A case of Ebstein's anomaly surviving to the age of 79

Color Doppler flow pattern in antenatal diagnosis of unguarded tricuspid valve

We describe an antenatally diagnosed case of unguarded tricuspid valve in a 15-week fetus. Because of its rarity, the differentiation of this anomaly from other tricuspid valve dysplasias is difficult. Tricuspid regurgitation is the hallmark of Ebstein's anomaly and other tricuspid valve abnormalities, whereas in unguarded tricuspid orifice there is total absence of the valve, resulting in 'to and fro' flow across the right-sided chambers. The color Doppler flow pattern helps in differentiating this anomaly from others. The antenatal diagnosis was confirmed on autopsy.

The clinical profile of Ebstein's malformation as seen from the fetus to the adult in 52 patients

Ebstein's malformation of the tricuspid valve is a rare but complex congenital cardiac lesion characterised by a variable degree of dysplasia and displacement of the proximal attachments of its inferior and septal leaflets from the true atrioventricular junction. The aim of our retrospective study is to report the risk factors for mortality, and to determine the clinical profile as seen in 52 cases diagnosed in our service between 1978 and 2002, concentrating in particular on the outcome for the neonatal patient. There were 26 females and 26 males, and the age at presentation ranged from 30 weeks gestational age to 46 years. We found 23 associated cardiac anomalies in 20 cases. Of the patients, 11 patients (21%) died. Actuarial survival at 30 years was 65%. Predictors of death included fetal or neonatal presentation, presence of associated defects, a grade within the Celermajer index of 3 or 4, and a cardiothoracic ratio equal to or greater than 65%. The diagnosis was made in the neonatal period in 24 patients, nine of whom died. Of the 15 survivors, only 4 are free of symptoms. Surgical treatment was undertaken in 9 patients, with a mortality rate of 33% without late deaths, with all the survivors being in good condition. The mean period of follow-up for the 41 living patients was 16.5 years. An arrhythmia of variable severity appeared during the evolution of 27 patients (66%). At present, only 7 cases are in the functional class III or IV of the grading system of the New York Heart Association, but 25 patients (61%) needed some medical treatment, meanly for arrhythmic events. Thus, fetal and neonatal presentation of Ebstein's malformation is associated with a poor outcome. Moreover, the echocardiographic appearance, marked cardiomegaly, and the presence of associated lesions are all risk factors for mortality. Arrhythmia and need of medical treatment are common in older children and adults. Survival after surgical treatment is associated with a good outcome.

Radiofrequency current catheter ablation of accessory atrioventricular pathways in Ebstein's anomaly

BACKGROUND

In patients with Ebstein's anomaly, localization of accessory pathways (APs) may be impeded by abnormal local electrograms recorded along the atrialized right ventricle and by the presence of multiple APs. The impact of these factors on radiofrequency (RF) current catheter ablation of APs has not been evaluated yet.

METHODS AND RESULTS

Twenty-one patients with Ebstein's anomaly and reentrant atrioventricular tachycardias underwent electrophysiological evaluation and subsequent attempts at RF catheter ablation. Thirty-four right-sided APs were found, with 30 located along the atrialized ventricle. Local electrograms in this region were normal in 10 patients but fragmented in 11. Fragmented electrograms prevented the clear distinction between atrial and ventricular activation potentials as well as the identification of AP potentials. Right coronary artery mapping was performed in 7 patients. Abolition of all 26 APs was achieved in the 10 patients with normal local electrograms and in 6 of 11 patients with abnormal electrograms. Right coronary artery mapping allowed AP localization and ablation in 5 patients. In the 5 patients with abnormal electrograms and a total of 8 APs, 6 APs could not be ablated. Unsuccessfully treated patients received antiarrhythmic drugs. During 22 +/- 12 months of follow-up, 5 patients had clinical recurrences, including 4 who had undergone a successful RF procedure.

CONCLUSIONS

In patients with Ebstein's anomaly and reentrant atrioventricular tachycardias, factors likely to account for failure of RF catheter ablation include an AP located along the atrialized right ventricle and the abnormal morphology of endocardial activation potentials generated in this region.

Ebstein's anomaly: presentation and outcome from fetus to adult

OBJECTIVES

This study was conducted to investigate the presentation and outcome of patients with Ebstein's anomaly of the tricuspid valve.

BACKGROUND

Ebstin's anomaly may present at any age and has a highly variable clinical course. Previous natural history studies have been based on clinical and angiographic diagnosis and have included mainly older children and adults. Echocardiography, however, has facilitated fetal and neonatal diagnosis so that the natural history needs to be redefined.

METHODS

We reviewed 220 cases of Ebstein's anomaly presenting from fetal to adult life between 1958 and 1991, with 1 to 34 years of follow-up.

RESULTS

The most common presentation in each age group was abnormal routine prenatal scan for fetuses (86%), cyanosis for neonates (74%), heart failure for infants (43%), incidental murmur for children (63%) and arrhythmia for adolescents and adults (42%). Early presentation was frequently associated with other cardiac lesions, usually pulmonary stenosis or atresia. Surgery was undertaken at some stage in 86 (39%) of the 220 patients. Actuarial survival for all liveborn patients was 67% at 1 year and 59% at 10 years. There were 58 deaths, including 26 from heart failure, 19 perioperative and 8 sudden. Predictors of death included echocardiographic grade of severity at presentation (relative risk 2.7 for each increase in grade, 95% confidence limits 1.6 to 4.6), fetal presentation (6.9, confidence limits 1.6 to 16.5) and right ventricular outflow tract obstruction (2.1, confidence limits 1.1 to 4.4). Morbidity was mainly related to arrhythmias and late hemodynamic deterioration. Of 155 survivors, 129 (83%) were in functional class 1 and 104 (67%) were receiving no medical therapy.

CONCLUSIONS

In Ebstein's anomaly, fetal and neonatal presentation is associated with a poor outcome and can be predicted by the echocardiographic appearance and presence of associated lesions. In older children and adults, incidental findings and arrhythmia are common and the long-term outcome is superior.

Morbid anatomy in neonates with Ebstein's anomaly of the tricuspid valve: pathophysiologic and clinical implications

The hearts of six neonates with Ebstein's anomaly of the tricuspid valve who died in the 1st month of life were compared with hearts of six age- and size-matched control neonates. All six hearts had morphologically severe disease with gross right atrial dilation and marked apical displacement of the tricuspid valve. All had a secundum atrial septal defect and four had additional cardiac lesions (pulmonary atresia in two, ventricular septal defect in two). There was significant thinning of the right ventricular free wall distal to the tricuspid valve (3 +/- 0.2 mm vs. control 4.2 +/- 0.2, p less than 0.01) and right ventricular fiber diameter was reduced (7.2 +/- 0.3 microns vs. control 11.4 +/- 0.6, p less than 0.001). The fibrous tissue content of both right and left ventricular free walls was increased (right, 29.3 +/- 2.6% vs. control 8.7 +/- 1.1, p less than 0.001; left, 23.2 +/- 1.5% vs. control 8.5 +/- 0.7%, p less than 0.001). Although the right ventricular abnormalities might be explained by hemodynamic stress in utero, abnormalities of the left ventricular free wall suggest that either genetic or nonhemodynamic environmental factors are involved in the morphogenesis of this condition. Increased right and left ventricular fibrosis may contribute to the poor early outcome in this group and may predispose to late complications, such as subnormal exercise performance, hemodynamic deterioration or late sudden death that may occur in patients with Ebstein's anomaly who survive the neonatal period.

Outcome in neonates with Ebstein's anomaly

The presentation and outcome of 50 patients with neonatal Ebstein's anomaly seen from 1961 to 1990 were reviewed. The majority (88%) presented in the 1st 3 days of life; cyanosis (80%) was the most common presenting feature. Associated defects, present in 27 infants (54%), included pulmonary stenosis in 11 and atresia in 7. Nine patients (18%) died in the neonatal period; there were 15 late deaths (due to hemodynamic deterioration in 9, sudden death in 5 and a noncardiac cause in 1) at a mean age of 4.5 years (range 4 months to 19 years). Actuarial survival at 10 years was 61%. A new echocardiographic grade (1 to 4 in order of increasing severity of the defect) was devised with use of the ratio of the area of the right atrium and atrialized right ventricle to the area of the functional right ventricle and left heart chambers. Cardiac death occurred in 0 of 4 infants with grade 1, 1 (10%) of 10 with grade 2, 4 (44%) of 9 with grade 3 and 5 (100%) of 5 with grade 4. In a multivariate analysis of clinical and investigational features at presentation, echocardiographic grade of severity was the best independent predictor of death. Neonates with Ebstein's anomaly have a high early mortality rate and those surviving the 1st month of life remain at high risk of late hemodynamic deterioration or sudden death. Echocardiographic grading of severity of the defect permits prognostic stratification.

Surgical intervention in cases of Ebstein's anomaly. Abnormal origin and structure of the tricuspid valve

During the ten-year period 1972-81 four patients, two men and two women, with Ebstein's disease underwent operation at our institution. Their average age was 34. Central cyanosis at rest, clubbing and polycythaemia were the most common clinical features of the patients. Enlarged heart, a small pulmonary arterial arch and transluminal lung fields were seen in chest X-ray. Operative findings were a grossly enlarged right atrium and ventricle, the latter having a segment that was typically atrialized and thin-walled but was contracting synchronously with the true right ventricle, and a wide variation in the leaflets of the tricuspid valve and their origins. The atrial septal defect was small in all cases. Artificial heart valves (1 Cutter-Smeloff, 2 Björk-Shiley, 1 St. Jude) were used in the tricuspid reconstruction in addition to closure of the ASDs. One of the patients died postoperatively, the other three are doing well.

Left-sided anomalies in Ebstein's malformation of the tricuspid valve

A review of 34 autopsied cases with classical Ebstein's malformation of the tricuspid valves revealed 8 cases with left-sided anomalies. Among these, appearing in 1 case each, were aortic atresia and persistent common atrioventricular canal. The latter 2 conditions were dominant clinically. In the remaining 6 cases the left-sided anomalies were not apparent clinically and probably of no functional significance. These conditions were parachute mitral valve, bicuspid aortic valve, cor triatriatum and pulmonary stenosis, cleft mitral valve, stenosis of individual pulmonary veins, and prolapse of mitral valve.

Ebstein's anomaly of the tricuspid valve and prolapse of the mitral valve

The hearts from 10 necropsy patients with Ebstein's anomaly of the tricuspid valve were examined for abnormalities of the mitral valve. Five patients were under 1 year of age and none had an abnormal mitral valve. The other five patients were ages 18 to 72 years (mean 36 years); all had focal fibrous thickening of the mitral leaflets and three had prolapse of one or both mitral leaflets. Only one of the three patients with mitral valve prolapse had an atrial septal defect (secundum type), indicating that the association of mitral valve prolapse with Ebstein's anomaly is not due to the presence of an atrial septal defect.

Massive congenital tricuspid insufficiency in the newborn

Three cases of massive congenital tricuspid incompetence in the newborn are reported and discussed from diagnostic, pathologic and etiologic points of view. The diagnosis is important as cases have been reported with spontaneous resolution.

Surgical treatment of Ebstein's anomaly. Early and late results in seven consecutive cases

The surgical treatment of Ebstein's anomaly is discussed on the basis of our experience with 7 patients who underwent operation at this clinic during the last ten years. The age of the patients (2 males, 5 females) ranged from 17 to 47 years (mean 27 years) at the time of operation. Two patients were in functional class II and five in classes III or IV (N.Y.H.A.). The Wolff-Parkinson-White syndrome was concomitant in 2/7 cases and patent foramen ovale or atrial septal defect (ASD) with right-to-left shunt was present in 6/7 cases. The valvular anomaly was typical in 5 patients and stenosis of displaced tricuspid leaflets into right ventricular outflow region was detected in two patients. Tricuspid valve replacement (TVR) with disc valve prosthesis was performed in 5 patients (Björk-Shiley model in 4 cases, Kay-Shiley model in one) and tricuspid valve commissurotomy in two patients. All six patients with interatrial communication underwent closure of this communication simultaneously. One patient had concomitant epicardial mapping and attempted division of the anomalous conduction pathways was unsuccessful. This patient died on the 14th postoperative day from ventricular fibrillation. No other early or late mortality was recorded. Life-long anticoagulation therapy was introduced in all 5 patients with TVR. Thrombotic malfunction of the prosthetic valves necessitated re-operation and new prosthetic valve replacement in two patients 15 and 16 months after the first TVR. One of these patients had recurrent prosthetic thrombosis twice which was successfully treated with streptokinase. The other patient's prosthesis is functioning well 18 months after re-operation. All 6 long-term survivors were improved and remained in good condition, in functional class I, 1, 3, 3, 8, 9, and 10 years, respectively, after operation.

Clinical classification of Ebstein's anomaly

Twenty-six patients with Ebstein's anomaly were classified into three types according to their clinical features, heart catheterization data, angiocardiographic and anatomical findings which were obtained on surgery or autopsy. The hemodynamics in each type were discussed. 1. Tricuspid Stenosis Dominant Type. Eight patients, who were cyanotic and had severe symptoms, mild to moderate cardiomegaly, and the "double-ball sign" on angiocardiography were classified into this type. A pressure gradient across the tricuspid valve was demonstrated in 5 patients. 2. Tricuspid Insufficiency Dominant Type. Four cyanotic patients, who had mild symptoms despite the severe cardiomegaly were grouped into this type. The "double-ball sign" was found in all. In three patients, incompetent tricuspid valve was observed. Tricuspid insufficiency necessitates the volume overwork of the right atrium and the functioning right ventricle, resulting in severe dilatation. 3. Mild Type. Fourteen patients who showed no or mild cyanosis, no or mild symptoms, and mild to moderate cardiomegaly, were classified into this type. It is considered that the adequate cardiac output in these patients is attributable to the good function of the tricuspid valve.

Successful pregnancy in a patient with Ebstein's anomaly

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

Mild Ebstein's anomaly

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Ebstein's anomaly: discovered in a 75-year-old subject in the dissecting laboratory

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Low insertion of the tricuspid valve and tricuspid incompetence

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Ebstein's anomaly

Four cases of Ebstein's anomaly are described, revealing that the clinical features permit diagnosis in the majority of instances and that cardiac catheterization affords precise confirmation of the diagnosis. The occurrence of this anomaly in acyanotic adults is pointed out, and the similarity to acquired valvular rheumatic heart disease is stressed.