| Ebstein's anomaly |
|
Pathological specimen and ultrasound image of a heart with Ebstein's anomaly. Abbreviations: RA: Right atrium; ARV: Atrialized right ventricle; FRV: Functional right ventricle; AL: Anterior leaflet; SL: Septal leaflet; LA: Left atrium; LV: Left ventricle; asterisk: grade II tethering of the tricuspid septal leaflet.
|
| Classification and external resources |
| Specialty |
medical genetics |
| ICD-10 |
Q22.5 |
| ICD-9-CM |
746.2 |
| OMIM |
224700 |
| DiseasesDB |
4039 |
| MedlinePlus |
007321 |
| eMedicine |
med/627 |
| MeSH |
D004437 |
|
[edit on Wikidata]
|
Ebstein's anomaly is a congenital heart defect in which the septal and posterior leaflets of the tricuspid valve are displaced towards the apex of the right ventricle of the heart.
Contents
- 1 Presentation
- 2 Risk factors
- 3 History
- 4 Related abnormalities
- 4.1 Anatomic abnormalities
- 4.2 Electrophysiologic abnormalities
- 5 Management
- 5.1 Pharmacological
- 5.2 Surgical
- 6 References
- 7 External links
Presentation
The annulus of the valve is still in the normal position. The valve leaflets, however, are to a varying degree, attached to the walls and septum of the right ventricle. There is subsequent 'atrialization' of a portion of the morphologic right ventricle (which is then contiguous with the right atrium). This causes the right atrium to be large and the anatomic right ventricle to be small in size.
- S3 heart sound
- S4 heart sound
- Triple or quadruple gallop due to widely split S1 and S2 sounds plus a loud S3 and/or S4
- Systolic murmur of tricuspid regurgitation = Holosystolic or early systolic murmur along the lower left sternal border depending on the severity of the regurgitation
- Right atrial hypertrophy
- Right ventricular conduction defects
- Wolff-Parkinson-White syndrome often accompanies
Risk factors
There is an enlargement of the aorta; there may be an increased risk of abnormality in infants of women taking lithium during the first trimester of pregnancy[1] (though some have questioned this)[2] and in those with Wolff-Parkinson-White syndrome.
History
Ebstein's anomaly was named after Wilhelm Ebstein,[3][4] who in 1866 described the heart of the 19-year-old Joseph Prescher.
Related abnormalities
While Ebstein's anomaly is defined as the congenital displacement of the tricuspid valve towards the apex of the right ventricle, it is often associated with other abnormalities.
Anatomic abnormalities
Typically, there are anatomic abnormalities of the tricuspid valve, with enlargement of the anterior leaflet of the valve. The other leaflets are described as being plastered to the endocardium.
About 50% of individuals with Ebstein's anomaly have an associated shunt between the right and left atria, either an atrial septal defect or a patent foramen ovale. [5]
Electrophysiologic abnormalities
About 50% of individuals with Ebstein's anomaly have evidence of Wolff-Parkinson-White syndrome, secondary to the atrialized right ventricular tissue.
10-lead ECG of a woman with
Ebstein's anomaly. The ECG shows signs of right atrial enlargement, best seen in V1. Other P waves are broad and tall, these are termed "Himalayan" P waves. There is also a right bundle branch block pattern and a first degree atrioventricular block (prolonged PR-interval) due to intra-atrial conduction delay. There is no evidence of a Kent-bundle in this patient. There is T wave inversion in V1-4 and a marked Q wave in III; these changes are characteristic for Ebstein's anomaly and do not reflect ischemic ECG changes in this patient.
Other abnormalities that can be seen on the ECG include:
- signs of right atrial enlargement or tall and broad 'Himalayan' P waves
- first degree atrioventricular block manifesting as a prolonged PR-interval
- low amplitude QRS complexes in the right precordial leads
- atypical right bundle branch block
- T wave inversion in V1-V4 and Q waves in V1-V4 and II, III and aVF.[6]
Management
Pharmacological
Ebstein's cardiophysiology typically presents as an (antidromic) AV reentrant tachycardia with associated pre-excitation. In this setting, the preferred pharmacological treatment agent is procainamide. Since AV-blockade may promote conduction over the accessory pathway, drugs like beta blockers, calcium channel blockers and digoxin are contraindicated.
If there is atrial fibrillation with pre-excitation, treatment options include procainamide, flecainide, propafenone, dofetilide and ibutilide since these medications slow conduction in the accessory pathway causing the tachycardia and should be administered before considering electrical cardioversion. Intravenous amiodarone may also convert atrial fibrillation and/or slow the ventricular response.
Surgical
The Canadian Cardiovascular Society (CCS) recommends surgical intervention for the following indications:[7]
- Limited exercise capacity (NYHA III-IV).
- Increasing heart size (cardiothoracic ratio greater than 65%).
- Important cyanosis (resting oxygen saturation of less than 90%). (Level B)
- Severe tricuspid regurgitation with symptoms.
- Transient ischemic attack or stroke
The CCS further recommends patients who require operation for Ebstein's anomaly should be operated on by congenital heart surgeons who have substantial specific experience and success with this operation. Every effort should be made to preserve the native tricuspid valve.[7]
References
- ^ Attenhofer Jost CH, Connolly HM, Dearani JA, Edwards WD, Danielson GK (2007). "Ebstein's anomaly". Circulation. 115 (2): 277–85. doi:10.1161/CIRCULATIONAHA.106.619338. PMID 17228014.
- ^ Yacobi S, Ornoy A (2008). "Is lithium a real teratogen? What can we conclude from the prospective versus retrospective studies? A review". Isr J Psychiatry Relat Sci. 45 (2): 95–106. PMID 18982835.
- ^ synd/435 at Who Named It?
- ^ W. Ebstein. Über einen sehr seltenen Fall von Insufficienz der Valvula tricuspidalis, bedingt durch eine angeborene hochgradige Missbildung derselben. Archiv für Anatomie, Physiologie und wissenschaftliche Medicin, Leipzig, 1866, 238-254.
- ^ كتاب A Practical Approach to Clinical Echocardiography, p.119 Jaypee Brothers, First Edition 2014, ISBN 978-93-5152-140-2.
- ^ Khairy P, Marelli AJ (December 2007). "Clinical use of electrocardiography in adults with congenital heart disease". Circulation. 116 (23): 2734–46. doi:10.1161/CIRCULATIONAHA.107.691568. PMID 18056539.
- ^ a b Silversides, C. K.; Salehian, O.; Oechslin, E.; Schwerzmann, M.; Vonder Muhll, I.; Khairy, P.; Horlick, E.; Landzberg, M.; Meijboom, F.; Warnes, C.; Therrien, J. (2010). "Canadian Cardiovascular Society 2009 Consensus Conference on the management of adults with congenital heart disease: Complex congenital cardiac lesions". The Canadian journal of cardiology. 26 (3): e98–117. doi:10.1016/S0828-282X(10)70356-1. PMC 2851473. PMID 20352139.
External links
|
Wikimedia Commons has media related to Ebstein's anomaly. |
- Ebstein's Malformation information from Seattle Children's Hospital Heart Center
- Ebstein's Anomaly at Cardiopedia
- Overview and diagram at Mayo Clinic
- Information and support for those affected by Ebstein's anomaly
- Ebstein's anomaly information for parents.
|
Congenital heart defects (Q20–Q24, 745–746)
|
|
Cardiac shunt/
heart septal defect |
| Aortopulmonary septal defect |
- R→L: Double outlet right ventricle
- Transposition of the great vessels
- Persistent truncus arteriosus
|
|
| Atrial septal defect |
- L→R: Sinus venosus atrial septal defect
- Lutembacher's syndrome
|
|
| Ventricular septal defect |
- L→R and R→L: Eisenmenger's syndrome
- R→L, with other conditions: Tetralogy of Fallot
|
|
| Atrioventricular septal defect |
|
|
|
Valvular heart disease/
heart chambers |
| Right |
- pulmonary valves
- tricuspid valves
- stenosis
- atresia
- Ebstein's anomaly
- Hypoplastic right heart syndrome
|
|
| Left |
- aortic valves
- stenosis
- insufficiency
- bicuspid
- mitral valves
- Hypoplastic left heart syndrome
|
|
|
| Other |
- Dextrocardia
- Levocardia
- Cor triatriatum
- Crisscross heart
- Brugada syndrome
- Coronary artery anomaly
- Anomalous aortic origin of a coronary artery
- Ventricular inversion
|