckeberg (Verhandlungen der Deutschen Gesellschaft für Pathologie, 14, 1910, 64) over a century ago to define abnormal connections across the atrioventricular junctions, as these definitions retain their validity for the identification of gross myocardial connections across the insulating tissues of the atrioventricular junctions. In one specimen, we found two discrete accessory myocardial connections across the parietal right atrioventricular junction. In all of the hearts, we found so-called nodoventricular connections, and in one heart we also observed a well-formed connection originating from the penetrating atrioventricular bundle. In addition to accessory myocardial connections across the parietal right atrioventricular junction, therefore, our histological findings demonstrate a potential role for direct connections between the atrioventricular conduction axis and the ventricular myocardium in the setting of Ebstein's malformation.
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Affiliation(s)
- Damián Sánchez-Quintana
- Department of Human Anatomy and Cell Biology, Faculty of Medicine, University of Extremadura, Badajoz, Spain
| | - José Angel Cabrera
- Unidad de Arritmias, Departamento de Cardiología, Hospital Universitario Quirón-Salud Madrid and Complejo Hospitalario Ruber Juan Bravo, Universidad Europea de Madrid, Madrid, Spain
| | - Beatriz Picazo-Angelin
- Sección de Cardiología Pediátrica, Departamento de Enfermedades Cardiovasculares, Hospita Regional Universitario Carlos Haya de Málaga, Málaga, Spain
| | | | - Robert H Anderson
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
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Marcondes L, Sanders SP, Del Nido PJ, Walsh EP. Examination of pathologic features of the right atrioventricular groove in hearts with Ebstein anomaly and correlation with arrhythmias. Heart Rhythm 2020; 17:1092-1098. [PMID: 31978592 DOI: 10.1016/j.hrthm.2020.01.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 01/07/2020] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Luciana Marcondes
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Stephen P Sanders
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pathology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Edward P Walsh
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.
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15
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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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16
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Pérez-Riera AR, Barbosa-Barros R, Daminello-Raimundo R, de Abreu LC, Nikus K. Electro-vectorcardiographic and electrophysiological aspects of Ebstein's anomaly. Ann Noninvasive Electrocardiol 2018; 24:e12590. [PMID: 30106198 DOI: 10.1111/anec.12590] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 06/17/2018] [Accepted: 07/25/2018] [Indexed: 11/26/2022] Open
Abstract
Ebstein's anomaly is a congenital heart disease where the most important anatomic feature is the inferior displacement of the tricuspid valve leaflets. Vectorcardiographic features are mainly forgotten and electrocardiographic features may be unrecognized by cardiologists handling adult patients.
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Affiliation(s)
- Andrés Ricardo Pérez-Riera
- Design of Studies and Scientific Writing Laboratory in the ABC School of Medicine, Santo Andre, Sao Paulo, Brazil
| | - Raimundo Barbosa-Barros
- Coronary Center of the Messejana Hospital Dr. Carlos Alberto Studart Gomes, Fortaleza, Ceara, Brazil
| | - Rodrigo Daminello-Raimundo
- Design of Studies and Scientific Writing Laboratory in the ABC School of Medicine, Santo Andre, Sao Paulo, Brazil
| | - Luiz Carlos de Abreu
- Design of Studies and Scientific Writing Laboratory in the ABC School of Medicine, Santo Andre, Sao Paulo, Brazil
| | - Kjell Nikus
- Heart Center, Faculty of Medicine and Life Sciences, Tampere University Hospital, University of Tampere, Tampere, Finland
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Kumareswaran R, Frankel DS. Wide complex tachycardia in a patient with Ebstein's anomaly. J Cardiovasc Electrophysiol 2018; 29:1321-1324. [PMID: 29722467 DOI: 10.1111/jce.13624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 04/23/2018] [Accepted: 04/26/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Ramanan Kumareswaran
- Cardiovascular Division, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - David S Frankel
- Cardiovascular Division, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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18
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Wu MH, Lu CW, Chen HC, Kao FY, Huang SK. Adult Congenital Heart Disease in a Nationwide Population 2000-2014: Epidemiological Trends, Arrhythmia, and Standardized Mortality Ratio. J Am Heart Assoc 2018; 7:JAHA.117.007907. [PMID: 29437602 PMCID: PMC5850200 DOI: 10.1161/jaha.117.007907] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The adult congenital heart disease (ACHD) population will grow with medical advances, but data are limited. We investigated the epidemiological profile of ACHD in Taiwan, a country with a congenital heart disease program since 1955, population of 23 million, and easily accessible high-standard medical care. METHODS AND RESULTS ACHD patients, born after 1954, were identified from the nationwide database 2000-2014. The ACHD prevalence in the population aged 18 to 59 was 140.53, 157.08, 182.45, and 217.00 per 100 000 in 2000, 2005, 2010, and 2014, respectively (increasing time trend, P<0.0001). Percentage of severe ACHD also increased over time (P<0.0001) and was 11.70% in 2014. The 5 leading ACHD diagnoses were ventricular septal defect, secundum atrial septal defect, patent ductus arteriosus, pulmonary stenosis, and tetralogy of Fallot. Freedom from tachyarrhythmia at age 50 years was 0.574 and 0.710 for severe and simple ACHD, respectively. Cardiac causes accounted for the majority of deaths, followed by malignancy in simple ACHD and external causes/sudden death/out-of-hospital death in severe ACHD patients. The proportion of unexpected death was 10%. Compared with the general population, the standardized mortality ratio was higher not only in severe ACHD (3.164; 95% confidence interval, 2.664-3.664), but also in women with simple ACHD (1.704; 95% confidence interval, 1.499-1.909), with a higher proportion of cardiac, labor, and sudden death as causes of death. CONCLUSIONS We demonstrated an increasing trend in ACHD prevalence and medical complexity. They are at risk of tachyarrhythmia, higher mortality, and unexpected deaths, suggesting a gap in their medical care.
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Affiliation(s)
- Mei-Hwan Wu
- Department of Pediatrics, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Chun-Wei Lu
- Department of Pediatrics, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Hui-Chi Chen
- Department of Obstetrics and Gynecology, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Feng-Yu Kao
- National Health Insurance Administration, Taipei, Taiwan
| | - San-Kuei Huang
- National Health Insurance Administration, Taipei, Taiwan
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19
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Abstract
Ebstein anomaly is a rare form of congenital heart disease with a uniquely high prevalence of arrhythmias. The most prevalent arrhythmia mechanisms are intrinsic to the underlying embryologic defects and may manifest at any stage. Current electrophysiological and surgical strategies are well equipped to address these arrhythmia mechanisms, yet despite available technology and a robust understanding of the mechanisms, these cases remain challenging. Surgical techniques that render arrhythmia substrates unreachable mandate comprehensive presurgical electrophysiological assessment and potential ablation. As the population ages, the need to address atrial fibrillation management and risk stratification for sudden cardiac death becomes ever more pertinent.
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Affiliation(s)
- Elizabeth D Sherwin
- Division of Cardiology, Children's National Health System, 111 Michigan Avenue NW, Washington, DC 20010, USA
| | - Dominic J Abrams
- Division of Cardiac Electrophysiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
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20
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Sanatani S, Cunningham T, Khairy P, Cohen MI, Hamilton RM, Ackerman MJ. The Current State and Future Potential of Pediatric and Congenital Electrophysiology. JACC Clin Electrophysiol 2017; 3:195-206. [PMID: 29759513 DOI: 10.1016/j.jacep.2017.01.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 01/11/2017] [Accepted: 01/16/2017] [Indexed: 10/19/2022]
Abstract
Pediatric electrophysiologists specialize in the diagnosis and treatment of rhythm abnormalities in pediatric, congenital heart disease, and inherited arrhythmia syndrome patients. The field originated out of the unique knowledge base that rhythm management in young patients required. In the 1970s, pediatric electrophysiology was recognized as a distinct cardiac subspecialty and it has evolved rapidly since that time. Despite the considerable growth in personnel, technology, and complexity that the field has undergone, further opportunities to progress pediatric electrophysiology exist. In this review, we highlight some of the clinical focus of pediatric and adult congenital electrophysiologists to date and identify areas within this specialty where the pediatric and congenital electrophysiology community could come together in order to drive improvements in rhythm management for patients.
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Affiliation(s)
- Shubhayan Sanatani
- Children's Heart Centre, British Columbia Children's Hospital, Vancouver, British Columbia, Canada.
| | - Taylor Cunningham
- Children's Heart Centre, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Paul Khairy
- Adult Congenital Heart Center, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Mitchell I Cohen
- Phoenix Children's Heart Center, Phoenix Children's Hospital, Phoenix, Arizona
| | - Robert M Hamilton
- Division of Cardiology, The Labatt Heart Centre, The Hospital for Sick Children, and Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Michael J Ackerman
- Departments of Cardiovascular Diseases, Pediatric and Adolescent Medicine, and Molecular Pharmacology and Experimental Therapeutics, Divisions of Heart Rhythm Services and Pediatric Cardiology, Windland Smith Rice Sudden Death Genomics Laboratory, Rochester, Minnesota
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21
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Hebe J. [Congenital heart defects in adulthood : Supraventricular tachycardia]. Herzschrittmacherther Elektrophysiol 2016; 27:110-21. [PMID: 27225166 DOI: 10.1007/s00399-016-0431-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 03/26/2016] [Indexed: 11/25/2022]
Abstract
Supraventricular tachycardia (SVT) based on congenital substrates, such as accessory pathways or dual atrioventricular nodal properties, occur with an increased probability linked to specific congenital heart defects (CHDs). In the literature, the association of Ebstein's anomaly with accessory pathways and with Mahaim fibers is most prominent. Compared with patients with otherwise normal hearts, the clinical relevance of SVT is typically more severe and therefore antiarrhythmia treatment is a necessity in many cases. Diagnostics, pharmaceutical treatment, and interventional therapy of SVT in patients with CHD are often demanding owing to anatomical, hemodynamic, and electro-anatomical peculiarities. The use of antiarrhythmic medication is often limited because of intolerable side effects and a lack of reliability in suppressing arrhythmia relapses in the long term. Within the last 15-20 years catheter ablation has thus become established as the first-choice treatment for SVT, even in patients with CHD. However, rates of success, recurrence, and risks are still inferior to those observed in patients with a normally functioning heart owing to the co-existence of vascular and cardiac anomalies, surgically created alterations, an unusual electro-anatomy, and lower tolerance to hemodynamic changes. Successful treatment in patients with CHDs and SVT requires a deep understanding and knowledge of all the disciplines discussed above and should only be practiced in dedicated centers, as patient numbers are small and therefore experience is limited.
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Affiliation(s)
- J Hebe
- Zentrum f. Elektrophysiologie Bremen, Am Klinikum Links der Weser, Sen.-Weßling-Str. 1, 28277, Bremen, Deutschland.
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22
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Clark BC, Berul CI. Arrhythmia diagnosis and management throughout life in congenital heart disease. Expert Rev Cardiovasc Ther 2016; 14:301-20. [PMID: 26642231 DOI: 10.1586/14779072.2016.1128826] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Arrhythmias, covering bradycardia and tachycardia, occur in association with congenital heart disease (CHD) and as a consequence of surgical repair. Symptomatic bradycardia can occur due to sinus node dysfunction or atrioventricular block secondary to either unrepaired CHD or surgical repair in the area of the conduction system. Tachyarrhythmias are common in repaired CHD due to scar formation, chamber distension or increased chamber pressure, all potentially leading to abnormal automaticity and heterogeneous conduction properties as a substrate for re-entry. Atrial arrhythmias occur more frequently, but ventricular tachyarrhythmias may be associated with an increased risk of sudden cardiac death, notably in patients with repaired tetralogy of Fallot or aortic stenosis. Defibrillator implantation provides life-saving electrical therapy for hemodynamically unstable arrhythmias. Ablation procedures with 3D electroanatomic mapping technology offer a viable alternative to pharmacologic or device therapy. Advances in electrophysiology have allowed for successful management of arrhythmias in patients with congenital heart disease.
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Affiliation(s)
- Bradley C Clark
- a Division of Cardiology , Children's National Health System , Washington , DC , USA.,b Department of Pediatrics , George Washington University School of Medicine , Washington , DC , USA
| | - Charles I Berul
- a Division of Cardiology , Children's National Health System , Washington , DC , USA.,b Department of Pediatrics , George Washington University School of Medicine , Washington , DC , USA
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23
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Aiello VD. Understanding the morphology of the specialized conduction tissues in congenitally malformed hearts. World J Pediatr Congenit Heart Surg 2015; 6:239-49. [PMID: 25870343 DOI: 10.1177/2150135115572376] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
To repair congenital heart defects by means of open heart surgery, the surgeon needs guidance about the location and distribution of the specialized conduction tissues, in order to avoid their direct damage and consequent conduction disturbances. This review addresses the historical steps of the morphological study of the conduction system in different types of heart defects, providing updated information about the subject.
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Affiliation(s)
- Vera Demarchi Aiello
- Laboratory of Pathology, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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24
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[Interventional treatment of tachyarrhythmia in children with congenital heart disease]. Herzschrittmacherther Elektrophysiol 2014; 25:172-82. [PMID: 25070933 DOI: 10.1007/s00399-014-0333-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
In children and adolescents with congenital heart disease (CHD) tachyarrhythmia occurs more frequently compared to patients with otherwise normal hearts. Arrhythmia substrates may be a natural part of certain congenital cardiac malformations or may result from long lasting myocardial deterioration as a result of CHD and/or cardiac surgery. Treatment of tachycardia is more frequently required even in early childhood, as the impact on quality of life, morbidity and mortality is higher due to an often reduced hemodynamic tolerance. Over the past 20 years interventional electrophysiology has been established as the therapy of choice for the majority of chronic or chronically recurrent tachycardia even in children with CHD. The success and risks of treatment are predominantly influenced by the individual expression of the cardiac anomaly and, if surgery has been performed, the highly variant postoperative anatomy. Introduction of 3D electroanatomical mapping systems together with modern cardiac imaging tools have significantly contributed to an improved understanding, particularly in postoperative tachycardia. Despite such progress, success rates are lower and recurrences are more frequent compared to patients without CHD. Complex and often multiple tachycardia courses account for the still limited performance as well as a frequently insufficient lesion formation with the use of radiofrequency current in the hypertrophic and fibrotic myocardium. Electrophysiology in children and adolescents, particularly if CHD is present, represents a highly specialized discipline requiring a high expertise in CHD, CHD surgery and cardiac electrophysiology and is ideally imbedded within an interdisciplinary cardiological and cardiosurgical setting.
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25
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Khairy P, Dore A, Talajic M, Dubuc M, Poirier N, Roy D, Mercier LA. Arrhythmias in adult congenital heart disease. Expert Rev Cardiovasc Ther 2014; 4:83-95. [PMID: 16375631 DOI: 10.1586/14779072.4.1.83] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Recent advances in pediatric cardiology and cardiac surgery have allowed a rapidly expanding population of patients with congenital heart disease to thrive well into their adult years. Often after prolonged uneventful clinical courses as children and adolescents, arrhythmias may surface later in life. These arrhythmias are a major source of morbidity. In addition, sudden death is the leading cause of mortality in adult patients with congenital heart disease. This review highlights the various types of brady- and tachyarrhythmias encountered in the more common forms of adult congenital heart disease and explores prognostic implications and therapeutic options.
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Affiliation(s)
- Paul Khairy
- Electrophysiology and Adult Congenital Heart Disease, Montreal Heart Institute, Montreal, QC H1T 1C8, Canada.
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26
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Park SJ, Chung S, On YK, Kim JS, Yang JH, Jun TG, Jang SY, Lee OJ, Song J, Kang IS, Huh J. Fragmented QRS complex in adult patients with Ebstein anomaly and its association with arrhythmic risk and the severity of the anomaly. Circ Arrhythm Electrophysiol 2013; 6:1148-55. [PMID: 24235269 DOI: 10.1161/circep.113.000636] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Fragmented QRS complex (fQRS) on 12-lead ECG, a marker of myocardial scar, is a predictor of arrhythmic events in patients with ischemic and nonischemic cardiomyopathy. We investigated whether the presence of fQRS is associated with the severity of the anomaly and with increased arrhythmic events in adult patients with Ebstein anomaly (EA). METHODS AND RESULTS In 51 consecutive adult patients with EA (median age, 37 years; 18 males), the severity index of EA calculated from echocardiographic data and clinical arrhythmic events were analyzed. The extent of fQRS in each patient was measured by counting the number of ECG leads showing fQRS. There were 35 (68.6%) patients with fQRS (fQRS group) and 16 (31.4%) patients without fQRS (non-fQRS group). fQRS was observed more frequently in the inferior (n=26) and precordial (n=25) leads versus the lateral leads (n=5). The patients in the fQRS group had a worse functional class, greater cardiothoracic ratios, more severe tricuspid regurgitation, larger atrialized right ventricular areas, higher EA severity scores, and more frequent arrhythmic events compared with those in the non-fQRS group. The atrialized right ventricular area showed a positive correlation with the fQRS extent (r=0.51; P<0.001). In multivariable Cox regression models, the presence of fQRS was independently associated with arrhythmic events (P=0.036). CONCLUSIONS Fragmented QRS on 12-lead ECG was associated with larger atrialized right ventricular area and an increased risk of arrhythmic events in adult patients with EA.
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Affiliation(s)
- Seung-Jung Park
- Departments of Medicine, Thoracic and Cardiovascular Surgery, and Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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27
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Escudero C, Khairy P, Sanatani S. Electrophysiologic Considerations in Congenital Heart Disease and Their Relationship to Heart Failure. Can J Cardiol 2013; 29:821-9. [DOI: 10.1016/j.cjca.2013.02.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 02/14/2013] [Accepted: 02/20/2013] [Indexed: 10/26/2022] Open
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28
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Jensen B, van den Berg G, van den Doel R, Oostra RJ, Wang T, Moorman AFM. Development of the hearts of lizards and snakes and perspectives to cardiac evolution. PLoS One 2013; 8:e63651. [PMID: 23755108 PMCID: PMC3673951 DOI: 10.1371/journal.pone.0063651] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 04/04/2013] [Indexed: 12/16/2022] Open
Abstract
Birds and mammals both developed high performance hearts from a heart that must have been reptile-like and the hearts of extant reptiles have an unmatched variability in design. Yet, studies on cardiac development in reptiles are largely old and further studies are much needed as reptiles are starting to become used in molecular studies. We studied the growth of cardiac compartments and changes in morphology principally in the model organism corn snake (Pantherophis guttatus), but also in the genotyped anole (Anolis carolinenis and A. sagrei) and the Philippine sailfin lizard (Hydrosaurus pustulatus). Structures and chambers of the formed heart were traced back in development and annotated in interactive 3D pdfs. In the corn snake, we found that the ventricle and atria grow exponentially, whereas the myocardial volumes of the atrioventricular canal and the muscular outflow tract are stable. Ventricular development occurs, as in other amniotes, by an early growth at the outer curvature and later, and in parallel, by incorporation of the muscular outflow tract. With the exception of the late completion of the atrial septum, the adult design of the squamate heart is essentially reached halfway through development. This design strongly resembles the developing hearts of human, mouse and chicken around the time of initial ventricular septation. Subsequent to this stage, and in contrast to the squamates, hearts of endothermic vertebrates completely septate their ventricles, develop an insulating atrioventricular plane, shift and expand their atrioventricular canal toward the right and incorporate the systemic and pulmonary venous myocardium into the atria.
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Affiliation(s)
- Bjarke Jensen
- Department of Bioscience-Zoophysiology, Aarhus University, Aarhus, Denmark.
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29
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Radojevic J, Inuzuka R, Alonso-Gonzalez R, Borgia F, Giannakoulas G, Prapa M, Liodakis E, Li W, Swan L, Diller GP, Dimopoulos K, Gatzoulis MA. Peak oxygen uptake correlates with disease severity and predicts outcome in adult patients with Ebstein's anomaly of the tricuspid valve. Int J Cardiol 2013; 163:305-308. [DOI: 10.1016/j.ijcard.2011.06.047] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Accepted: 06/06/2011] [Indexed: 10/18/2022]
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30
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Negoi RI, Ispas AT, Ghiorghiu I, Filipoiu F, Negoi I, Hostiuc M, Hostiuc S, Ginghina C. Complex Ebstein's Malformation: Defining Preoperative Cardiac Anatomy and Function. J Card Surg 2013; 28:70-81. [DOI: 10.1111/jocs.12032] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Ruxandra Irina Negoi
- Universityof Medicine and Pharmacy “Carol Davila”; Bucharest Romania
- “Prof. Dr. C.C. Iliescu” Institute of Cardiovascular Diseases; Bucharest Romania
| | | | - Ioana Ghiorghiu
- “Prof. Dr. C.C. Iliescu” Institute of Cardiovascular Diseases; Bucharest Romania
| | - Florin Filipoiu
- Universityof Medicine and Pharmacy “Carol Davila”; Bucharest Romania
| | - Ionut Negoi
- Universityof Medicine and Pharmacy “Carol Davila”; Bucharest Romania
| | - Mihaela Hostiuc
- Universityof Medicine and Pharmacy “Carol Davila”; Bucharest Romania
| | - Sorin Hostiuc
- Universityof Medicine and Pharmacy “Carol Davila”; Bucharest Romania
| | - Carmen Ginghina
- Universityof Medicine and Pharmacy “Carol Davila”; Bucharest Romania
- “Prof. Dr. C.C. Iliescu” Institute of Cardiovascular Diseases; Bucharest Romania
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Abstract
PURPOSE OF REVIEW In this review, we aim at presenting and discussing the cellular and molecular mechanisms of embryonic epicardial development that may underlie the origin of congenital heart disease (CHD). RECENT FINDINGS New discoveries on the multiple cell lineages that form part of the original pool of epicardial progenitors and the roles played by epicardial transcription factors and morphogens in the regulation of epicardial epithelial-to-mesenchymal transition, epicardial-derived cell (EPDCs) differentiation, coronary blood vessel morphogenesis and cardiac interstitium formation are presented in a comprehensive manner. SUMMARY We have provided evidence on the critical participation of epicardial cells and EPDCs in normal and abnormal cardiac development, suggesting the implication of defective epicardial development in various forms of CHD.
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Wessels A, van den Hoff MJB, Adamo RF, Phelps AL, Lockhart MM, Sauls K, Briggs LE, Norris RA, van Wijk B, Perez-Pomares JM, Dettman RW, Burch JBE. Epicardially derived fibroblasts preferentially contribute to the parietal leaflets of the atrioventricular valves in the murine heart. Dev Biol 2012; 366:111-24. [PMID: 22546693 DOI: 10.1016/j.ydbio.2012.04.020] [Citation(s) in RCA: 174] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2011] [Revised: 04/11/2012] [Accepted: 04/16/2012] [Indexed: 12/27/2022]
Abstract
The importance of the epicardium for myocardial and valvuloseptal development has been well established; perturbation of epicardial development results in cardiac abnormalities, including thinning of the ventricular myocardial wall and malformations of the atrioventricular valvuloseptal complex. To determine the spatiotemporal contribution of epicardially derived cells to the developing fibroblast population in the heart, we have used a mWt1/IRES/GFP-Cre mouse to trace the fate of EPDCs from embryonic day (ED)10 until birth. EPDCs begin to populate the compact ventricular myocardium around ED12. The migration of epicardially derived fibroblasts toward the interface between compact and trabecular myocardium is completed around ED14. Remarkably, epicardially derived fibroblasts do not migrate into the trabecular myocardium until after ED17. Migration of EPDCs into the atrioventricular cushion mesenchyme commences around ED12. As development progresses, the number of EPDCs increases significantly, specifically in the leaflets which derive from the lateral atrioventricular cushions. In these developing leaflets the epicardially derived fibroblasts eventually largely replace the endocardially derived cells. Importantly, the contribution of EPDCs to the leaflets derived from the major AV cushions is very limited. The differential contribution of EPDCs to the various leaflets of the atrioventricular valves provides a new paradigm in valve development and could lead to new insights into the pathogenesis of abnormalities that preferentially affect individual components of this region of the heart. The notion that there is a significant difference in the contribution of epicardially and endocardially derived cells to the individual leaflets of the atrioventricular valves has also important pragmatic consequences for the use of endocardial and epicardial cre-mouse models in studies of heart development.
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Affiliation(s)
- Andy Wessels
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, USA.
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Aanhaanen WTJ, Moorman AFM, Christoffels VM. Origin and development of the atrioventricular myocardial lineage: insight into the development of accessory pathways. ACTA ACUST UNITED AC 2011; 91:565-77. [PMID: 21630423 DOI: 10.1002/bdra.20826] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Revised: 03/11/2011] [Accepted: 03/14/2011] [Indexed: 12/16/2022]
Abstract
Defects originating from the atrioventricular canal region are part of a wide spectrum of congenital cardiovascular malformations that frequently affect newborns. These defects include partial or complete atrioventricular septal defects, atrioventricular valve defects, and arrhythmias, such as atrioventricular re-entry tachycardia, atrioventricular nodal block, and ventricular preexcitation. Insight into the cellular origin of the atrioventricular canal myocardium and the molecular mechanisms that control its development will aid in the understanding of the etiology of the atrioventricular defects. This review discusses current knowledge concerning the origin and fate of the atrioventricular canal myocardium, the molecular mechanisms that determine its specification and differentiation, and its role in the development of certain malformations such as those that underlie ventricular preexcitation.
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Affiliation(s)
- Wim T J Aanhaanen
- Heart Failure Research Center, Academic Medical Center, Meibergdreef 15, Amsterdam, The Netherlands
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Sánchez-Quintana D, Picazo-Angelín B, Cabrera A, Murillo M, Cabrera JA. Koch's triangle and the atrioventricular node in Ebstein's anomaly: implications for catheter ablation. Rev Esp Cardiol 2010; 63:660-7. [PMID: 20515623 DOI: 10.1016/s1885-5857(10)70140-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION AND OBJECTIVES The development of ablation techniques for supraventricular arrhythmias in patients with Ebstein's anomaly have led to a need for better understanding of the morphology of the triangle of Koch and the position of the atrioventricular (AV) node in this structure. METHODS The study involved 17 human hearts: 11 with Ebstein's anomaly (age range: 37 weeks' gestation to 1 week after birth) and 6 structurally normal hearts (age range: 35 weeks' gestation to 2 days after birth). The area of the triangle of Koch was calculated and the length of the AV node and the bundle of His were measured. RESULTS The area of the triangle of Koch was significantly smaller in specimens with Ebstein's anomaly than in control specimens (17.5+/-4.5 mm2 vs. 25.5+/-6.5 mm2; P< .05). The length of the AV node and its extensions were similar in hearts with Ebstein's anomaly and normal hearts. The AV node was displaced towards the base of the triangle in 73% of specimens with Ebstein's anomaly, and the inferior extensions reached the level of the cavotricuspid isthmus. In 91% of specimens with Ebstein's anomaly, the entry of the His bundle occurred before the apex of the triangle was reached and its length was shorter. CONCLUSIONS Morphologic findings in this study indicate that performing an ablation procedure close to the base of the triangle of Koch in patients with Ebstein's anomaly could result in AV nodal block.
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Affiliation(s)
- Damián Sánchez-Quintana
- Departamento de Anatomía y Biología Celular, Universidad de Extremadura, Facultad de Medicina, Badajoz, España.
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Sánchez-Quintana D, Picazo-Angelín B, Cabrera A, Murillo M, Cabrera JÁ. El triángulo de Koch y el nodo AV en la anomalía de Ebstein: implicaciones en la ablación con catéter. Rev Esp Cardiol 2010. [DOI: 10.1016/s0300-8932(10)70158-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ebstein anomaly of the tricuspid valve, atrial septal defect, and severe right ventricular dysfunction in an adult: transesophageal echocardiographic images. Anesth Analg 2010; 110:719-20; discussion 721. [PMID: 20042447 DOI: 10.1213/ane.0b013e3181cb3f1b] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Khairy P, Balaji S. Cardiac arrhythmias in congenital heart diseases. Indian Pacing Electrophysiol J 2009; 9:299-317. [PMID: 19898654 PMCID: PMC2766579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Arrhythmias figure prominently among the complications encountered in the varied and diverse population of patients with congenital heart disease, and are the leading cause of morbidity and mortality. The incidence generally increases as the patient ages, with multifactorial predisposing features that may include congenitally malformed or displaced conduction systems, altered hemodynamics, mechanical or hypoxic stress, and residual or postoperative sequelae. The safe and effective management of arrhythmias in congenital heart disease requires a thorough appreciation for conduction system variants, arrhythmia mechanisms, underlying anatomy, and associated physiology. We, therefore, begin this review by presenting the scope of the problem, outlining therapeutic options, and summarizing congenital heart disease-related conduction system anomalies associated with disorders of the sinus node and AV conduction system. Arrhythmias encountered in common forms of congenital heart disease are subsequently discussed. In so doing, we touch upon issues related to risk stratification for sudden death, implantable cardiac devices, catheter ablation, and adjuvant surgical therapy.
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Affiliation(s)
- Paul Khairy
- Adult Congenital Heart Center and Electrophysiology Service, Montreal Heart Institute, University of Montreal, Montreal, QC, Canada
| | - Seshadri Balaji
- Division of Pediatric Cardiology, Department of Pediatrics, Oregon Health & Science University, Portland, OR, USA
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Barbara DW, Edwards WD, Connolly HM, Dearani JA. Surgical pathology of 104 tricuspid valves (2000–2005) with classic right-sided Ebstein's malformation. Cardiovasc Pathol 2008; 17:166-71. [DOI: 10.1016/j.carpath.2007.07.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2007] [Revised: 07/09/2007] [Accepted: 07/19/2007] [Indexed: 11/28/2022] Open
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Kolditz DP, Wijffels MCEF, Blom NA, van der Laarse A, Hahurij ND, Lie-Venema H, Markwald RR, Poelmann RE, Schalij MJ, Gittenberger-de Groot AC. Epicardium-derived cells in development of annulus fibrosis and persistence of accessory pathways. Circulation 2008; 117:1508-17. [PMID: 18332266 DOI: 10.1161/circulationaha.107.726315] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND The developmental mechanisms underlying the persistence of myocardial accessory atrioventricular pathways (APs) that bypass the annulus fibrosis are mainly unknown. In the present study, we investigated the role of epicardium-derived cells (EPDCs) in annulus fibrosis formation and the occurrence of APs. METHODS AND RESULTS EPDC migration was mechanically inhibited by in ovo microsurgery in quail embryos. In ovo ECGs were recorded in wild-type (n=12) and EPDC-inhibited (n=12) hearts at Hamburger-Hamilton (HH) stages 38 to 42. Subsequently, in these EPDC-inhibited hearts (n=12) and in additional wild-type hearts (n=45; HH 38-42), ex ovo extracellular electrograms were recorded. Electrophysiological data were correlated with differentiation markers for cardiomyocytes (MLC2a) and fibroblasts (periostin). In ovo ECGs showed significantly shorter PR intervals in EPDC-inhibited hearts (45+/-10 ms) than in wild-type hearts (55+/-8 ms, 95% CI 50 to 60 ms, P=0.030), whereas the QRS durations were significantly longer in EPDC-inhibited hearts (29+/-14 versus 19+/-2 ms, 95% CI 18 to 21 ms, P=0.011). Furthermore, ex ovo extracellular electrograms (HH 38-42) displayed base-first ventricular activation in 44% (20/45) of wild-type hearts, whereas in all EPDC-inhibited hearts (100%, 12/12), the ventricular base was activated first (P<0.001). Small periostin- and MLC2a-positive APs were found mainly in the posteroseptal region of both wild-type and EPDC-inhibited hearts. Interestingly, in all (n=10) EPDC-inhibited hearts, additional large periostin-negative and MLC2a-positive APs were found in the right and left lateral free wall coursing through marked isolation defects in the annulus fibrosis until the last stages of embryonic development. CONCLUSIONS EPDCs play an important role in annulus fibrosis formation. EPDC outgrowth inhibition may result in marked defects in the fibrous annulus with persistence of large APs, which results in ventricular preexcitation on ECG. These APs may provide a substrate for postnatally persistent reentrant arrhythmias.
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Affiliation(s)
- Denise P Kolditz
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, PO Box 9600, 2300 RC, Leiden, The Netherlands
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Häussler A, Prêtre R. Surgical correction of Ebstein anomaly: the Zurich approach. Multimed Man Cardiothorac Surg 2008; 2008:mmcts.2006.002428. [PMID: 24415366 DOI: 10.1510/mmcts.2006.002428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Ebstein's anomaly is a congenital defect primarily due to a failed-development of the tricuspid valve. The defect affects significantly surrounding structures (conducting tissue, right atrium and ventricle), which often need concomitant correction. We have extended our techniques for the repair of conventional atrio-ventricular valve insufficiency to this specific pathology. The video sequences show the repair of a severe form of Ebstein's anomaly with extensive mobilisation of the displaced leaflets and creation of a subvalvular apparatus with artificial chordae. Because of the absence of arrhythmia, the adjunction of ablation surgery to abnormal atrio-ventricular pathways was not necessary in this case and is not demonstrated in the videos.
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Affiliation(s)
- Achim Häussler
- Division of Pediatric Cardiovascular Surgery, University and Children Hospital Zürich, Steinwiesstrasse 75, CH-8032 Zurich, Switzerland
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Affiliation(s)
- Paul Khairy
- From the Adult Congenital Heart Center and Electrophysiology Service (P.K.), Montreal Heart Institute, University of Montreal, and the McGill Adult Unit for Congenital Heart Disease Excellence (MAUDE Unit) (A.J.M.), Montreal, Canada
| | - Ariane J. Marelli
- From the Adult Congenital Heart Center and Electrophysiology Service (P.K.), Montreal Heart Institute, University of Montreal, and the McGill Adult Unit for Congenital Heart Disease Excellence (MAUDE Unit) (A.J.M.), Montreal, Canada
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Reemtsen BL, Fagan BT, Wells WJ, Starnes VA. Current surgical therapy for Ebstein anomaly in neonates. J Thorac Cardiovasc Surg 2006; 132:1285-90. [PMID: 17140943 DOI: 10.1016/j.jtcvs.2006.08.044] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2006] [Revised: 07/19/2006] [Accepted: 08/11/2006] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Neonates with profound heart failure resulting from Ebstein anomaly have historically had poor outcomes. We report our institutional experience with the surgical management of Ebstein anomaly in severely symptomatic neonates. METHODS A retrospective review of all patients (n = 16) undergoing neonatal intervention for Ebstein anomaly between 1992 and 2005 has been carried out. The indications for operation were overt heart failure, cyanosis, and acidosis associated with tricuspid regurgitation, depressed right ventricular function, and severe cardiomegaly. The magnitude of cardiac enlargement was assessed by cardiothoracic ratio and Great Ormond Street ratio (area of right atrium + atrialized right ventricle/area of functional left atrium + left ventricle). The operative strategy was first to assess for the possibility of tricuspid valve repair with or without right ventricular outflow tract reconstruction. If this was not feasible, then right ventricular exclusion was performed by oversewing the tricuspid valve with a pericardial patch. A reduction atrioplasty was done and, depending on the extent of the atrialized portion of the right ventricle, plication was performed. A modified Blalock-Taussig shunt provided pulmonary blood flow. This univentricular approach (Starnes procedure) evolved to include a fenestration in the tricuspid valve patch to allow for right ventricular decompression. Analysis included overall and group-specific survival as well as the testing of perioperative clinical, morphologic, and surgical variables for correlation with mortality and morbidity. RESULTS Mean age and weight at operation were 8 +/-10 days and 3.1 +/- 0.4 kg. Tricuspid valve repair was undertaken in 3 patients with 1 requiring conversion to right ventricular exclusion 3 months after the initial operation. In those with right ventricular exclusion, the tricuspid valve patch was fenestrated in 10 and nonfenestrated in 3. One patient had heart transplant as the initial procedure. There were 5 hospital deaths (31%) and no late deaths among the survivors. Survival in the cohort with a fenestrated tricuspid valve patch was 80% (8/10) versus 33% (1/3) for the nonfenestrated group. This difference did not reach statistical significance, although the trend seems clinically important. There was no difference in the cardiothoracic ratio (0.82 fenestrated vs 0.84 nonfenestrated: P = .802) or the Great Ormond Street ratio (1.2 fenestrated vs 1.02 nonfenestrated: P = .477) between the two groups. Among the 9 survivors of right ventricular exclusion, 3 have had completion of their Fontan, and all 9 have undergone a bidirectional Glenn procedure. All operations including homograft placement in the right ventricular outflow tract, whether during repair or during right ventricular exclusion, ended in death. CONCLUSION Right ventricular exclusion with a fenestrated tricuspid valve patch combined with right atrioplasty and right ventriculoplasty and a Blalock-Taussig shunt (Starnes procedure) has provided effective palliation for neonates presenting with critical Ebstein anomaly and a tricuspid valve that cannot be repaired.
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Affiliation(s)
- Brian L Reemtsen
- Children's Hospital Los Angeles and the Keck School of Medicine, Los Angeles, Calif 90027, USA.
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Blomström-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ, Campbell WB, Haines DE, Kuck KH, Lerman BB, Miller DD, Shaeffer CW, Stevenson WG, Tomaselli GF, Antman EM, Smith SC, Alpert JS, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Hiratzka LF, Hunt SA, Jacobs AK, Russell RO, Priori SG, Blanc JJ, Budaj A, Burgos EF, Cowie M, Deckers JW, Garcia MAA, Klein WW, Lekakis J, Lindahl B, Mazzotta G, Morais JCA, Oto A, Smiseth O, Trappe HJ. ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary. Circulation 2003; 108:1871-909. [PMID: 14557344 DOI: 10.1161/01.cir.0000091380.04100.84] [Citation(s) in RCA: 312] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Blomström-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ, Campbell WB, Haines DE, Kuck KH, Lerman BB, Miller DD, Shaeffer CW, Stevenson WG, Tomaselli GF, Antman EM, Smith SC, Alpert JS, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Hiratzka LF, Hunt SA, Jacobs AK, Russell RO, Priori SG, Blanc JJ, Budaj A, Burgos EF, Cowie M, Deckers JW, Garcia MAA, Klein WW, Lekakis J, Lindahl B, Mazzotta G, Morais JCA, Oto A, Smiseth O, Trappe HJ. ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias∗∗This document does not cover atrial fibrillation; atrial fibrillation is covered in the ACC/AHA/ESC guidelines on the management of patients with atrial fibrillation found on the ACC, AHA, and ESC Web sites.—executive summary. J Am Coll Cardiol 2003; 42:1493-531. [PMID: 14563598 DOI: 10.1016/j.jacc.2003.08.013] [Citation(s) in RCA: 379] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
MESH Headings
- Anti-Arrhythmia Agents/therapeutic use
- Atrial Flutter/diagnosis
- Atrial Flutter/therapy
- Cardiac Pacing, Artificial
- Catheter Ablation
- Costs and Cost Analysis
- Diagnosis, Differential
- Electrocardiography
- Electrophysiologic Techniques, Cardiac
- Female
- Heart Conduction System/physiopathology
- Heart Defects, Congenital/complications
- Humans
- Male
- Pregnancy
- Pregnancy Complications, Cardiovascular/diagnosis
- Pregnancy Complications, Cardiovascular/therapy
- Quality of Life
- Tachycardia, Atrioventricular Nodal Reentry/diagnosis
- Tachycardia, Atrioventricular Nodal Reentry/therapy
- Tachycardia, Ectopic Atrial/diagnosis
- Tachycardia, Ectopic Atrial/therapy
- Tachycardia, Ectopic Junctional/diagnosis
- Tachycardia, Ectopic Junctional/therapy
- Tachycardia, Paroxysmal/diagnosis
- Tachycardia, Paroxysmal/therapy
- Tachycardia, Sinus/diagnosis
- Tachycardia, Sinus/therapy
- Tachycardia, Supraventricular/diagnosis
- Tachycardia, Supraventricular/epidemiology
- Tachycardia, Supraventricular/therapy
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Ansari A, Goltz D, McCarthy KP, Cook A, Ho SY. The conduction system in hearts with pulmonary atresia and intact ventricular septum. Ann Thorac Surg 2003; 75:1502-5. [PMID: 12735569 DOI: 10.1016/s0003-4975(02)04896-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Although a regular course of the conduction system is anticipated in hearts with pulmonary atresia and intact ventricular septum (PAIVS), it has never been demonstrated anatomically. In view of one of the surgical options in repair being debulking of the right ventricular wall, it is important to establish the location of the major conduction pathways. METHODS Four hearts belonging to fetuses aged 18, 20, 22, and 29 weeks were examined. Entire hearts were serially sectioned and step sections were stained. The sinus node and atrioventricular conduction bundles were identified and their locations described. RESULTS The conduction system in hearts with PAIVS is similar to that in normal hearts, although there was a minor variation in one of them. This was a heart affected by Ebstein malformation of the tricuspid valve. In this case, the right bundle branch terminated abruptly soon after its origin. CONCLUSIONS Confirmation of the regular course of the cardiac conduction system is important to the development of strategies for surgical repair of PAIVS.
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Affiliation(s)
- Aneel Ansari
- Department of Paediatrics, Imperial College, Faculty of Medicine, London, United Kingdom
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Knott-Craig CJ, Overholt ED, Ward KE, Ringewald JM, Baker SS, Razook JD. Repair of Ebstein's anomaly in the symptomatic neonate: an evolution of technique with 7-year follow-up. Ann Thorac Surg 2002; 73:1786-92; discussion 1792-3. [PMID: 12078770 DOI: 10.1016/s0003-4975(02)03507-5] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Ebstein's anomaly in the severely symptomatic neonate is usually fatal. Until recently, successful repair has not been reported and various palliative operations have been associated with prohibitive mortality. Recently, we published our initial results with biventricular repair in 3 severely symptomatic neonates. We now update our experience with emphasis on the evolution of our surgical technique and the medium-term follow-up of these patients. METHODS Since 1994, 8 severely symptomatic neonates and young infants underwent biventricular repair by one surgeon. Six had Ebstein's anomaly and 2 had physiologically similar pathology with severe tricuspid valve dysplasia, cyanosis, and gross cardiomegaly. One Ebstein patient (2 months old) had undergone a Starnes operation elsewhere. Weight of the patients at operation ranged from 2.1 to 6.4 kg (mean 2.7 kg). Five patients had either anatomical (n = 3) or functional (n = 2) pulmonary atresia. Severe (4/4) tricuspid regurgitation was present in all except 1 (Starnes operation), and cardiothoracic ratio exceeded 0.85 in all patients. Echocardiography severity scores were >1.5 in 6 (grade 4/4) and 1.3 in 1 (grade 3/4). Repair consisted of tricuspid valve repair, reduction atrioplasty, relief of right ventricular outflow tract obstruction, partial closure of atrial septal defect, and correction of all associated cardiac defects. Technique of tricuspid valve repair evolved over time: 3 had Danielson-type repairs, 3 had DeVega-type repairs, and 2 had complex repairs. RESULTS One patient died in hospital: a 2.1 kg patient with tricuspid dysplasia, anatomical pulmonary atresia, and hypoplastic pulmonary arteries. The other 7 patients are all in functional class I and in sinus rhythm. Although 3 patients had symptomatic tachyarrhythmias before surgery, no child has experienced SVT after discharge. At recent echocardiography 4 patients had mild tricuspid regurgitation, and 2 had mild-moderate (2/4) tricuspid regurgitation. Three patients are now 7 years old, 2 are almost 2 years old, and the remaining 2 patients are 1 year old. CONCLUSIONS Surgical repair of the severely symptomatic neonate with Ebstein's anomaly is feasible and safe. The repair appears durable and with good medium-term outcome.
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Affiliation(s)
- Christopher J Knott-Craig
- Section of Thoracic and Cardiovascular Surgery, Children's Hospital at Oklahoma University Medical Center, Oklahoma City 73104, USA.
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Kim JS, Virágh S, Moorman AF, Anderson RH, Lamers WH. Development of the myocardium of the atrioventricular canal and the vestibular spine in the human heart. Circ Res 2001; 88:395-402. [PMID: 11230106 DOI: 10.1161/01.res.88.4.395] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
To establish the morphogenetic mechanisms underlying formation and separation of the atrioventricular connections, we studied the remodeling of the myocardium of the atrioventricular canal and the extracardiac mesenchymal tissue of the vestibular spine in human embryonic hearts from 4.5 to 10 weeks of development. Septation of the atrioventricular junction is brought about by downgrowth of the primary atrial septum, fusion of the endocardial cushions, and forward expansion of the vestibular spine between atrial septum and cushions. The vestibular spine subsequently myocardializes to form the ventral rim of the oval fossa. The connection of the atrioventricular canal with the atria expands evenly. In contrast, the expression patterns of creatine kinase M and GlN2, markers for the atrioventricular and interventricular junctions, respectively, show that the junction of the canal with the right ventricle forms by local growth in the inner curvature of the heart. Growth of the caudal portion of the muscular ventricular septum to make contact with the inferior endocardial cushion occurs only after the canal has expanded rightward. The atrioventricular node develops from that part of the canal myocardium that retains its continuity with the ventricular myocardium.
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Affiliation(s)
- J S Kim
- Department of Anatomy & Embryology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Bertram H, Bökenkamp R, Peuster M, Hausdorf G, Paul T. Coronary artery stenosis after radiofrequency catheter ablation of accessory atrioventricular pathways in children with Ebstein's malformation. Circulation 2001; 103:538-43. [PMID: 11157719 DOI: 10.1161/01.cir.103.4.538] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Complications concerning the coronary arteries that are directly related to radiofrequency catheter ablation procedures have not been reported in children. Coronary artery lesions, however, have been demonstrated after the endocardial application of radiofrequency current in young animals. METHODS AND RESULTS Two boys with Ebstein's anomaly of the tricuspid valve developed clinically asymptomatic coronary artery stenosis after radiofrequency catheter ablation of right-sided accessory atrioventricular pathways with standard catheter technology. CONCLUSIONS The complication of coronary artery stenosis demonstrates a substantial risk after right atrial free wall radiofrequency current application in children. The risk of late coronary alterations should be considered when the use of catheter ablation procedures to young patients is proposed.
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Affiliation(s)
- H Bertram
- Department of Pediatric Cardiology and Pediatric Intensive Care, Hannover Medical School, Hannover, Germany.
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