Preoperative arrhythmia evaluation and treatment for Ebstein’s anomaly patients
Treating before treating
As Walsh and his collaborators, including Boston Children’s Chief of Cardiac Surgery Pedro Del Nido, MD, report in Heart Rhythm2, preoperative electrophysiologic studies (EPS) on Ebstein’s patients provide an opportunity to discover and correct rhythm dysfunctions preemptively, reducing the risk of sudden cardiac death following repair of the tricuspid anatomy.
“Arrhythmia problems are common in Ebstein’s, and you don’t want to be surprised after surgery,” Walsh says. “So when we have a patient come in for the cone procedure, we go looking for rhythm troubles and try to treat them before going into surgery.”
The Heart Rhythm paper presents the results of a retrospective review of the outcome of 74 Ebstein’s anomaly patients who underwent the cone procedure at Boston Children’s between 2006 and 2012. Of them, 42 underwent preoperative EPS.
EPS detected arrhythmias in 29 of the 42 patients. Many of these patients—23—had previously known or suspected arrhythmias. However, EPS revealed arrhythmias in eight patients with no prior history of electrophysiological concerns.
Seventeen of the EPS-positive patients underwent catheter ablation at the time of their arrhythmia evaluation; 35 also underwent ablation during their cone surgery. The choice of catheter versus surgical ablation was determined based on the specific arrhythmia, substrate location, patient age and other factors.
The promise of a proactive approach
Given the number of arrhythmias revealed anew by EPS, Walsh isn’t concerned that this more aggressive preoperative approach will lead to overtreatment. “The arrhythmias we found are not ones that will remain silent in the long run,” he cautioned. “These are problems that will cause morbidity or mortality sooner or later.”
Walsh is quick to note that this was an observational study, not a trial designed to draw statistical conclusions. “We set out to show that in our experience you could detect arrhythmias preoperatively in patients with Ebstein’s anomaly, and that you could treat them either in a catheterization or surgical setting,” he said.
That being said, the results do suggest that this more aggressive approach to preoperative evaluation and treatment could potentially benefit Ebstein’s patients in the long run. “If you take care of arrhythmias preoperatively, patients may fare much better postoperatively,” Walsh says.
1. da Silva et al. “The cone reconstruction of the tricuspid valve in Ebstein’s anomaly. The operation: early and midterm results.” J Thorac Cardiovasc Surg. 2007; 133(1):215-23.
2. Shivapour JK et al. “Utility of preoperative electrophysiologic studies in patients with Ebstein’s’s anomaly undergoing the cone procedure.” Heart Rhythm. 2014; 11(2):182-6.