Mild Ebstein's anomaly

When lithium hurts: a look at Ebstein anomaly

Ebstein anomaly (EA) is a congenital defect of the tricuspid valve (TV) and the right ventricle (RV) in which the attachments of the septal and posterior valve leaflets are apically displaced. The latter creates 3 morphologic components inside the right heart, namely the right atrium proper, the atrialized RV, and the functional RV. This rare anomaly accounts for <1.5% of all congenital heart diseases. The current opinion among authors is that it is a genetically heterogeneous condition caused by failure of delamination of the TV leaflets from the underlying myocardium and the interventricular septum. Its characteristic electrocardiographic findings include tall, broad, right atrial P waves, prolonged PR intervals, and deep Q waves in the right precordial leads. Echocardiography is currently the best technique for diagnosing this anomaly, although cardiac magnetic resonance imaging is also gaining traction as an alternative modality. The management strategies for EA correlate with the age of the patient, severity of the heart disease, and/or associated cardiac abnormalities. TV repair, rather than valve replacement, is preferred because of its favorable long-term prognosis. Nevertheless, a large, randomized study is still needed to compare the different valve repair techniques used in patients with EA.

Mitral valve billow and prolapse: a brief review at 45 years - with reference to : mitral valve billowing and prolapse : perspective at 25 years

Barlow's syndrome has become a regular, often-used and very often misused diagnosis. Its description followed extensive, prolonged and detailed clinical observation by JB Barlow and his co-workers. This major research effort was necessary because of the protean manifestations of the condition. The differentiation of Barlow's syndrome from other conditions with similar and sometimes identical symptoms requires clear and unambiguous criteria. These criteria were identified by penetrative clinical research. Consequently, it became possible to diagnose Barlow's syndrome with a high degree of specificity. Almost equally important were the gains made in understanding various conditions with similar symptoms but totally different management. An example of which, understanding some of the electrocardiographic patterns that emerge on effort in patients with ischaemic heart disease. Similarly, understanding mitral valve billow led to a greater knowledge of the entire pathophysiology of the mitral valve closure and important aspects of mitral regurgitation. Primary mitral valve billow, Barlow's syndrome, resulted from clinical research of the highest quality and has had a major application in clinical medicine.

First heart sound in Ebstein's anomaly: observations on the cause of wide splitting by echophonocardiographic studies before and after operative repair

Preoperative echophonocardiographic study of a 31 year old woman with Ebstein's anomaly and an atrial septal defect showed wide splitting of the first heart sound with an interval of 0.08 second between mitral valve and tricuspid valve closure. After application of the anterior tricuspid leaflet and anuloplasty, the mitral and tricuspid valves closed at the same time and there was a single first heart sound. These findings suggest that delayed tricuspid valve closure in Ebstein's anomaly is due to the abnormally large size and increased excursion of the anterior tricuspid leaflet rather than associated right bundle branch block or sluggish right ventricular contraction.

Prevalence of congenital heart disease in black schoolchildren of Soweto, Johannesburg

A survey conducted by cardiologists in Soweto, Johannesburg, provided an opportunity of assessing the frequency of congenital heart disease in black schoolchildren. Among 12,050 schoolchildren aged 2 to 18 years, 48 had a congenital heart defect, yielding a prevalence of 3.9 per 1000. Only in 2- to 6-year-old children did the prevalence exceed that of rheumatic heart disease. The distribution of the types of defects was largely similar to that reported in other surveys with a predominance (52%) of ventricular septal defects. Two unusual findings were the unexplained absence of persistent ductus arteriosus in these children, and the detection of 5 children with situs inversus (1 in 2410). In all but one child, the congenital heart defect was first discovered during the survey. Despite the limitations of a prevalence study, it can be concluded that congenital heart disease is at least as common in this South African black community as in Caucasians.

The problem of nonejection systolic clicks and associated mitral systolic murmurs: emphasis on the billowing mitral leaflet syndrome

Nonejection clicks and associated mitral systolic murmurs are common in routine cardiologic practice and can result from multiple etiologic factors affecting the complex mitral valve mechanism. Such factors include a specific syndrome the essential feature of which is that the mitral leaflets or part thereof, primarily the posterior one, are voluminous. The syndrome has stimulated widespread interest and study during the last decade and various descriptive terms, including the "billowing mitral leaflet syndrome" (BMLS), have been applied to it. A familial occurrence of the BMLS may be detected and symptoms include chest pain, palpitations, syncope, and anxiety. Arrhythmias, conduction defects, and ECG abnormalities which mimic occlusive coronary artery disease are important features which remain ill understood. It is suggested that there is a possible relationship between the so-called "athlete's heart" and the BMLS. We also postulate that the entity of acute myocardial infarction without demonstrable occlusive coronary artery disease is, in at least some instances, a complication of the BMLS-possibly on the basis of coronary spasm. More severe mitral regurgitation, infective endocarditis, or, rarely, sudden death may supervene in the BMLS but we conclude, from published data and our own experience, that the prognosis is generally good.

Tricuspid component of first heart sound

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Echocardiography in the diagnosis of Ebstein's anomaly of the tricuspid valve

Nineteen patients aged between 4 days and 40 years with Ebstein's anomaly of the tricuspid valve have been examined with echocardiography. The diagnosis was verified with angiocardiography in all but one patient. The results at echocardiography are compared with those found in some other patients where an echo from the anterior tricuspid leaflet could be obtained (atrial septal defect, total anomalous pulmonary venous return, pulmonary hypertension, and one patient with congenital tricuspid stenosis).

An echo from the anterior tricuspid leaflet could be obtained in all patients with Ebstein's anomaly. This echo had an abnormal pattern of movement with an abnormally anterior position during the entire diastole. A late tricuspid opening was found in most patients. A late tricuspid closure compared with the time of mitral closure was a constant finding. It is suggested that this late tricuspid closure is mainly caused by mechanical factors related to the abnormal, large anterior tricuspid leaflet. The abnormal pattern of movement of the echo from the anterior tricuspid leaflet with a late tricuspid closure has not been found in any other patient examined.

Sail sound in Ebstein's anomaly of the tricuspid valve

Ebstein's anomaly represents an anatomic, pathologic, and physiologic spectrum. There have been few hemodynamic correlates for the observed auscultatory events. Multiple components of the first sound and "ejection" sounds are frequently described.

Cardiac catheterization, intracardiac sound-pressure studies (Telco), and cineangiograms were performed in three patients with Ebstein's anomaly who had a prominent early systolic sound.

The right ventricular pressure pulse was abnormal in all; an initial delta-wave configuration, followed by a more rapid pressure rise, produced a prolonged rise to peak pressure. The right ventricular pressure pulse is not that of a conduction defect alone; rather it suggests that the altered pattern of ventricular contraction and abnormal leaflet placement are contributing factors.

The early systolic sound was recorded in the atrialized right ventricle or right ventricle in all. It occurred just after the peak of the c wave in the atrialized right ventricle. In the right ventricle the sound occurred at the point where initial slow delta portion of right ventricular pressure pulse gave rise to rapid upstroke. The early systolic sound most likely occurs when the large, sail-like tricuspid valve reaches the limit of systolic excursion. The sound has been designated as the "sail sound," and may be the most specific auscultatory event in Ebstein's anomaly.