Diagnosis and natural history of Ebstein's anomaly

Cyanotic Congenital Heart Disease in Pregnancy: A Review of Pathophysiology and Management

The advancement of medical treatment and surgical technique, along with the invention of cardiopulmonary bypass, has allowed for long-term survival of patients with cyanotic congenital heart disease (CHD)-with many women with CHD now reaching child-bearing age and wishing to become pregnant. Pregnancy in these women is a major concern as the physiologic adaptations of pregnancy, including an increased circulating volume, increased cardiac output, reduced systemic vascular resistance, and decreased blood pressure, place a substantial load on the cardiovascular system. These changes are essential to meet the increased maternal and fetal metabolic demands and allow for sufficient placental circulation during gestation. However, in women with underlying structural heart conditions, they place an additional hemodynamic burden on the maternal body. Overall, with appropriate risk stratification, pre-conception counseling, and management by specialized cardiologists and high-risk obstetricians, most women with surgically corrected CHDs are expected to carry healthy pregnancies to term with optimization of both maternal and fetal risks. In this article, we describe the current understanding of 5 cyanotic CHDs-Tetralogy of Fallot, Transposition of the Great Arteries, Truncus Arteriosus, Ebstein's Anomaly, and Eisenmenger Syndrome-and explore the specific hemodynamic consequences, maternal and fetal risks, current guidelines, and outcomes of pregnancy in women with these conditions.

Cardiac Catheterization in Adults with Ebstein Anomaly: Pathophysiologic Insights Regarding Surgical Repair and Prognosis

The underlying invasive hemodynamics and physiology in Ebstein anomaly (EA) are poorly understood. Moreover, the hemodynamic impact of tricuspid valve intervention in EA has not been well studied. Retrospective cohort of 52 adults with repaired and 36 with unrepaired EA undergoing right heart catheterization at Mayo Clinic, MN between 1993 and 2021. "Repaired" EA was defined as prior tricuspid valve repair and/or replacement (83% post-tricuspid valve replacement). Repaired patients were younger than those with unrepaired EA (41.3 ± 16.0 versus 50.6 ± 15.6 years, p = 0.008) and had a lower prevalence of ≥ moderate native or prosthetic tricuspid regurgitation (67% versus 81%, p = 0.01). Right atrial (RA) pressure was higher among patients with repaired EA than in unrepaired disease [13 (11; 18) versus 10 (8; 15) mmHg; p = 0.02], but these differences were no longer present when adjusting for ≥ moderate right ventricular systolic dysfunction and ≥ moderate tricuspid regurgitation. Cardiac index (Qs) was lower among those with unrepaired EA than in repaired EA (1.9 ± 0.7 versus 2.3 ± 0.6 l/min/m2, p = 0.01), even after adjusting for similar confounders. During a follow-up of 8.6 (3.2-13.3) years, 16 (18%) patients died. Systolic pulmonary artery pressure was independently associated with all-cause mortality. In summary, higher cardiac indices were found in those with repaired EA compared to those with unrepaired disease. RA hypertension was prevalent in both groups and no differences in right filling pressures were found between groups after adjusting for potential confounders. Elevation in pulmonary pressures was independently associated with survival. The use of pulmonary vasomodulators in EA requires further investigation.

Ebstein's Anomaly: From Fetus to Adult-Literature Review and Pathway for Patient Care

Ebstein's anomaly, first described in 1866 by Dr William Ebstein, accounts for 0.3-0.5% of congenital heart defects and represents 40% of congenital tricuspid valve abnormalities. Ebstein's anomaly affects the development of the tricuspid valve with widely varying morphology and, therefore, clinical presentation. Associated congenital cardiac lesions tend to be found more often in younger patients and may even be the reason for presentation. Presentation can vary from the most extreme form in fetal life, to asymptomatic diagnosis late in adult life. The most symptomatic patients need intensive care support in the neonatal period. This article summarizes and analyzes the literature on Ebstein's anomaly and provides a framework for the investigation, management, and follow-up of these patients, whether they present via fetal detection or late in adult life. For each age group, the clinical presentation, required diagnostic investigations, natural history, and management are described. The surgical options available for patients with Ebstein's anomaly are detailed and analyzed, starting from the initial mono-leaflet repairs to the most recent cone repair and its modifications. The review also assesses the effects of pregnancy on the Ebstein's circulation, and vice versa, the effects of Ebstein's on pregnancy outcomes. Finally, two attached appendices are provided for a structured echocardiogram protocol and key information useful for comprehensive Multi-Disciplinary Team discussion.

Anesthetic Care During Posterior Spinal Fusion in an Adolescent With Ebstein's Anomaly

Ebstein’s anomaly is a rare form of cyanotic congenital heart disease (CHD) that involves malformation and dysfunction of the tricuspid valve and right ventricle (RV). The severity of the defect impacts clinical presentation, survival, and treatment options. Presentation during the neonatal period with hypoxemia and cyanosis is noted in patients with severe tricuspid valve malformation, a hypoplastic RV, or RV outflow tract obstruction. However, presentation later in infancy is more common when there is a moderate tricuspid valve malformation and no associated RV outflow tract obstruction. Although Ebstein’s anomaly is not generally associated with other congenital defects, patients may occasionally require surgery for other comorbid conditions. We describe the perioperative anesthetic management of an adolescent with Ebstein’s anomaly for posterior spinal fusion. Previous reports of anesthetic care in this clinical scenario are reviewed, anesthetic considerations discussed, and options for intraoperative monitoring and anesthetic care presented.

Sinus venosus incorporation: contentious issues and operational criteria for developmental and evolutionary studies

The sinus venosus is a cardiac chamber upstream of the right atrium that harbours the dominant cardiac pacemaker. During human heart development, the sinus venosus becomes incorporated into the right atrium. However, from the literature it is not possible to deduce the characteristics and importance of this process of incorporation, due to inconsistent terminology and definitions in the description of multiple lines of evidence. We reviewed the literature regarding the incorporation of the sinus venosus and included novel electrophysiological data. Most mammals that have an incorporated sinus venosus show a loss of a functional valve guard of the superior caval vein together with a loss of the electrical sinuatrial delay between the sinus venosus and the right atrium. However, these processes are not necessarily intertwined and in a few species only the sinuatrial delay may be lost. Sinus venosus incorporation can be characterised as the loss of the sinuatrial delay of which the anatomical and molecular underpinnings are not yet understood.

Ebstein Anomaly and Sudden Childhood Death

A 13-year-old girl is reported who died suddenly and unexpectedly in her sleep from previously undiagnosed Ebstein anomaly. At autopsy, there was dilatation of the right atrium with marked dilatation of the right auricle and apical displacement of the tricuspid valve into the right ventricular cavity with atrialization of the upper portion of the right ventricle. There were also prominent dysplastic changes in both the septal and posterior leaflets of the tricuspid valve with thickening of the valve and fusion of leaflets to the wall of the ventricle. Histology of the myocardium showed focal, minor microscopic areas of interstitial fibrosis with marked fibrous dysplasia and thickening of the tricuspid valve. Lethal arrhythmias occur in this condition because of the geographical relationship of the conduction system to the abnormal anatomical structures. As adolescents who died suddenly are often minimally symptomatic, cases will rarely present de novo to forensic autopsy.

Natural Course of Adult Ebstein Anomaly When Treated according to Current Recommendation

The objectives of this study were to assess the clinical outcomes of adults with Ebstein Anomaly (EA) according to their treatment modalities. All adult EA patients diagnosed between October 1994 and October 2014 were retrospectively evaluated by medical record review. Total 60 patients were categorized into 3 groups according to their treatment strategy, i.e. non-operative treatment (Group I, n = 23), immediate operative treatment (Group II, n = 27), and delayed operative treatment (Group III, n = 10). A composite of major adverse cardiac and cerebrovascular events (MACCE) and factors associated with MACCE were assessed in each treatment group. MACCE occurred in 13.0% patients in Group I, 55.6% patients in Group II and 50% in Group III (P = 0.006). Event free survivals at 5 years were 90% in Group I, 52.7% in Group II, 50.0% in Group III (P = 0.036). Post-operatively, most patients showed improvement on clinical symptoms. However, event free survival rate was lower in patients with operation compared to those with non-operative treatment (58.7% vs. 90.9%; P = 0.007). Major arrhythmic event occurred more frequently even after surgical ablation (50.0% vs. 20.0%; P = 0.034). Re-operation was more frequent in patients underwent delayed surgery compared to those with immediate surgery (50.0% vs. 18.5%; P = 0.001). Current guideline to decide patient's treatment strategy appeared to be appropriate in adult patients with EA. However, surgical ablation for arrhythmia was not enough so that concomitant medical treatment should be considered. Therefore, attentive risk stratification and cautious decision of treatment strategy by experienced cardiac surgeon are believed to improve clinical outcome.

Perioperative and Anesthetic Considerations in Ebstein’s Anomaly

Ebstein’s anomaly is a complex and heterogeneous form of congenital heart disease characterized by malformation and apical displacement of the tricuspid valve leaflets. Patients may present at any time from the neonatal period to adulthood with symptoms ranging from cardiac failure and cyanosis to paroxysmal arrhythmias. Depending on the timing of presentation, various surgical options are available for the management of symptomatic patients. This review will discuss the perioperative and anesthetic management of patients with Ebstein’s anomaly with reference to the more common surgical approaches.

Anatomic repair of Ebstein's anomaly with isolated anterior leaflet downward displacement

OBJECTIVE

Ebstein's anomaly with isolated anterior leaflet downward displacement is rare and has not been reported in the literature to our knowledge. In this article, our experience of the surgical treatment in 6 cases with this anomaly is reported.

METHODS

From November 2005 to November 2013, 6 patients (3 male, 3 female, aged 2-39 years) with Ebstein's anomaly and isolated anterior leaflet downward displacement received anatomic repair at the First Hospital of Tsinghua University. The diagnosis was made by echocardiography and confirmed at operation. Surgery was performed under hypothermic cardiopulmonary bypass. Surgical technique included excision of a huge atrialized portion of the right ventricle located in the anterior wall of the heart; reconstruction of the right ventricle by repairing the "V"-shaped defect left by the excision procedure; detachment, repair, and reimplantation of the anterior leaflet; and reconstitution of the right atrioventricular connection. Intraoperative transesophageal echocardiography was used to evaluate the position, morphology, structure, and function of the tricuspid valve, as well as right ventricular function.

RESULTS

Five patients were discharged uneventfully, and 1 patient died of postoperative pneumonia. At follow-up from 2 months to 7 years, no notable tricuspid valve regurgitation or stenosis was found and all patients were maintaining a normal lifestyle. The 27-year-old female patient gave birth to a normal infant uneventfully 3 years after surgery.

CONCLUSIONS

Ebstein's anomaly with isolated anterior leaflet downward displacement is a complex and severe abnormality, and has several unique anatomic and clinical features and specific surgical requirements. Preoperative diagnosis can be made by clinical investigation and echocardiography. Excellent results can be achieved by anatomic correction.

Current Trends in the Management of Neonates With Ebstein's Anomaly

BACKGROUND

The optimal management strategy for neonates with Ebstein's anomaly is unknown. This analysis was undertaken to assess current trends in the management and prognosis of neonates born with Ebstein's anomaly in the United States, as reflected in an administrative database.

METHODS

The Pediatric Health Information System database (40 children's hospitals) was used to review the reported incidence and available data on neonates with Ebstein's anomaly treated in the United States between 2003 and 2007. Primary outcome was hospital survival. Of the 415 patients identified, 257 (62%) did not undergo initial surgical intervention as neonates. Aortopulmonary shunt only was done on 63 patients (15%), single-ventricle palliation on 36 (9%), two-ventricle repair on 16 (4%), heart transplantation in 3 (1%), and a catheter-based intervention or a hybrid palliative approach was applied in 40 (10%). Intergroup comparisons were done using chi-square analyses.

RESULTS

Mortality for the entire cohort was 24% (100 of 415). For medically treated patients, this was 22% (56 of 257). For surgically treated and hybrid patients, this was 30% and 23%, respectively (P = NS).

CONCLUSIONS

The majority of patients born with Ebstein's anomaly currently do not undergo surgical intervention as neonates. Significant early mortality in this group suggests that certain subsets of patients may benefit from earlier surgical intervention. Among the severely symptomatic neonates who do undergo early surgical intervention, the mortality remains high, irrespective of the surgical approach taken. A multicenter trial may be appropriate to identify strategies to optimize care for these critically ill neonates. Further analysis of risk factors for early mortality is warranted.

Canadian Cardiovascular Society 2009 Consensus Conference on the management of adults with congenital heart disease: outflow tract obstruction, coarctation of the aorta, tetralogy of Fallot, Ebstein anomaly and Marfan's syndrome

With advances in pediatric cardiology and cardiac surgery, the population of adults with congenital heart disease (CHD) has increased. In the current era, there are more adults with CHD than children. This population has many unique issues and needs. Since the 2001 Canadian Cardiovascular Society Consensus Conference report on the management of adults with CHD, there have been significant advances in the field of adult CHD. Therefore, new clinical guidelines have been written by Canadian adult CHD physicians in collaboration with an international panel of experts in the field. Part II of the guidelines includes recommendations for the care of patients with left ventricular outflow tract obstruction and bicuspid aortic valve disease, coarctation of the aorta, right ventricular outflow tract obstruction, tetralogy of Fallot, Ebstein anomaly and Marfan's syndrome. Topics addressed include genetics, clinical outcomes, recommended diagnostic workup, surgical and interventional options, treatment of arrhythmias, assessment of pregnancy risk and follow-up requirements. The complete document consists of four manuscripts that are published online in the present issue of The Canadian Journal of Cardiology. The complete document and references can also be found at www.ccs.ca or www.cachnet.org.

Successful radiofrequency ablation of atrial tachycardias in surgically repaired Ebstein's anomaly using the Carto XP system and the QwikStar catheter

We describe the case of a child with three different atrial tachyarrhythmias originating from the right atrium, in whom a limited modified maze procedure was performed during surgical repair of an Ebstein's anomaly. Successful radiofrequency transcatheter ablation of all atrial tachyarrhythmias, one re-entrant and two focal, was obtained using the Carto XP EP three-dimensional navigation and ablation system, the new QwikMap software technology and the new mapping/ablation QwikStar multipolar catheter. No conventional mapping was used in addition to the three-dimensional system. Total procedural time was about 3 h and fluoroscopy time was 40 min. There were neither recurrences of the tachycardias nor complications during the follow-up (15 months).

Caesarean section using total intravenous anaesthesia in a patient with Ebstein’s anomaly complicated by supraventricular tachycardia

Ebstein's anomaly is a rare congenital cardiac defect associated with both displacement and incompetence of the tricuspid valve. The condition is commonly complicated by supraventricular tachycardias. We describe the management of a patient with this condition undergoing caesarean section. Propofol and remifentanil total intravenous anaesthesia resulted in haemodynamic stability and delivery of a healthy baby who breathed spontaneously after two minutes.

Ebstein's anomaly: Indications for repair and surgical technique

Ebstein's anomaly of the tricuspid valve is characterized by a regurgitant tricuspid valve with a large anterior leaflet and septal and tricuspid leaflets displaced into the right ventricle. Associated anomalies are common, especially atrial septal communication and right ventricular outflow tract obstruction. Clinical presentation includes a spectrum from minimal hemodynamic derangement and mild exercise intolerance to severe cardiopulmonary abnormalities and grave illness. The natural history of the disease is extremely variable; the worst prognosis is in the youngest patients, who often have associated cardiac abnormalities. Operative procedures range from ligation of a patent ductus arteriosus to cardiac transplantation. Tricuspid valvuloplasty has been advanced by several investigators and can be considered in nearly all cases. Repairs are based on the creation of a monocuspid or bicuspid valve with reduction of the enlarged annulus. While tricuspid valve repair or replacement is indicated for symptomatic children and adults, the management of the symptomatic neonate is difficult. Patients are stratified according to clinical status and morphology, then treated with observation, valve repair, conversion to single ventricle, or transplantation. We review the anatomy and pathophysiology of Ebstein's anomaly, the indications for surgery, and the appropriate timing of surgical intervention. Current techniques of tricuspid valvuloplasty are described and unresolved issues are discussed, including the role for superior cavopulmonary anastomosis, the management of symptomatic infants, and the necessity of ventricular plication in valve repair. Copyright 1999 by W.B. Saunders Company

The adult patient with Ebstein anomaly. Outcome in 72 unoperated patients

Knowledge of the long-term outcome in unoperated adult patients with Ebstein anomaly is limited, and the therapeutic approach is still controversial. We studied unoperated adult patients with Ebstein anomaly to define the patterns of presentation, anatomic characteristics, outcome, and predictive factors for survival. Seventy-two unoperated survivors of Ebstein anomaly aged over 25 years attended from 1972 to 1997 were reviewed and followed-up from 1.6 to 22.0 years. Patients were classified in 3 groups of severity according to the echocardiographic appearance of the septal leaflet attachment of tricuspid valve. The mean age at diagnosis was 23.9 +/- 10.4 years, and the most common clinical presentation was an arrhythmic event (51.4%). There were 30 (42%) deaths, including 6 from arrhythmia, 12 related to heart failure, 7 sudden, 2 unrelated, and 3 unascertained. According to Cox regression analysis, predictors of cardiac-related death included age at diagnosis (hazard ratio 0.89 for each year of age, 95% confidence intervals CI[ 0.84-0.94), male sex (3.93, 95% CI, 1.50-10.29), degree of echocardiographic severity (3.34, 95% CI, 1.78-6.24), and cardiothoracic ratio > or = 0.65 (3.57, 95% CI, 1.15-11.03). During follow-up, morbidity was mainly related to arrhythmia and refractory late hemodynamic deterioration. The magnitude of tricuspid regurgitation, cyanosis, and the New York Heart Association (NYHA) functional class at time zero were significant risk factors according to the univariate analysis, but not after multivariable confrontation. The results of this study suggest that pattern of presentation, clinical course, and prognosis of unoperated adult patients with Ebstein anomaly are influenced by several factors. Although the initial symptoms are usually mild and commonly related to supraventricular arrhythmias, these are not associated with the long-term outcome. The severity of the morbid anatomy was the main determinant of survival only in extreme cases, but not in those with mild or moderate deformations, which are more common in adults. Other independent risk factors such as cardiothoracic ratio, sex, age at diagnosis, and the echocardiographic evaluation may help to determine the therapeutic approach. Adult patients with Ebstein anomaly should not be considered as a simple low-risk group.

The Pediatric Radiofrequency Ablation Registry's experience with Ebstein's anomaly. Pediatric Electrophysiology Society

INTRODUCTION

Abnormal anatomy and complex electrophysiology in patients with Ebstein's anomaly of the tricuspid valve may confound attempts at radiofrequency ablation (RFA).

METHODS AND RESULTS

Data for 65 pediatric Ebstein's patients (9.8+/-5.4 years, 4 months to 20 years; 39+/-25 kg, 5.1 to 108 kg) were obtained from the Pediatric Radiofrequency Ablation Registry. The degree of tricuspid regurgitation (DOTR) and the degree of Ebstein's anomaly were assessed with echocardiography/Doppler. Leading indications were drug refractoriness (24 [37%] of 65 patients) and life-threatening arrhythmia (14 [22%] of 65 patients). For the 65 patients, 82 typical (nondecremental) accessory pathways (APs) (62% right free wall, 34% right septal, and 4% left sided), 17 other supraventricular tachycardias (1 ectopic atrial, 7 AV reentry, 5 Mahaim, and 4 intra-atrial reentry tachycardias), and 1 ventricular mechanism were mapped. Thirty-four (52%) of 65 patients had a single AP (21 right free wall, 10 septal, and 3 left); 19 (29%) of 65 patients multiple APs; 6 (9%) of 65 patients a single AP plus a non-AP mechanism; and 6 (9%) of 65 patients non-AP mechanism(s) only. RFA acute success rates and recurrence rates for right free wall, right septal, and other mechanisms were 79%/32%, 89%/29%, and 75%/27%. Mild DOTR and a body surface area (BSA) < or = 1.7 m2 independently predicted a better acute success rate. BSA < or = 1.7 m2 also predicted long-term success.

CONCLUSION

In this patient subset, life-threatening arrhythmias and multiple electrophysiologic mechanisms are commonly encountered during RFA. Mild DOTR and a BSA < or = 1.7 m2 predict a higher acute success rate. While acute success rates are relatively high, recurrence is frequent.

Outcome in cyanotic neonates with Ebstein's anomaly

Clinical, angiographic, radiographic, and echocardiographic data on 46 neonates with Ebstein's anomaly presenting with cyanosis between 1954 and 1996 were reviewed to determine possible risk factors for mortality. Most patients (67%) presented at birth with 3 cases diagnosed in utero. Mean systemic oxygen saturation was 62+/-12%. An atrial septal defect > or = 4 mm was noted in 20 patients (44%). The patent right ventricle to pulmonary artery connection was present in 10 (22%), and pulmonary atresia was functional in 25 (54%) and anatomic in 11 patients (24%). Fifteen patients (35%) underwent surgical interventions. Total mortality was 70% (vs 14% in acyanotic patients diagnosed during the same time period; p <0.0001) and was related to low cardiac output and hypoxia in 20 patients (62%), postoperative complications in 8 (25%), and sudden death in 4 (13%). Kaplan-Meier survival estimates were 61% at age 1 week (95% confidence interval [CI], 47% to 75%), 48% at age 1 month (95% CI, 34% to 62%), and 36% at both 1 and 5 years of age (95% CI, 22% to 50%). Mortality improved from 81% in 1954 to 1985 to 47% in 1986 to 1996 (p = 0.04). Significant independent predictors of mortality included an atrial septal defect > or = 4 mm (odds ratio [OR] 2.39; p = 0.04), reduced left ventricular function (OR 4.10; p = 0.002), and functional or anatomic pulmonary atresia (OR 2.44, p = 0.003; and OR 5.97, p = 0.004, respectively). An echocardiographic ratio of the combined right atrial and atrialized right ventricular area to the area of the functional right ventricle and left heart >1.0 was 100% predictive of mortality.

Conversion of complex neonatal Ebstein's anomaly into functional tricuspid or pulmonary atresia

BACKGROUND

Ebstein's anomaly, due to failure of delamination of one or more leaflets of the tricuspid valve (TV), is associated with varying degrees of tricuspid regurgitation (TR) and dysplasia of the right ventricle (RV). Although refinement of tricuspid valvuloplasty and plication techniques have opened the way to a satisfactory outlook for the majority of older children and adults, Ebstein's anomaly presenting at neonatal age, secondary to ineffective forward flow into the pulmonary and systemic circulation, has a reported mortality rate of as high as 75%. In order to improve the dismal outcome in neonatal Ebstein's anomaly, we have strived for early univentricular palliation.

PATIENTS AND METHODS

Univentricular repair was performed in five neonates (median age 5 days; range 2-14 days) with Ebstein's anomaly, ductal dependent pulmonary blood flow, severe TR, absence of forward flow across the pulmonary valve, and small left ventricular (LV) area due to right-to-left bowing of the ventricular septum and ineffective LV loading (median indexed LV area 10.5 cm2/m2). In addition, two neonates had moderate pulmonary regurgitation (PR), one with additional pulmonary stenosis. In all patients, the indexed area of the combined right atrium and atrialized RV was greater than that of the combined functional RV, left atrium, and left ventricle (median 22.0 and 20.8 cm2/m2, respectively). The median preoperative systemic oxygen tension was 35 mmHg and the median pH 7.28. Repair consisted of TV closure with a pericardial patch (with the coronary sinus draining into the RV) (n = 3) or, in the presence of PR, resection of the dysplastic TV and division and oversewing of the main pulmonary artery (n = 2), as well as excision of the atrial septum, resection of redundant right atrial wall, and construction of an aortopulmonary shunt (n = 5).

RESULTS

The median indexed LV area increased from 10.5 to 18.8 cm2/m2 as a result of more effective loading of the left ventricle. There was no intraoperative or late mortality. The patients were extubated at a median of 7 days postoperatively. At discharge, the median systemic oxygen tension was 46 mmHg. In all five patients, at 6, 7, 10, 12 and 16 weeks of age, a bidirectional cavopulmonary anastomosis has been constructed.

CONCLUSIONS

In neonates with Ebstein's anomaly and ductal dependent pulmonary blood flow, rational palliation consists of the surgical creation of tricuspid atresia or, in the additional presence of PR or pulmonary stenosis, the creation of pulmonary atresia. These procedures may result in effective LV decompression and more effective volume loading of the left ventricle with increase of systemic output and improved clinical outcome.

Radiofrequency ablation of tachyarrhythmias in patients with Ebstein's anomaly

We performed radiofrequency catheter ablation in five patients associated with Ebstein's anomaly to cure their refractory tachyarrhythmias. The presenting arrhythmias were four cases of orthodromic circus movement tachycardia using accessory pathways as a requisite limb, including one case of a Mahaim fiber and one of atrial flutter of common variety. All accessory pathways, including the Mahaim fiber, were ablated by RF energy delivered through the catheter placed at the AV annulus rather than the displaced anatomical AV groove. Interestingly, the antegrade or retrograde conduction interval over these accessory pathways was relatively longer than that of usual accessory pathways, and the accessory pathway potential was fractionated in some cases. The location of the atrioventricular node was displaced from the usual position to the postero-inferior area of Koch's triangle in one case. The configuration of the flutter wave was larger than usual in height as well as in width. All tachyarrhythmias were cured by RF catheter ablation. In the case of RF catheter ablation for patients with Ebstein's anomaly, close attention is indispensable in order to accomplish it safely and successfully, because of the anatomical and functional differences peculiar to Ebstein's anomaly.

Ebstein's anomaly presenting in adulthood: the role of cine magnetic resonance imaging in diagnosis

Three adult patients with late presentation of Ebstein's anomaly were studied using MRI, including cine MRI. Spin-echo MRI demonstrated a large right atrium in each case and suggested an abnormal tricuspid valve in two. Systolic signal loss, on cine MRI, deep within the right ventricular cavity correctly indicated the presence of an abnormally positioned and incompetent tricuspid valve, and the diagnosis of Ebstein's anomaly in each patient. Selective presaturation MRI demonstrated an associated atrial septal defect in one patient. The diagnosis was confirmed by echocardiography in each case and cardiac catheterization with contrast angiography in one case. Cine MRI clearly demonstrates abnormal tricuspid valve morphology and function in Ebstein's anomaly and is a useful technique when other imaging is unclear.

Ebstein's malformation of the tricuspid valve: genetic and environmental factors. The Baltimore-Washington Infant Study Group

Ebstein's anomaly is a specific structural deformity of the tricuspid valve, and its rarity has hampered etiologic evaluation. Cases of Ebstein's anomaly registered in the Baltimore Washington Infant Study (BWIS), a regional case-control study of cardiovascular malformations (CVM) in infancy, are reviewed. Between 1981 and 1989 a total of 4,390 CVM cases, including 47 Ebstein cases, and 3,572 controls were registered. The prevalence of Ebstein's anomaly was 5.2 per 100,000 livebirths. Additional cardiac anomalies were present in 38.3% of Ebstein cases. Non-cardiac malformations were present in 19.1% of Ebstein cases vs. 25.5% of other CVM, and 1.7% of controls. Case-fatality by 1 year of age was 23.4% in Ebstein vs. 18.1% in other CVM. Interviews of parents of Ebstein cases, other CVM, and controls (n = 44, 3,335, and 3,572, respectively) elicited information on family history of malformations, maternal illnesses, reproductive history, therapeutic drugs, parental lifestyle, and environmental exposures during the periconceptional period. Case-control analyses suggest genetic, reproductive, and environmental risk factors: twins [odds ratio (OR) 8.2, 95% confidence interval (CI) 2.6-25.3]; family history of CVM (OR 6.4, 95% CI 1.8-22.2); white race (OR 2.9 with non-whites as reference, 95% CI 1.2-7.0); previous miscarriages (OR 2.0, 95% CI 1.2-3.3); maternal exposure to benzodiazepines (OR 5.4, 95% CI 1.5-19.1); and varnishing (OR 3.4, 95% CI 1.3-9.1). Additional multicenter investigations are warranted to elucidate the role of genetic, reproductive, and environmental factors in the etiology of this anomaly.

Ebstein's anomaly: outcome of pregnancy

OBJECTIVES

The outcome of pregnancy in Ebstein's anomaly was studied in 72 such patients (44 women, 28 men) who had had pregnancies or fathered children.

BACKGROUND

Patients with Ebstein's anomaly often reach childbearing age. Reports of the outcome of pregnancy in Ebstein's anomaly are available; however, the number of patients is small.

METHODS

The medical and surgical data bases at the Mayo Clinic were reviewed, and 145 patients (62 men, 83 women) of childbearing age with Ebstein's anomaly were located. All patients were contacted, and 72 patients (44 women, 28 men) with offspring were identified and reviewed in detail to assess the outcome of pregnancy.

RESULTS

Forty-four women had 111 pregnancies resulting in 85 live births (76%). Seventy-six deliveries (89%) were vaginal, and nine (11%) were by cesarean section. Twenty-three deliveries were premature. There were 19 spontaneously unsuccessful pregnancies, 7 therapeutic abortions and 2 early neonatal deaths. The mean birth weight of the infants born to cyanotic women was 2.53 kg, which was significantly lower than the mean birth weight of infants born to acyanotic women (3.14 kg [p < 0.001]). The overall incidence of congenital heart disease in the 158 offspring of parents with Ebstein's anomaly was 4% (6 of 158). The incidence of congenital heart disease was 6% (5 of 83) in the offspring of women with Ebstein's anomaly and 1% (1 of 75) in that of men. There was a 0.6% (1 of 158) incidence of familial Ebstein's anomaly. There were no serious pregnancy-related maternal complications, which included maternal death, stroke, congestive heart failure, arrhythmias or endocarditis.

CONCLUSIONS

Pregnancy in women with Ebstein's anomaly is well tolerated. It is associated with an increased risk of prematurity, fetal loss and congenital heart disease in the offspring. In addition, a significantly lower birth weight is found in the offspring of cyanotic versus acyanotic women with Ebstein's anomaly. Paternal Ebstein's anomaly also seems to result in an increased risk of congenital heart disease in the offspring compared with the incidence in the general population.

Ebstein's anomaly: a long-term study of survival

This study examines data regarding the survival of patients with Ebstein's malformation. Of 61 patients studied at the University of Minnesota, 31 are currently alive, with the average survival being 15 years. Several factors adversely affected survival: NYHA functional classification, hemoglobin level, right atrial pressure, symptoms during the neonatal period, and cardiac surgery. Data from a multi-institutional study collected during the past decade adds information regarding survival. Of 18,281 patients in the study, 71 (0.4%) had Ebstein's malformation. Sixteen of these were among 7235 infants, and of these seven died during the first year of life. In contrast, among 55 patients over the age of 1 year, four died, each after cardiac surgery. The data help our understanding of the course of patients with Ebstein's malformation and decisions regarding surgical treatment.

Effect of Ebstein's anomaly on short- and long-term outcome of surgically treated patients with Wolff-Parkinson-White syndrome

BACKGROUND

Ebstein's anomaly is the most commonly occurring congenital abnormality associated with the Wolff-Parkinson-White (WPW) syndrome. However, the effects of Ebstein's anomaly on the risks and benefits of surgical ablation of accessory pathways in patients with WPW syndrome are unknown.

METHODS AND RESULTS

This study compared the long-term outcome of 38 WPW patients with Ebstein's anomaly undergoing accessory pathway ablation to a reference population of 384 similarly treated patients without the anomaly. Ebstein's anomaly was mild in 21 patients (55%) and moderate-to-severe in 17 patients (45%). Sixteen patients (42%) required tricuspid valve surgery, and 23 (61%) had an atrial septal defect or patent foramen ovale repaired. Baseline clinical characteristics and preoperative clinical arrhythmias were similar in both groups. Ten-year survival was 92.4% and 91.2% for patients with and without Ebstein's anomaly, respectively (p = NS). During a mean follow-up of 6.2 +/- 3.8 and 5.3 +/- 3.6 years, 82% of patients with and 90% without Ebstein's anomaly had either clinically insignificant or no arrhythmias, and 18% versus 10% reported symptoms suggesting arrhythmias lasting longer than 1 minute, respectively. Atrial fibrillation was reduced postoperatively to 9% (p less than 0.001) in patients with and to 4% (p less than 0.001) in those without the anomaly. Fewer hospitalizations were reported postoperatively by 90% versus 96% of patients with and without Ebstein's anomaly; 9.4% versus 6.0% of patients were disabled at follow-up, respectively (p = NS).

CONCLUSIONS

Patients with Ebstein's anomaly are improved significantly after accessory pathway ablation. The presence of this anomaly should not preclude accessory pathway ablation in these patients.

Predictors of long-term survival with Ebstein's anomaly of the tricuspid valve

In patients with Ebstein's anomaly of the tricuspid valve, predictors of death and indications for surgery are poorly defined. We retrospectively reviewed 48 patients with Ebstein's anomaly, 17 (35%) of whom presented in the first week of life. Duration of follow-up extended to 32 years (greater than 10 years in 35%). Twenty of the 48 patients (42%) died, 6 in the first week of life and 1 at age 5 months. Thirteen of the 41 patients surviving to age 6 months subsequently died, 50% probability of survival being reached at 47 years. Significant (p less than or equal to 0.05) predictors of death in this group were: male sex, cardiothoracic ratio greater than or equal to 0.65, New York Heart Association class III or IV, breathlessness and the absence of Wolff-Parkinson-White syndrome. Eight patients died suddenly. A cardiothoracic ratio greater than or equal to 0.65 was a better predictor of sudden death than functional status. All who developed atrial fibrillation died within 5 years. Other atrial arrhythmias were not helpful in predicting sudden death. In view of these findings, tricuspid valve surgery is recommended before the cardiothoracic ratio reaches 0.65, regardless of the symptomatic state.

Pregnancy outcome and Ebstein's anomaly

BACKGROUND

Ebstein's anomaly is an uncommon congenital cardiac abnormality that may be associated with cyanosis and arrhythmias. For those female patients with the anomaly who survive to adult life there is little information available about pregnancy, maternal complications, and fetal outcome. This study was designed to address this issue so that these patients can receive appropriate advice and management.

METHODS AND RESULTS

Forty two pregnancies in 12 women with Ebstein's anomaly were studied. The mothers' cardiac lesions were assessed on the basis of symptoms, the presence of cyanosis or arrhythmia, and by echocardiographic grading of severity. In the absence of important maternal cyanosis or arrhythmia, pregnancy was well tolerated. Neonatal outcome was good though there was an increased risk of prematurity and dysmaturity in the babies born to mothers with cyanosis.

CONCLUSIONS

This study indicates that women with Ebstein's anomaly who reach child-bearing age can be advised that pregnancy is likely to be well tolerated with good fetal outcome. Maternal arrhythmia or cyanosis are indications for closer maternal and fetal observation.

Surgery for Ebstein's anomaly: the clinical and echocardiographic evaluation of a new technique

Ten consecutive patients (age range 4 to 44 years, mean 22) underwent surgical repair of Ebstein's anomaly by vertical plication of the right ventricle and reimplantation of the tricuspid valve leaflets. No patient died during or after operation. Intraoperative postbypass echocardiography documented a good result in nine patients but severe tricuspid regurgitation in one patient, who then underwent prosthetic valve replacement during a second period of cardiopulmonary bypass. Two of four patients who had had right ventricular papillary muscle dysfunction in the early postoperative period showed improved papillary muscle function with concomitant reduction of tricuspid regurgitation 6 months later. All patients were evaluated clinically and by echocardiography 2 to 23 months later. All patients showed clinical improvement, seven by one functional class and three by two classes. All were in sinus rhythm. The mean cardiothoracic ratio decreased by 6% (p less than 0.05). On bicycle ergometry performed in six patients, peak oxygen consumption exceeded 20 ml/kg per min in five. Tricuspid regurgitation diminished in eight patients (by three grades in two patients, by two grades in five and by one grade in one patient); it remained unchanged in two. Comparison of preoperative and postoperative pulsed Doppler flow velocities across the pulmonary valve showed an increase in the peak velocity of flow across the valve (mean 83 +/- 14 versus 97 +/- 11 cm/s, p less than 0.005) and a decrease in the time to peak velocity (mean 130 +/- 16 versus 91 +/- 23 ms, p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Tricuspid valve disease with significant tricuspid insufficiency in the fetus: diagnosis and outcome

The echocardiographic studies and clinical course of 27 fetuses (mean gestational age 26.9 weeks) diagnosed in utero with tricuspid valve disease and significant tricuspid regurgitation were reviewed. The diagnosis of Ebstein's anomaly was made in 17 of the fetuses, 7 had tricuspid valve dysplasia with poorly developed but normally attached leaflets and 2 had an unguarded tricuspid valve orifice with little or no identifiable tricuspid tissue. One fetus was excluded from data analysis because a more complex heart lesion was documented at autopsy. All fetuses had massive right atrial dilation and most who were serially studied had progressive right-sided cardiomegaly. Hydrops fetalis was found in six cases and atrial flutter in five. Associated cardiac lesions included pulmonary stenosis in five cases and pulmonary atresia in six. Four fetuses with normal forward pulmonary artery flow at the initial examination were found at subsequent study to have retrograde pulmonary artery and ductal flow in association with the development of pulmonary stenosis (n = 1) and pulmonary atresia (n = 3). On review of the clinical course of the 23 fetuses (excluding 3 with elective abortion), 48% of the fetuses died in utero and 35% who were liveborn died despite vigorous medical and, when necessary, surgical management, many of whom had severe congestive heart failure. Of the four infants who survived the neonatal period, three had a benign neonatal course, all of whom were diagnosed with mild to moderate Ebstein's anomaly; only one had pulmonary outflow obstruction. An additional finding at autopsy was significant lung hypoplasia documented in 10 of 19 autopsy reports.(ABSTRACT TRUNCATED AT 250 WORDS)

Coexistent cardiac tumours and malformations of the heart

Cardiac tumours and anatomical malformations of the heart may produce similar clinical signs and symptoms. The coexistence of these two abnormalities complicates diagnosis and probably adversely affects prognosis. We present a review of four cases of this rare combination. In the first case, Ebstein's malformation was present in a child with tuberous sclerosis and cardiac rhabdomyomata. Right ventricular rhabdomyomata were associated with a hypoplastic tricuspid valve in the second case. In the third case, cardiac myxomas were detected in a child with a double-chambered right ventricle. The fourth case was a child with a fibroma of the right ventricle with pulmonary atresia. We propose that, in some circumstances, a space-occupying lesion may be associated with, or possibly induce, a malformation within the developing heart.

Ebstein's anomaly of the tricuspid and mitral valves in an otherwise normal heart

A case in which there was Ebstein's anomaly of both the tricuspid and mitral valve is described: the structure of the h eart was otherwise normal.

The plain chest radiograph in uncomplicated Ebstein's disease

Displacement of the origin of the tricuspid valve into the right ventricle, redundancy of its leaflets and tricuspid incompetence are all present to varying degrees in Ebstein's disease. Cardiac arrhythmias are a common feature. Presentation in infancy with severe displacement of the valve, right-sided heart failure, cyanosis and gross cardiomegaly are the classic features. More recently, echocardiography has revealed a group presenting with arrhythmias but with no significant haemodynamic disturbance, or with an asymptomatic murmur who have a normal or near normal chest radiograph and mild displacement of the valve. Before the availability of echocardiography, most of this group escaped diagnosis as there were insufficient indications for cardiac catheterisation.