Post-operative arrhythmias after tricuspid valve surgery in Ebstein's anomaly: incidence, predictors, and the role of pre-operative electrophysiology study

Background

Patients with Ebstein’s anomaly (EA) undergoing tricuspid valve surgery are at risk of post-operative (post-op) arrhythmias due to accessory pathway (AP), supraventricular tachycardia (SVT), atrial fibrillation (AF), atrial flutter (AFl), and ventricular tachycardia (VT). Current guidelines recommend routine pre-operative (pre-op) electrophysiology study (EPS) in all EA patients undergoing tricuspid valve surgery.

Purpose

To determine the incidence and predictors of late postoperative arrhythmias following tricuspid valve surgery in patients with EA, and to evaluate the impact of preoperative EPS on arrhythmic outcomes.

Methods

We retrospectively analyzed all consecutive patients with EA who underwent tricuspid valve surgery at our Clinic between 2010 and 2024. Clinical, echocardiographic, and surgical data were obtained from medical records. The primary endpoint was sustained tachyarrhythmia (>30 seconds) occurring ≥30 days after surgery, including SVT, VT, AF, or AFl. Cox proportional hazards modeling was used to identify predictors of postoperative arrhythmias.

Results

Among 718 patients with EA (median age 21 years [IQR 9–42], 46% male), 212 (29%) underwent preoperative EPS. EPS was performed in 50 (43%) patients with a prior history of sustained arrhythmia or pre-excitation on electrocardiogram and in 162 (27%) patients without known arrhythmia.

During a median follow-up of 3.1 years (IQR 0.4–7.5), 117 patients (16%) developed one or more sustained arrhythmias. Postoperative arrhythmias included AF in 56 patients (7.8%), AFl in 40 (5.6%), SVT in 37 (5.2%), and VT/sudden cardiac death in 13 (1.9%).

On univariable analysis, older age at surgery, prior EPS, preoperative sustained arrhythmia, reduced left ventricular ejection fraction (LVEF), and reduced tricuspid annular plane systolic excursion (TAPSE) were associated with postoperative arrhythmias. (Figure 1) Kaplan–Meier analysis demonstrated a higher incidence of postoperative arrhythmias among patients who underwent preoperative EPS in the overall cohort (p < 0.001). (Figure 2A) However, in the subgroup without prior arrhythmia or pre-excitation (n = 400), preoperative EPS was not associated with a significant difference in postoperative arrhythmia incidence (p = 0.20). (Figure 2B)

Conclusion

Sustained arrhythmias occurred in 16% of EA patients undergoing tricuspid valve surgery with AF and AFl being most common. Patients with reduced left and right ventricular function and those undergoing valve replacement were at a higher risk. In patients without a known history of arrhythmias or pre-excitation, pre-op EPS was not associated with reduced post-op arrhythmias. Additional studies are needed to assess strategies to prevent post-op atrial arrhythmias including surgical techniques and medical management in high-risk individuals.univariable analysis arrhythmia predictorsKaplan Meier time to arrhythmia analysis