@Article{chd.12841,
AUTHOR = {Nicholas Y. Tan, Christine H. Attenhofer Jost, Murray D. Polkinghorne, Emily R. Vargas, David O. Hodge, Joseph A. Dearani, Samuel J. Asirvatham, Heidi M. Connolly, Christopher J. McLeod},
TITLE = {Cerebrovascular accidents in Ebstein’s anomaly},
JOURNAL = {Structural and Congenital Heart Disease},
VOLUME = {14},
YEAR = {2019},
NUMBER = {6},
PAGES = {1157--1165},
URL = {http://www.techscience.com/schd/v14n6/38909},
ISSN = {3071-1738},
ABSTRACT = {<b>Introduction:</b> 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.<br/>
<b>Methods:</b> 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.<br/>
<b>Results:</b> 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.<br/>
<b>Conclusion:</b> 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.},
DOI = {10.1111/chd.12841}
}