The Adult Patient with Ebstein Anomaly: Outcome in 72 Unoperated Patients

Abstract

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.

2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease

“…If the valve leaflets are not adherent, there is redundancy *See Patients with Ebstein's anomaly may be asymptomatic with no cyanosis and no atrial arrhythmias. They often are cyanotic owing to right-to-left shunting, 830 which is associated with exercise intolerance. RV dysfunction may eventually lead to right-sided congestive heart failure frequently exacerbated by an atrial arrhythmia such as atrial tachycardia, atrial flutter, or atrial fibrillation.…”

Impact of Surgery in Ebstein’s Anomaly Using Current Surgical Criteria

“…12 In contrast, in a group with only clinical follow-up of adult patients, estimated cumulative overall survival was 76% at 10 years and 41% at 20 years of follow-up. 10 In the present study, comparing patients with similar characteristics in surgical and non-surgical groups, survival at 10 years was 92.8% vs. 90.7%; and at 20 years, 85.7% vs. 81.0%, respectively. Interestingly the surgical group had higher early mortality (18.36%) than in other series: 5.9% at 30 days.…”

“…1 Severity was classified according to echocardiography by measuring valve attachment percentage at end diastole. 10 Tricuspid septal valve attachment was measured as the distance between the anterior mitral valve insertion and tricuspid septal valve attachment to the interventricular septum. To measure attachment percentage, the total interventricular septal distance was measured and the following formula applied: (total interventricular septal distance-tricuspid septal valve attachment distance)/total interventricular septal distance.…”

A Case of Pregnancy with Ebstein’s Anomaly

“…6 The prognosis depends on severity of the anomaly, degree of tricuspid regurgitation, degree of heart failure, associated anatomical defects and associated arrhythmias. 7 Patients presenting in infancy generally have severe disease and a poor prognosis. 8 However the prognosis for neonatal Ebstein's anomaly has improved with modern surgical techniques.…”