Open Access

ARTICLE

Cerebrovascular accidents in Ebstein’s anomaly

Nicholas Y. Tan¹, Christine H. Attenhofer Jost¹, Murray D. Polkinghorne¹, Emily R. Vargas², David O. Hodge², Joseph A. Dearani³, Samuel J. Asirvatham^1,4, Heidi M. Connolly¹, Christopher J. McLeod¹

1 Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
2 Health Sciences Research, Mayo Clinic Florida, Jacksonville, Florida
3 Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
4 Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota

* Corresponding Author: Christopher J. McLeod, Department of Cardiovascular Diseases, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905. Email:

Congenital Heart Disease 2019, 14(6), 1157-1165. https://doi.org/10.1111/chd.12841

Abstract

Introduction: Mechanisms and risk factors for cerebrovascular accidents (CVAs) in Ebstein’s anomaly (EA) are not well understood; hence, we aimed to clarify these in a large cohort of EA patients.
Methods: Patients with a confirmed diagnosis of EA were retrospectively reviewed. Baseline characteristics were compared between patients with and without a prior history of CVA using logistic regression modeling. Cox regression analysis was used to identify predictors of CVA following initial evaluation. CVA incidence from birth and following tricuspid valve surgery were estimated using the Kaplan‐Meier method.
Results: Nine hundred sixty‐eight patients (median age 21.1 years, 41.5% male) were included, in which, 87 patients (9.0%) had a history of CVA (54 strokes, 33 transient ischemic attacks; 5 associated with brain abscesses) prior to their initial evaluation. The odds of atrial septal defect/patent foramen ovale (odds ratio [OR] 4.91; 95% CI 2.60‐21.22; p = .0002) and migraines/headaches (OR 2.38; 95% CI 1.40‐4.04; p = .0013) but not atrial arrhythmias (OR 0.75; 95% CI 0.44‐1.30; p = .31) were sig‐ nificantly higher among patients with prior CVA following multivariable adjustment. Seventeen patients experienced CVA following initial evaluation; no examined vari‐ ables including atrial arrhythmias (HR 2.38; 0.91‐6.19; p = .076) were predictive of CVA risk. The 10‐year, 50‐year, and 70‐year incidences of CVA were 1.4%, 15.9%, and 23.5%, respectively, with paradoxical embolism heavily implicated.
Conclusion: Patients with EA are at substantive risk for CVA. Histories of migraines/ headaches and interatrial shunts should prompt concern for paradoxical embolic CVAs. This has significant implications for all patients with atrial‐level shunting.

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