Ebstein s Anomaly in Those Surviving to Adult Life A Single Centre Experience

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1 Heart, Lung and Circulation (2015) 24, /04/$ ORIGINAL ARTICLE Ebstein s Anomaly in Those Surviving to Adult Life A Single Centre Experience Queenie Luu a, Preeti Choudhary a,b, Dan Jackson a, Carla Canniffe a, Mark McGuire a, Richard Chard c, David S. Celermajer a,b* a Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia b Discipline of Medicine, Central Clinical School, University of Sydney, Sydney, Australia c Department of Cardiothoracic Surgery, Westmead Hospital, Sydney, Australia Received 9 November 2014; received in revised form 15 March 2015; accepted 22 March 2015; online published-ahead-of-print 4 April 2015 Background Ebstein s anomaly (EA) occurs in about one to five per live births. Long-term follow-up data of adults with EA is scarce due to the relatively low frequency of the disease and the variation of its anatomic and haemodynamic severity. Methods Since 1995, in our adult congenital heart disease (ACHD) centre, we have practised a uniform approach to management of adults with EA, with surgery reserved for those with refractory arrhythmia (failed medical and/or catheter-based treatment) or worsening symptoms of breathlessness. A retrospective review of medical records of all such patients with EA and normal cardiac connections was performed. Results Fifty-one EA patients (17 males) were identified. Mean age at diagnosis was 21+/-21 years and mean follow-up time at our centre was years. During this time, 18 patients (35%) had documented supraventricular arrhythmia. Sixteen patients (30%) underwent ablation therapy with long-term relief from arrhythmia in nine (56%). Nine patients (18%) underwent tricuspid valve (TV) surgery (four repair and five replacement), with seven patients having undergone a tricuspid valve surgery prior to referral to our unit. Three patients died, one of cardiogenic shock after redo surgery (58 years), one of progressive heart failure (45 years) and one with malignancy. Overall survival was 100% to age 40 years, 95% to age 50 years and 81% to age 60 years. Conclusions Ebstein s Anomaly in adulthood often has severe morphological abnormalities but is compatible with good medium-term survival, with a generally symptom driven approach to the indications for interventions. Keywords Tricuspid Valve Congenital Heart Disease Arrhythmia Introduction Ebstein s anomaly (EA) is a rare form of CHD, occurring in approximately one to five per live births, thus accounting for less than 1% of all congenital heart disease [1]. It occurs when the septal leaflet of the tricuspid valve joins to the septal surface below the valve annulus, into the body of the right ventricle, often with marked displacement of the tricuspid valve, displacing the coaptation point towards the right ventricle apex and/or outflow tract [2]. It is commonly associated with other cardiac anomalies such as atrial septal defect (ASD) (prevalence 80 94%[3]), ventricular septal defects (VSD) and ventricular pre-excitation (prevalence 15%) [4]. The structural tricuspid valve anomaly may lead to tricuspid regurgitation (TR) and increased right atrial volume. Age at clinical presentation varies depending on the severity of TR and on the presence of associated heart diseases. [5]. Repair of the tricuspid valve and/or ablation therapy are often indicated[1]. Optimal timing of intervention is often challenging, requiring careful *Corresponding author at: Cardiology, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia. Tel.: ; fax: , david.celermajer@ .cs.nsw.gov.au 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.

2 Ebstein s Anomaly in Those Surviving to Adult Life 997 consideration of patient symptoms, perioperative risk and the potential need for late re-operation [4]. Since the establishment of our Adult Congenital Heart Disease (ACHD) service, we have adopted a uniform approach of watchful waiting to the management of EA, with surgery reserved either for those with refractory arrhythmia (failed medical and/or catheter based treatment) or worsening cardiac symptoms. A lower threshold for surgery was applied in cases when the tricuspid valve was judged likely reparable (compared to requiring replacement) and was more often undertaken in those judged to have an adequate left ventricle and functional right ventricle. Long-term follow up data of adults with EA are scarce due to the relatively low frequency of the disease and the remarkable variation of its anatomic and haemodynamic severity [5]. Therefore, we aimed to evaluate the long-term clinical outcomes of our adult patients (aged over 16) with EA and normal cardiac connections. Methods The study was approved by our Institutional Ethics Committee. Study Population Patients were identified from our ACHD database, which contains 3682 patients aged over 16 years, seen at least once between 2000 and The median age when first seen at our service was 30 years (IQR years). The median age at the time of last follow up was 39 years (IQR years). Patients who had EA and concordant cardiac connections were included in the study. Those with EA in the setting of congenitally corrected transposition of the great arteries (n=10 in our database) were excluded. Clinical data were retrospectively obtained from case notes, 12 lead electrocardiograms, echocardiograms and surgical reports. The date of last follow-up was recorded as the last contact with the patient and survival data was censored at this point. Vital status was obtained for all EA patients from the Australian National Death Index Registry, with an ascertainment date at the end of The first transthoracic echocardiogram (TTE) after the age of 16 years was used to assess for a small left ventricle, defined as end diastolic diameter less than 40 mm. Echocardiography data was unavailable for six patients. For the remaining patients, echocardiographic grading of right atrial systolic size and tricuspid regurgitation into mild, moderate and severe was based on visual assessment by experienced congenital heart disease specialists. New York Heart Association (NYHA) Functional Classification was used to assess patient s severity of heart failure symptoms at follow-up. Management decisions were determined by the patient s ACHD cardiologist +/- cardiothoracic team in each case, as part of routine clinical care. Statistical Methods Analysis was performed using SPSS version 20 (IBM, Armonk, New York). Data for categorical variables are reported as frequency and percentage (%) and data for continuous variables are summarised using mean standard deviation. Continuous variables that were not normally distributed were reported as median and range (minimum and maximum). Kaplan-Meier curves were used to estimate survival, freedom from surgical intervention and freedom from ablation intervention. Results Patient Characteristics Fifty-one adults were identified with EA and concordant cardiac connections. Seventeen (33%) were men. The mean age at diagnosis was 15 years (IQR 1-35 years). Sixteen patients (31%) were first diagnosed at 16 years of age, at our ACHD centre, with the remaining 35 patients diagnosed in childhood and transitioned to our ACHD service. Thirty-four (67%) patients had an associated congenital heart lesion, with eight patients (16%) having more than one associated congenital heart lesion. (Table 1) Fourteen patients (27%) had undergone cardiac surgery prior to first review at our centre. Prior surgery for other congenital heart diseases included ASD and/or VSD repair (n=9), pulmonary valvotomy (n=3), pulmonary valve replacement (n=1), septoplasty (n=1) and septostomy (n=1). Seven patients had had tricuspid valve surgery including tricuspid valve repair in five and bioprosthetic valve replacement in two patients. Echocardiographic Features at Baseline At first TTE at our centre, mean right atrial (RA) area was 44.3 cm 2 22 cm 2 ( cm 2, median 38 cm 2 ). Four Table 1 Associated congenital heart disease in patients with Ebstein s anomaly. Associated Congenital Heart Lesions Frequency in patients (n=51) Number % (of overall EA patients) ASD Pulmonary Stenosis 6 12 VSD 5 10 Mitral Valve Prolapse 4 8 Cleft Mitral Valve 1 2 Persistent ductus arteriosus 1 2 Associated congenital heart disease in patients with Ebstein s anomaly. Note, some patients have more than one associated congenital lesion. ASD= atrial septal defect, PFO= patent foramen ovale, VSD= ventricular septal defect.

3 998 Q. Luu et al. patients (8%) had no RA dilatation, three patients (6%) had mild RA dilatation, 15 patients (29%) had moderate RA dilatation, 20 patients (39%) had severe RA dilatation. Right atrial size was not available for nine patients. Three patients (6%) had no tricuspid regurgitation (TR), five patients (9%) had trivial TR, nine patients (10%) had mild TR, seven patients (14%) had mild to moderate TR, nine patients (18%) had moderate TR, five patients (9%) had moderate to severe TR and nine patients (18%) had severe TR. Mean diastolic left ventricular dimension was 38+/-8 mm and a small left ventricle was present in 20 (39%) cases. Survival and Long-Term Outcomes The mean period of follow-up was years. Vital status for all patients was established in December At last follow-up, most surviving patients were asymptomatic. Thirty-seven patients (73%) had NYHA Functional Class I symptoms, seven patients (14%) had Class II, two patients (4%) had Class III and none had Class IV functional capacity. NYHA classification was unavailable for five patients. Survival Overall survival was 100% to age 40 years, 95% to age 50 years and 81% to age 60 years, as shown in Figure 1. There were three deaths in our cohort. The first was a 58 yearold female who was diagnosed with Ebstein s anomaly at age 55 years. She had a history of prior ASD repair at 10 years of age and VSD repair at 11 years of age, but was first diagnosed with EA at 52 years of age. Other congenital heart lesions included mild pulmonary stenosis and cleft mitral valve with mitral regurgitation. She underwent a Star type atrial fibrillation ablation procedure[6] and TV replacement at 57 years of age for symptoms of atrial fibrillation and worsening right heart failure. She was readmitted to hospital three months following TV replacement for management of decompensated Figure 1 Overall survival with Ebstein s anomaly. biventricular dysfunction with severe mitral regurgitation. Mitral valve surgery was attempted but abandoned due to dense pericardial adhesions. It was her fourth redo-sternotomy. She died 10 days after this last procedure from cardiogenic shock and multi-organ failure. The second patient was a 45 year-old female diagnosed with Ebstein s at the age of seven years. She also had a small atrial septal defect with left to right shunting. Her left ventricle was small with a large right ventricle and a severely enlarged right atrium. After her second pregnancy, she developed atrial fibrillation that was well controlled with beta-blockade. She did not attend further follow-up and died six years later, due to cardiac failure at the age of 45 years. The third patient was a 72 year-old male who died due to a malignancy, diagnosed at the age of 65 years. Other co-morbidities included a small atrial septal defect and ischaemic heart disease requiring coronary bypass grafts. The atrial septal defect was repaired at the same time. He also had had atrial fibrillation, which was well controlled with amiodarone. He died due to metastatic squamous cell carcinoma. Arrhythmias Eighteen patients (35%) had a documented history of supraventricular arrhythmia including atrial fibrillation in five patients, atrial flutter in three patients, atrial tachycardia in two patients and Wolff-Parkinson-White syndrome in eight patients. During follow-up, 16 (31%) patients underwent ablation therapy. Indications for ablation included supraventricular tachycardia in eight patients, atrial flutter or atrial tachycardia in four and atrial fibrillation in four patients. One patient experienced recurrent palpitations within 30 days, and required a second catheter ablation. Nine patients had catheter-based ablation only, six patients had surgical ablation only (four Star procedures, two Maze procedures), and one patient had catheter ablation which failed and subsequently underwent a Maze procedure. The overall freedom from arrhythmia was over 80% at age 30 years, as shown in Figure 2. Twelve patients (24%) were taking regular anti-arrhythmic medication at the time of their last follow-up. These included beta-blockers (n=7) including sotalol (n=3), amiodarone (n=3), calcium channel blockers (n=1) and/or digoxin (n=2). Three patients developed procedural complications within 30 days: two patients who had the Star procedure developed complete heart block requiring a pacemaker; and one patient who had catheter ablation developed a small pericardial effusion, which was managed conservatively and resolved. Nine of these 16 ablated patients (18%) had long-term relief from the arrhythmia. Of the seven patients who did not have long term relief, four patients were on anti-arrhythmic medications and three patients were being monitored off medication at last follow up. In total, five patients (9%) required permanent pacemaker (PM) implantation. Indications for PM implantation were heart block post ablation (n=2), heart block post tricuspid

4 Ebstein s Anomaly in Those Surviving to Adult Life 999 Two patients required a redo TV surgery. One patient had severe tricuspid regurgitation due to prosthetic valve tear, which was replaced with another bio-prosthetic valve one month later. The second patient had bio-prosthetic valve stenosis and required redo valve replacement with a mechanical prosthetic valve nine years following the initial replacement. Figure 2 Overall freedom from arrhythmia. valve surgery (n=1) and recurrent atrial tachy-arrhythmias/ fibrillation with a need to augment anti-arrhythmia medication regime (n=2). One patient underwent cardiac defibrillator implant for documented non-sustained ventricular tachycardia, in the setting of recurrent atrial tachy-arrhythmias and a dilated, severely impaired right ventricle. Tricuspid Valve Surgery Nine patients (18%) underwent tricuspid valve (TV) surgery for symptoms related to heart failure during their follow up in our ACHD centre. Four patients had TV repair and five had bio-prosthetic valve replacements. In these patients the mean time between diagnosis of EA and surgery was years (5 43 years, median 24 years). The mean age at time of surgery was years (24 62 years, median 49 years). Figure 3 shows the Kaplan-Meier freedom from surgery curve. Figure 3 Freedom from Tricuspid Valve Surgery. Discussion Ebstein s anomaly is a rare form of CHD. Long-term follow-up data for adults with this condition is limited due to the relatively low frequency of the condition and the variation of its anatomic and haemodynamic profile. Current international guidelines are restricted by the lack of available evidence and there are no randomised control studies to inform management strategies. The most recent recommendations from both the European Society of Cardiology, 2010[7] and American Heart Association, 2008[8] for the management of grown-up congenital heart disease are predominantly based on retrospective studies, registries or single-centre experiences (level of evidence B or C). Since the formal establishment of our ACHD service in the early 1990s, we prospectively made the decision to concentrate ACHD expertise in one centre in our state and to practise a uniform general approach of watchful waiting, with operation reserved for either those with symptoms of refractory arrhythmia (failed medical and/or catheter based treatment) or worsening symptoms of breathlessness, with a lower threshold for surgery in cases with tricuspid valves judged likely reparable (compared with requiring replacement) and in those with what was judged to be an adequate LV and functional RV. This is endorsed by the most recent ESC Guidelines, which advocates surgical repair of TV for patients with more than moderate TR and symptoms (NYHA >II or arrhythmias) or deteriorating exercise capacity on cardiopulmonary exercise testing (Class I, level of evidence C) [7]. For patients who survive to the age of 16 years and are followed up at a tertiary centre, our series suggests that this approach is compatible with good medium term survival. Overall, there were fewer males than expected, 17 (33%) in our series. Other adult series suggest that there is an equal distribution between the sexes [3,9,10]. Our study cohort was also slightly younger compared to previously published cohorts with the mean age at diagnosis of years. Legius et al.[3], reported a mean age at diagnosis of years in a series of 49 patients in 2010 and Attie et al.[10] described a mean age at diagnosis of years in 72 patients. The younger age at diagnosis in our cohort may reflect an increasing rate of referrals to specialised congenital heart clinics for patients as well as perhaps reflecting improving diagnostic tools with TTE and cardiac MRI. Survival There were three deaths (6%) in our series. Legius et al. reported five deaths (10.2%) in their cohort in 2010 [3], whilst

5 1000 Q. Luu et al. Brown et al. reported that 13 (19%) of their cohort had died at a median follow-up of 84 months [11]. Chang et al. reported a similar experience to our own, with only two deaths (4%) in their cohort of patients that survived the neonatal period, and were classified as late presenters [12]. Arrhythmias Eighteen (35%) patients in our series had documented supraventricular arrhythmia, with typical Wolff-Parkinson- White syndrome in eight patients. Our cohort seemed to have a lower incidence of arrhythmias compared to other reports. Legius et al. [3] reported that 52% of their cohort exhibited supraventricular arrhythmia, with the typical Wolff-Parkinson-White syndrome in 15 patients (31%), whilst Chang et al. reported supraventricular tachycardia in 50% of their cohort [12]. The reason for the lower rate of arrhythmia recorded in our population is unclear. We would have expected to see more arrhythmias given the long period of follow-up, on the basis of other published series. Sixteen (30%) of our patients underwent ablation therapy, with long-term relief from arrhythmia achieved in over half (56%) of these, in keeping with the recognised lower success rate in patients with structural heart disease [12]. For those with EA in particular, there are varying reports on the success rates of ablation therapy. Cappato et al. reported a recurrence rate of 23% at months follow-up in a group of 21 patients with EA and accessory atrio-ventricular pathways [13]. Chetaille et al. reported an ablation success rate of 68% at months follow-up, in their cohort of patients with EA [14]. Five (10%) patients in our cohort required pacemaker implantation. Of note, three of these were required following surgical interventions. This is comparable with other cohorts. Legius et al. similarly reported permanent pacemaker implantation in 10% of their cohort. All those who required PM implantation had undergone previous tricuspid valve surgery [3]. Tricuspid Valve Surgery Successful surgery for tricuspid regurgitation in EA was first described in 1962 where the tricuspid valve was replaced by a prosthetic valve [1]. Previously high operative mortality rates have fallen significantly, and are currently reported to be 4% in specialised centres [4]. In our series, 16 (30%) patients had tricuspid valve surgery; 11 tricuspid valve repairs and five tricuspid valve replacements. Seven (14%) patients had undergone tricuspid valve surgery prior to review at our adult centre. In contrast, Legius et al. reported that half of their patients required tricuspid valve surgery, 16 valve repair and nine valve replacement [3]. Likewise, Chang et al. suggested that beyond the neonatal stage, surgeries involving tricuspid valvuloplasty or concomitant Glenn shunts were required in over half of the patients at the age of 40 years [12]. Our series had no operative mortality related to tricuspid valve surgery, however one patient died within 10 days of attempted mitral valve surgery, following prior TV replacement and in the context of multiple re-do sternotomy procedures resulting in dense adhesions. Three (19% of operated) patients in our series required redo tricuspid valve surgery. This is low compared to other series, despite the fact that our follow-up time is longer. Legius et el. reported that 32% of their cohort required redo tricuspid surgery during a mean follow up time of 11.4 years [3]. They recorded similar rates of TV repair (64%) and TV replacement (36%) as the initial surgical intervention. We report lower rates of re-do surgery compared to Legius et al. despite a longer follow-up duration. The reason for this difference is unclear, and may reflect our institution s conservative watchful waiting approach to referral for surgical repair. Limitations Our main limitation was retrospective data from a single institution. Thus for example, chest X-rays and serial echocardiographic imaging were not routinely available for analysis, in many subjects. We were able to, however, obtain complete mortality data from the National Death Registry and thus vital status was known for all cases. Given that this is the only adult congenital heart disease referral centre within the state, the clinical management approach, including referral for surgery or catheter ablation, was fairly uniform. As the patients included within the study were those that survived to 16 years of age and presented to a tertiary level ACHD service, our survival data does not include mortality in childhood or adolescence. Thus, our survival data suggests a favourable long-term outlook for patients that do survive to adolescence and present to a specialist ACHD service for long-term follow-up and cannot be generalised to all EA patients. Treatment strategies were physician-guided, rather than randomised. Compared to other studies, one of the strengths of our series is the longer duration of follow-up available. Finally, several echocardiographic variables were only assessed qualitatively (such as TR severity and RV sizes), rather than by quantification methods (which themselves are imprecise, in the right heart). Conclusions Ebstein s anomaly is a rare form of congenital heart disease with often severe morphological abnormalities. However, our series suggests that it is compatible with good medium to long-term survival in patients who survive to the age of 16 years, when a generally symptom-driven approach to surgical intervention is adopted in a specialist ACHD setting. Conflict of Interest The authors have no conflict of interest to declare related to the manuscript.

6 Ebstein s Anomaly in Those Surviving to Adult Life 1001 Acknowledgements Dr Choudhary is supported by National Health and Medical Research Committee & National Heart Foundation Postgraduate Scholarship No References [1] Attenhofer Jost CH, Connolly HM, Edwards WD, Hayes E, Warnes CA, Danielson GK. Ebstein s anomaly - review of a multifaceted congenital cardiac condition. Swiss Med Wkly 2005;135(19 20): [2] Sommer RJ, Hijazi ZM, Rhodes JF. Pathophysiology of congenital heart disease in the adult: part III: Complex congenital heart disease. Circulation 2008;117(10): [3] Legius B, Van De Bruaene A, Van Deyk K, Gewillig M, Troost E, Meyns B, et al. Behavior of Ebstein s anomaly: single-center experience and midterm follow-up. Cardiology 2010;117(2):90 5. [4] Attenhofer Jost CH, Connolly HM, Scott CG, Burkhart HM, Warnes CA, Dearani JA. Outcome of cardiac surgery in patients 50 years of age or older with Ebstein anomaly: survival and functional improvement. J Am Coll Cardiol 2012;59(23): [5] Celermajer DS, Bull C, Till JA, Cullen S, Vassillikos VP, Sullivan ID. Ebstein s anomaly: presentation and outcome from fetus to adult. J Am Coll Cardiol 1994;23(1): [6] Rahman NM, Chard RB, Thomas SP. Outcomes for surgical treatment of atrial fibrillation using cryoablation during concomitant cardiac procedures. The Annals of Thoracic Surgery 2010;90(5): [7] Baumgartner H, Bonhoeffer P, De Groot NM, de Haan F, Deanfield JE, Galie N, et al. ESC Guidelines for the management of grown-up congenital heart disease (new version 2010). Eur Heart J 2010;31(23): [8] Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA, et al. ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2008;52(23):e [9] Arizmendi AF, Pineda LF, Jiménez CQ, Azcárate MJM, Sarachaga IH, Urroz E, et al. The clinical profile of Ebstein s malformation as seen from the fetus to the adult in 52 patients. Cardiol Young 2004;14(1): [10] Attie F, Rosas M, Rijlaarsdam M, Buendia A, Zabal C, Kuri J, et al. The adult patient with Ebstein anomaly. Outcome in 72 unoperated patients. Medicine (Baltimore) 2000;79(1): [11] Brown M, Dearani J, Danielson G, Cetta F, Connolly H, Warnes C, et al. The outcomes of operations for 539 patients with Ebstein Anomaly. J Thorac Cardiovasc Surg 2008;135: [12] Chang Y-M, Wang J-K, Chiu S-N, Lin MT, Wu ET, Chen CA, et al. Clinical spectrum and long-term outcome of Ebstein s anomaly based on a 26- year experience in an Asian cohort. Eur J Pediatr 2009;168(6): [13] Cappato R, Schluter M, Weiß C, Antz M, Koschyk DH, Hofmann T, et al. Radiofrequency Current Catheter Ablation of Accessory Atrioventricular Pathways in Ebstein s Anomaly. Circulation 1996;94: [14] Chetaille P, Walsh EP, Triedman JK. Outcomes of radiofrequency catheter ablation of atrioventricular reciprocating tachycardia in patients with congenital heart disease. Heart Rhythm 2004;1(Jul (2)):