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Psychotropic Use during Pregnancy
Published in “Bert” Bertis Britt Little, Drugs and Pregnancy, 2022
Three congenital anomalies (5 percent) were reported among 60 infants exposed to lithium in utero, which is not different from the background rate in the general population (Schou and Amidsen, 1971). Among 50 women who took lithium during gestation, one infant had myelomeningocele, one had unilateral hernia, and none had congenital heart defects (Cunniff et al., 1989). No maternal history of lithium ingestion was found among 40 infants with Ebstein’s anomaly and in 44 with tricuspid atresia (Kallen, 1988). The risk of Ebstein’s anomaly and other birth defects was reevaluated, and the risk of cardiac anomalies appears to be much less than estimated in previous studies (Cohen et al., 1994; Miller, 1994a, 1996). The early recommendation that women who take lithium salts during early gestation should undergo prenatal diagnosis with fetal echocardiography (Allan et al., 1982) is still valid (Yonkers et al., 2004). The risk of birth defects associated with lithium was probably overestimated in the past (Yonkers et al., 2004). The risk is “likely to be weak if it exists” and the ‘data certainly do not support the 30-fold increased risk of Ebstein’s anomaly suggested by the Register of Lithium Babies’ (Moore, 1995). Nonetheless, first-trimester exposure to lithium is an indication for a fetal echocardiogram, targeting the competence and function of the tricuspid valve.
Adult Congenital Heart Disease
Published in Takahiro Shiota, 3D Echocardiography, 2020
Pastora Gallego, Silvia Montserrat
2D TTE is one of the most important tests in the evaluation of Ebstein anomaly. The key echocardiographic findings include exaggerated apical displacement of the tricuspid annulus (≥8 mm/m2) compared with the mitral annulus in an apical four-chamber view and a dysplastic TV with RV dysfunction24 (Figure 16.26). Table 16.2 summarizes characteristics of Ebstein anomaly demonstrable by 2D echocardiography.
OSCE 11 – Explain Lithium Therapy
Published in Bhaskar Punukollu, Michael Phelan, Anish Unadkat, MRCPsych Part 1 In a Box, 2019
Bhaskar Punukollu, Michael Phelan, Anish Unadkat
5. Explain practical points – Blood tests initially at baseline including thyroid function, renal function, urea and electrolytes. A baseline ECG will also be required. Blood will be tested weekly until the correct plasma level is reached, then every 3–6 months. Ask if the patient is planning to get pregnant and explain that they will need to tell the team in advance if this is the case. If asked, risks to the unborn include Ebstein’s anomaly. The patient may wish to stop Lithium before conception and restart in the 3rd trimester. Breast feeding should not be performed when taking Lithium. If Lithium is stopped altogether, there is a high chance (50%) of relapse especially after child birth.
Management for atrial arrhythmias in adults with complex congenital heart disease
Published in Expert Review of Cardiovascular Therapy, 2023
Victor Waldmann, Christophe Vô, Stefano Bartoletti, Francis Bessière, Marie Wilkin, Nabil Dib, Nicolas Combes, Paul Khairy
In patients with Ebstein anomaly, right atrial dilation predisposes to various types of atrial arrhythmias [35]. The most common arrhythmia is cavotricuspid isthmus-dependent IART, although circuits may also propagate around atrial incisions and septal scars in patients with prior surgical repair [36,37]. Arguments can also be made in support of routine electrophysiological studies in patients without documented arrhythmias to unmask and address potential arrhythmic substrates by catheter ablation before surgery or to inform concomitant surgical ablation [38]. Replacing a tricuspid valve or inserting an annuloplasty ring can compromise future attempts to ablate accessory pathways along the right atrioventricular groove or to electrically block the cavotricuspid isthmus. Acute success rates for catheter ablation of substrates around the tricuspid annulus were reported to be 94%, 92%, and 73% in patients with no surgery, tricuspid valve repair, and tricuspid valve replacement or ring, respectively [39]. In patients with a prosthetic tricuspid valve, ablation along the ventricular side of the annulus is sometimes required to achieve bidirectional block for cavotricuspid isthmus-dependent IART [40]. Atrial fibrillation and other left atrial arrhythmias can also occur in patients with Ebstein anomaly, especially in those with left atrial enlargement due to acquired comorbidities or right-to-left-shunting.
Peripartum anesthetic management in patients with Ebstein anomaly: a case series
Published in Baylor University Medical Center Proceedings, 2023
Carmelina Gurrieri, Emily E. Sharpe, Heidi M. Connolly, Carl H. Rose, Katherine W. Arendt
Ebstein anomaly (EA) is a rare congenital cardiac malformation that affects 1 in 10,000 to 1 in 50,000 live births1 and is characterized by abnormalities of both the tricuspid valve leaflets and the right ventricle (RV)1(Figure 1). Typically, the valve is displaced and presents various degrees of regurgitation. The RV is divided into two portions: the more proximal, referred to as the “atrialized” RV, and the more distal, functional RV, which is typically small, and it can be affected by an inherent myopathy with declining function over time.2 Patients with EA may have other associated cardiac abnormalities, including atrial septal defect or patent foramen ovale, with a right-to-left shunt and an RV outflow tract obstruction. Arrhythmias are also common, including atrial fibrillation, atrial flutter, and Wolff-Parkinson-White syndrome.2 Pregnant women affected by EA are at increased risk of adverse outcomes, such as fetal loss, premature birth, cesarean delivery (CD), postpartum hemorrhage, congenital heart disease in offspring, and major adverse cardiac events, including congestive heart failure and arrhythmias requiring intervention.3–5 We retrospectively assessed the peripartum anesthetic management and outcomes of patients with EA who delivered at our institution.
Ebstein’s anomaly during pregnancy: experience from a tertiary care centre – a case series and review of literature
Published in Journal of Obstetrics and Gynaecology, 2022
J. Yavana Suriya, Ashwini Raj, Ajith Ananthakrishna Pillai, Santhosh Satheesh, Nishad Plakkal, Pankaj Kundra, Anish Keepanasseril
Ebstein’s anomaly is a rare congenital cardiac anomaly, with wide functional and morphological spectrum of abnormalities of the tricuspid valve (TV) and right ventricle. Usually, it is associated with other lesions such as ASD (80–94%), patent foramen ovale, Wolf Parkinson’s White syndrome, first degree heart block (50%), RBBB or pulmonary hypertension or tricuspid atresia (30%) (Smith et al. 1982). Cyanosis, dyspnoea from cardiac failure being the commonest symptoms in the early childhood and those presenting in the adolescence or as adult usually have palpitations, fatigue or decreased exercise tolerance. Even though it could be diagnosed with foetal echocardiography, in the absence of a systematic foetal or neonatal cardiac screening in low to middle income countries, it may present for the first-time during pregnancy as in our case series.