First described by Wilhelm Ebstein in 1866, Ebstein's anomaly is a congenital malformation of the heart, characterised by apical displacement of the septal and posterior tricuspid valve leaflets, leading to part of the right ventricle becoming part of the right atrium, with a variable degree of malformation and displacement of the anterior leaflet.
- It accounts for less than 1% of cases of congenital heart diseases.
- True prevalence is unknown because mild forms often remain undiagnosed.
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Most cases are sporadic and familial Ebstein's anomaly is rare. Studies have shown both genetic and environmental risk factors:
- The anomaly is more common in twins and in those with a family history of congenital heart disease.
- Environmental factors found in studies include maternal exposure to benzodiazepines. Maternal lithium therapy can rarely lead to Ebstein's anomaly in the baby.
- Ebstein's anomaly presents with a spectrum of congenital abnormalities of the tricuspid valve and the right ventricle.
- The abnormality of the tricuspid valve leads to tricuspid regurgitation. The degree of tricuspid regurgitation is variable, ranging from mild to severe regurgitation.
- Presentation is often between the ages of 10 and 30 years but can present at various stages of life:
- Fetal life: diagnosed incidentally by echocardiography.
- Neonatal life and infancy: presents with cyanosis and/or severe heart failure. Symptoms presenting in infancy often improve as the pulmonary vascular resistance decreases.
- Adult life: fatigue, exertional dyspnoea, cyanosis, tricuspid regurgitation and/or right heart failure and palpitations (arrhythmias are common).
- Additional associated anomalies include bicuspid aortic valves, pulmonary atresia or hypoplastic pulmonary artery, subaortic stenosis, coarctation of the aorta, mitral valve prolapse, accessory mitral valve tissue or muscle bands of the left ventricle, ventricular septal defects and pulmonary stenosis.
- Cyanosis: common and often due to associated atrial right-to-left shunt and/or severe heart failure. Cyanosis is often transient in neonatal life with recurrence in adult life, but may appear for the first time in adult life. In adult life, cyanosis progressively worsens and may be transiently increased due to paroxysmal arrhythmias.
- Fatigue and dyspnoea: due to right ventricular failure and decreased left ventricular ejection fraction.
- Palpitations and sudden cardiac death: due to paroxysmal supraventricular tachycardia or fatal ventricular arrhythmias.
Signs are variable depending on the extent of the anomaly.
- Cyanosis and clubbing: variable degrees of cyanosis, and transient worsening with arrhythmias.
- Precordial asymmetry: usually left parasternal prominence and occasionally right parasternal prominence.
- Jugular venous pressure (JVP): may be normal due to a large, thin-walled right atrium, which can absorb the volume and pressure transmitted from the right ventricle through an incompetent tricuspid valve.
- Signs of right heart failure: ankle oedema, hepatomegaly and ascites. Large A and V waves in the JVP.
- Heart sounds: the first heart sound is widely split with a loud tricuspid component. The second sound is usually normal but may be widely split. The third and fourth heart sounds are often present, even in the absence of congestive heart failure.
- The pansystolic murmur of tricuspid regurgitation is best heard at the lower left parasternal area and sometimes at the apex.
- Accessory pathway-mediated Wolff-Parkinson-White syndrome and supraventricular tachycardia (SVT).
- Cyanotic congenital heart diseases.
- Tricuspid valve dysplasia and prolapse.
- Arrhythmogenic right ventricular cardiomyopathy.
- Atrial septal defect.
- Cases of severe right heart failure.
- Transposition of the great vessels.
- CXR: may be normal or demonstrate cardiomegaly, decreased pulmonary vasculature, large right atrium.
- The ECG is abnormal in most patients with Ebstein's anomaly. There may be tall and broad P waves (right atrial enlargement) and complete or incomplete right bundle-branch block. The R waves in leads V1 and V2 are small. Bizarre abnormalities of the terminal QRS pattern may also be present.
- Echocardiogram: allows definitive diagnosis.
- Cardiac catheterisation: rarely required.
- Electrophysiology studies: can delineate accessory conduction pathways. Right-sided pathways are more common and 50% of patients have multiple pathways.
Non-surgical management of Ebsein's anomaly includes:
- Antibiotic prophylaxis for infective endocarditis.
- Management of heart failure.
- Treatment of arrhythmias.
Increasingly the trend is for operative intervention early in the development of heart failure. Ebstein's anomaly in symptomatic neonates has been shown to be possible, with good survival and excellent functional status.
In patients over 50 years of age with Ebstein's anomaly, surgery is associated with good long-term survival and improved functional status, although long-term survival might be improved by performing surgery earlier.
- Tricuspid valve repair is preferred over valve replacement. Bioprosthetic valves are preferred over mechanical prosthetic valves.
- Both the atrialised portion of the right ventricle and the very dilated, thin-walled right atrium can be resected.
- Associated heart abnormalities:
- Correction of any associated intra-cardiac defects.
- Associated septal defects may be closed.
- Surgical treatment of associated arrhythmias.
- Palliative procedures: are usually reserved for severely ill infants with an otherwise poor prognosis. These include:
- Creation of atrial septal defect.
- Closure of tricuspid valve with plication of the right atrium.
- Maintenance of pulmonary blood flow through an aorto-pulmonary shunt.
- Heart transplantation is appropriate in selected patients.
- Right heart failure.
- Infective endocarditis.
- Paradoxical embolism (passage of thrombus from venous system to arterial system via a septal heart defect); stroke and transient ischaemic attacks.
- Brain abscess due to right-to-left shunt.
- Sudden cardiac death.
- The prognosis depends on severity of the anomaly, degree of tricuspid regurgitation, degree of heart failure, associated anatomical defects and associated arrhythmias.
- Patients presenting in infancy generally have severe disease and a poor prognosis.
- One study found that actual survival for all live-born patients was 67% at 1 year and 59% at 10 years. Predictors of death were echocardiographic grade of severity at presentation, fetal presentation, and right ventricular outflow tract obstruction.
- However, the prognosis for neonatal Ebstein's anomaly has improved with modern surgical techniques. 
- For those patients first presenting in the middle teenage years, approximately 5% of these patients survive beyond the age of 50 years.
- Pregnancy is usually well tolerated in patients with Ebstein's anomaly.
- In rare cases, patients with Ebstein's anomaly have lived for more than 70 years.
Further reading & references
- Attenhofer Jost CH, Connolly HM, Edwards WD, et al; Ebstein's anomaly - review of a multifaceted congenital cardiac condition. Swiss Med Wkly. 2005 May 14;135(19-20):269-81.
- Attenhofer Jost CH, Connolly HM, Dearani JA, et al; Ebstein's anomaly. Circulation. 2007 Jan 16;115(2):277-85.
- Riaz K; Ebstein Anomaly, Medscape, Oct 2012
- Brown ML, Dearani JA, Danielson GK, et al; Effect of operation for Ebstein anomaly on left ventricular function. Am J Cardiol. 2008 Dec 15;102(12):1724-7. Epub 2008 Oct 1.
- Boston US, Goldberg SP, Ward KE, et al; Complete repair of Ebstein anomaly in neonates and young infants: a 16-year follow-up. J Thorac Cardiovasc Surg. 2011 May;141(5):1163-9. Epub 2011 Feb 25.
- Attenhofer Jost CH, Connolly HM, Scott CG, et al; Outcome of cardiac surgery in patients 50 years of age or older with Ebstein anomaly: survival and functional improvement. J Am Coll Cardiol. 2012 Jun 5;59(23):2101-6.
- Jaquiss RD, Imamura M; Management of Ebstein's anomaly and pure tricuspid insufficiency in the neonate. Semin Thorac Cardiovasc Surg. 2007 Fall;19(3):258-63.
- Brown ML, Dearani JA, Danielson GK, et al; Functional status after operation for Ebstein anomaly: the Mayo Clinic experience. J Am Coll Cardiol. 2008 Aug 5;52(6):460-6.
- Riesgo CA, Gomez LG, Higareda SH, et al; [Ebstein anomaly and pregnancy]. Ginecol Obstet Mex. 2008 Aug;76(8):461-7.
|Original Author: Dr Colin Tidy||Current Version: Dr Colin Tidy||Peer Reviewer: Prof Cathy Jackson|
|Last Checked: 10/12/2012||Document ID: 2084 Version: 22||© EMIS|
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