Detection of abnormal aortic elastic properties in asymptomatic patients with Marfan syndrome by combined transoesophageal echocardiography and acoustic quantification

OBJECTIVE

To evaluate the potential value of transoesophageal echocardiography combined with automated border detection and acoustic quantification for the assessment of elastic properties of the thoracic aorta in patients with Marfan syndrome.

SUBJECTS

16 patients with Marfan syndrome and 12 age matched normal controls.

METHODS

Transoesophageal echocardiography was performed in all subjects. Minimum and maximum diameters of the descending thoracic aorta were obtained from M mode images and acoustic quantification was used for the on-line evaluation of cross sectional aortic area and peak positive area changes over time. Compliance, distensibility, and stiffness index were calculated using M mode data and non-invasively measured blood pressure and were compared with the indices derived from acoustic quantification.

RESULTS

Aortic dimensions normalised for body surface area were not statistically different between patients and normal controls, but there were significant differences for all elasticity indices except compliance. Marfan patients had a lower distensibility [4.2 (SD 1.8) v 5.8 (2.1) cm2/dyn, P < 0.05] and a higher stiffness index [9.7 (3.0) v 7.1 (1.8), P < 0.05]. The dynamic indices derived from the acoustic quantification were significantly smaller in Marfan patients [peak positive area change: 5.1 (1.0) v 7.7 (1.7) cm2/s; P < 0.001; and normalised peak positive area change: 2.5 (1.2) v 4.0 (0.8) cm2/s respectively, P < 0.001] and were suitable to discriminate between normal and abnormal elastic properties.

CONCLUSIONS

In Marfan syndrome elastic properties of the descending aorta are significantly different from normal controls, even in the absence of vessel dilatation. In addition to established static indices, indices derived from acoustic quantification reflect dynamic changes of the cross sectional area for the evaluation of regional vessel mechanics. The on-line assessment of peak positive area change allows differentiation from normal individuals and may be more accurate than standard M mode measurements.

Composite graft in annulo-aortic ectasia. Nineteen years' experience without graft inclusion

OBJECTIVE

The original Bentall procedure for the surgery of annulo-aortic ectasia (AAE) includes the risk of leakage and pseudo-aneurysm formation in the coronary anastomosis. To avoid the complications mentioned above we have used the open technique without the graft inclusion. In this study we evaluate our early and late results.

MATERIAL AND METHODS

One hundred consecutive patients with annuloaortic ectasia underwent surgical repair with composite graft between December 1975 and February 1994. In all cases the aneurysmal tissue was radically resected and the origins of the coronary arteries were directly reimplanted to the tube prosthesis. No wrapping was used. Twenty-two patients met the clinical criteria of Marfan syndrome. Thirteen of the patients underwent an emergency operation, because of a rupture of aneurysm in 2 cases and an acute dissection in 11 cases. Additional procedures were performed in 16 patients: mitral valve replacement in 2, coronary artery bypass grafting in 12 patients and in 2 cases the tube prosthesis included aortic arch, too.

RESULTS

The overall hospital mortality was 3.0% (3/100). In the elective group there was one hospital death (1/87; 1.1%). In the emergency group two patients died in the operation room (2/13; 16.7%). There have been 13 late deaths among the 97 hospital survivors (13.4%). Four of the late deaths were surgery related. Routine control angiography was performed in all patients 6 months after surgery. Sixty patients who had lived at least 3 years after surgery were called to reangiography and 53 of them came. No pseudo-aneurysm or leakage at distal anastomosis or coronary anastomosis could be seen. A slight dilatation of one or both coronary origins was observed on 15 patients; 9 of whom had Marfan syndrome.

CONCLUSIONS

The open technique is simple and can be used in all anatomical variations of the annulo-aortic ectasia. The early and late results are at least comparable with those achieved by other techniques.

Lumbar spine in Marfan syndrome

Lumbar spine radiographs of 28 patients with Marfan syndrome and a gender and age-matched control group were evaluated for scoliosis and morphologic changes of the L2, L3, and L4 vertebrae. No patient or control subject had any serious low back problems. The Marfan patients showed a high incidence of scoliosis (64%). The incidence of lumbosacral transitional vertebra was also high (18%). The end plates of the vertebral bodies in the Marfan patients were more biconcave than in the control group. In addition, the transverse processes were longer in relation to the vertebral body width in the Marfan group than in the controls. These findings indicate that biconcave vertebral bodies can be added to the list of skeletal manifestations of the Marfan syndrome, and Marfan syndrome to the list of differential diagnoses for biconcave vertebrae ("codfish vertebrae").

The thoracolumbar spine in Marfan syndrome

We analyzed the prevalence, inheritance, progression, and functional implications of spinal deformity in Marfan syndrome using four different groups of patients. We studied 113 patients who had Marfan syndrome, eighty-two of whom were skeletally immature, in order to characterize the alignment and function of the spine. The patients were selected from a clinic that provides total care with no bias toward the presence of orthopaedic conditions. Scoliosis was identified in fifty-two of the eighty-two patients, and the prevalences for the sexes were equal. The thoracic portion of the curve was convex to the right in all but two patients. The mean kyphosis was greater than that in the general population. Five distinct sagittal profiles were identified on the basis of whether the thoracic kyphosis was within, greater than, or less than normal limits and whether the transition between the kyphosis and lordosis occurred at or caudad to the normal level or whether the curves were reversed. Spondylolisthesis was present in five patients (6 per cent), with a mean slip of 30 per cent. Fourteen pedigrees were studied in depth. There was no familial pattern of the scoliosis. A separate group of fifty-six patients with scoliosis, for whom serial follow-up radiographs were available, was studied for progression. Patients who had a curve of more than 30 degrees had mild progression, and those who had a curve of more than 50 degrees had marked progression (mean, 3 +/- 4 degrees per year). Pain and function of the back were studied in thirty patients who were thirty-five to forty-five years old; these patients were found to be more impaired than matched controls. The presence of scoliosis was associated with pain in the region of the curve in these patients.

Aortic distensibility and stiffness index measured by magnetic resonance imaging in patients with Marfan's syndrome

OBJECTIVES

To use magnetic resonance imaging to measure the elastic properties of the aorta of adults with Marfan's syndrome and to compare these results with those obtained by echocardiography.

PATIENTS AND METHODS

12 patients with Marfan's syndrome and 12 controls matched for age. Transverse luminal areas of the ascending and descending aorta were measured using electrocardiographic gated magnetic resonance imaging. Echocardiography was used to measure the diameter of the ascending aorta and aortic arch in patients with Marfan's syndrome. Blood pressure was measured during both scans.

RESULTS

In diastole, transverse luminal areas of the ascending and descending aorta were significantly greater in patients with Marfan's syndrome when measured by magnetic resonance imaging and corrected for body surface area; P < 0.02 and P < 0.05 respectively. Patients with Marfan's syndrome had a higher stiffness index (112.77 v 5.78, P < 0.05) and a lower distensibility (0.0066 v 0.0105, P < 0.05) than controls. Results produced by MRI and echocardiography were not significantly different.

CONCLUSIONS

Magnetic resonance imaging gives good quality reproducible images of the ascending and descending aorta. In patients with Marfan's syndrome, aortic distensibility and stiffness index measured by magnetic resonance imaging were abnormal (but did not always relate directly to the size of the aorta.

Sensitive detection of abnormal aortic architecture in Marfan syndrome with high-frequency ultrasonic tissue characterization

BACKGROUND

Aneurysmal dilation of the aorta with subsequent rupture or dissection occurs frequently in patients with Marfan syndrome and is the primary cause of morbidity. These complications are related to the altered composition and disorganized structure of the aortic media. Our goal was to use high-frequency ultrasonic tissue characterization to identify these structural changes in abnormal aorta from patients with Marfan syndrome. We measured integrated backscatter and anisotropy of backscatter of ultrasound from specimens of aorta from patients with Marfan syndrome undergoing aortic root replacement and compared these values with those from aortic specimens of patients without clinical aortic pathology.

METHODS AND RESULTS

Aortic tissue was obtained at the time of surgery from 11 patients with Marfan syndrome undergoing repair of an aortic aneurysm or dissection. Normal tissue was obtained at the time of autopsy from 8 patients without evidence of aortic disease. Acoustic microscopy at 50 MHz was performed to measure integrated backscatter from each specimen. The magnitude of ultrasonic anisotropy of backscatter for each tissue type was determined as an index of the three-dimensional (3D) organization of the vessel matrix. The collagen content of each specimen was determined with a hydroxyproline assay. Marfan aortas exhibited less backscatter than did normal aortas (-40.9 +/- 2.9 versus -32.6 +/- 2.2 dB for patients with Marfan syndrome and healthy subjects, respectively, P < .0001). No significant difference in collagen concentrations was observed between normal and Marfan aorta (262.7 +/- 52.7 versus 282.4 +/- 41.8 mg/g tissue for normal and Marfan aortas, respectively, P = .42), despite the large difference in backscatter. Histological analysis revealed striking differences in both the amount and organization of the elastin in the aortic aneurysm segments from patients with Marfan syndrome compared with normal aorta. Normal aorta was characterized by well-formed elastin fibers arranged in a lamellar pattern. The media from aneurysms in Marfan aorta exhibited a profound decrease in elastin content that was associated with loss of the highly aligned and ordered lamellar arrangement. The directional dependence of scattering, or ultrasonic anisotropy, also differed dramatically between the two tissue types. Backscatter from normal aorta decreased substantially when the media was insonified parallel compared with perpendicular to the principal axis of the elastin fibers. Marfan aorta exhibited a much smaller directional dependence of scattering. Normal aortas manifested a 14-fold greater ultrasonic anisotropy than did Marfan aortas (24.1 +/- 3.7 versus 12.4 +/- 3.3 dB for normal and Marfan aortas, P < .0001), which is indicative of the profound extent of matrix disorganization in Marfan syndrome.

CONCLUSIONS

These data show that high-frequency ultrasonic tissue characterization sensitively detects changes in vessel wall composition and organization that occur in the aorta of patients with Marfan syndrome. Aortic segments from these patients manifested a significant decrease in integrated backscatter compared with normal aorta (approximately 8 dB, or greater than a 6-fold decrease in scattering). A 15-fold reduction in the ultrasonic anisotropy of Marfan tissue was observed, which suggests a marked disorganization of the 3D architecture of these aortas. These data support the hypothesis that high-frequency ultrasonic tissue characterization may be useful for identifying abnormalities of vessel wall composition, architecture, and material properties.

Echocardiographic diagnosis of fetal Marfan syndrome at 34 weeks' gestation

Fetal echocardiography was performed during the third trimester in a normal primigravida. The fetal heart was severely affected with the typical cardiac manifestations of Marfan syndrome. The medical history of the father was investigated and a mild form of the syndrome was diagnosed. The neonate died at 2 months of age of congestive heart failure.

Abnormal mechanical properties of the aorta in Marfan's syndrome

OBJECTIVES

Aortic dilatation, dissection and rupture are among the major causes of death in subjects with Marfan's syndrome. The aim of the study was to investigate the mechanical properties or compliance of the aorta in these subjects and compare them with a healthy age- and sex-matched reference population.

MATERIALS AND METHODS

An ultrasound phase-locked echo-tracking system was used to determine diameter and pulsatile diameter change of the infrarenal aorta in nine subjects with Marfan's syndrome which were then compared with the values for 165 healthy individuals. Compliance, defined as the inverse of Ep (pressure strain elastic modulus) or stiffness (beta), was calculated from pulsatile diameter change and blood pressure obtained by the auscultatory method with a sphygmomanometer. For statistical analysis confidence intervals (95%) obtained from the healthy controls were used for comparison. Analysis of covariance (ANCOVA) was performed for the female patients. The sample size for males (n = 2) was too small for the latter analysis.

RESULTS

Compared with normal subjects and their confidence intervals, subjects with Marfan's syndrome had an increased Ep and stiffness (beta) and decreased strain (fractional diameter change) in the infrarenal aorta. Furthermore, ANCOVA in the female patients showed increased beta (p < 0.01) and Ep (p < 0.01) and a decreased strain (p < 0.001). Aortic diameters, MAP, as well as the pulse pressure, were similar in the two groups.

CONCLUSION

This investigation demonstrates alterations in the mechanical properties of the aorta in Marfan's syndrome in the form of increased stiffness of the aortic wall. This may be of importance in the pathogenesis of aortic dissection and rupture.

Relation between age, arterial distensibility, and aortic dilatation in the Marfan syndrome

This study examined the relations between age, arterial distensibility, and systemic hemodynamics in patients with the Marfan syndrome. The study group included 170 patients referred to a specialist clinic, of whom 55 (age 26 +/- 12 years) were diagnosed as having Marfan syndrome. The remaining 115 patients (age 25 +/- 14 years) formed a control group. Each patient underwent echocardiographic examination, with measurement of ascending aorta diameter at end-diastole and end-systole, and aortic flow velocities. The elastic properties of the aorta were indexed by calculation of aortic distensibility, wall stiffness, and systemic pulse wave velocity. Mean end-diastolic aortic diameter in the Marfan group (38 +/- 9 mm) was greater than that in the controls (26 +/- 4 mm, p < 0.01). Resting heart rate and aortic flow velocities were similar in the 2 groups, but systemic arterial pulse pressure was greater in the Marfan group (50 +/- 12 mm Hg) than in the controls (41 +/- 8 mm Hg, p < 0.01). Aortic diameter increased with age in both groups, but at all ages the Marfan group exhibited greater aortic diameters (p < 0.05). Aortic distensibility was less in the Marfan group (2.6 +/- 1.3 cm2.dynes-1 x10(-6)) than in the controls (6.2 +/- 2.1 cm2.dynes-1 x 10(-6), p < 0.01), and the aortic wall stiffness index was greater in the Marfan group (7.9 +/- 3.4) than in the controls (2.8 +/- 0.6, p < 0.01). Aortic wall stiffness increased with age and aortic diameter, but at all ages the Marfan group exhibited a stiffer aorta for a given diameter than did the controls.(ABSTRACT TRUNCATED AT 250 WORDS)

[Diagnosis of pseudoaneurysm of the ascending aorta after implantation of a valved conduit by multiplane transesophageal echocardiography]

In a 48-year-old male patient with Marfan syndrome who underwent composite graft replacement of the ascending aorta and the aortic valve with reimplantation of the coronary arteries a cardiac enlargement was detected by routine chest x-ray. Transthoracal echocardiography showed a pseudoaneurysm around the composite graft. The examination with a multiplane transesophageal echocardiographic probe demonstrated a systolic-diastolic jet into the pseudoaneurysm with the site of origin at the ostium of the right coronary artery.

Metacarpophalangeal pattern profile analysis in Sotos and Marfan syndrome

Patients with Sotos and Marfan syndrome have unusually long metacarpals and phalanges which may make the differential diagnosis difficult in younger children. Using Q-scores, we compared metacarpophalangeal pattern profile (MCPP) analysis in these two syndromes and identified distinct and different pattern profiles. This illustrates that the MCPPs are specific in these syndromes, even at an early age, and not related solely to the unusually long metacarpals and phalanges. For this study we used data from 50 Sotos patients (34 from the United Kingdom and 16 from the Netherlands, with a total of 95 hand films) and 36 Marfan patients (from the Netherlands, with 98 hand films). Of all patients over age 3 years the bone length (including the epiphysis) was determined. The patients under 7 1/2 years (29 Sotos and 12 Marfan) were also measured without inclusion of the epiphysis. The patients measured without epiphysis had a relative short metacarpal 1 (MC1) and long distal phalanx 1 (DPh1) in Sotos syndrome, and a relative long MC1 and short DPh1 in Marfan syndrome. Between age 3 and 7 1/2 years more than 90% of the films could be classified correctly using these two variables. Of the roentgenograms measured with epiphyses, about 80% were classified correctly.

Coronary air embolism complicating accessory pathway catheter ablation: detection by echocardiography

Percutaneous radiofrequency catheter ablation has been recently introduced for treatment of Wolff-Parkinson-White syndrome. Access to left free-wall atrioventricular accessory pathways can be obtained either via retrograde cardiac catheterization or via the transseptal procedure, which allows ablation of the accessory pathway at its ventricular or atrial insertion, respectively. We describe a patient with Wolff-Parkinson-White syndrome in whom coronary air embolism occurred as a complication of transseptal percutaneous radiofrequency catheter ablation. The diagnosis was made by two-dimensional echocardiography showing a marked echocontrast effect in the posterior wall and in the posterior half of the interventricular septum. A grossly evident breakage of the rubber seal of the vascular sheath was supposed to be the cause of air insinuation. This report suggests that the transseptal approach should be used with caution in performing percutaneous radiofrequency catheter ablation to avoid the risk of air embolization. Two-dimensional echocardiography is an ideal tool to detect this complication.

Echocardiographic diagnosis of mitral valve prolapse

The present editorial, besides providing a historical review, offers a succinct definition and a new classification and terminology. It is hoped that this or a similar classification would clarify some of the confusion surrounding the diagnosis of mitral valve prolapse. The current echocardiographic criteria are reviewed. Some difficulty in the diagnosis of milder forms of prolapse is inevitable because a distinction between normal bulging and excessive hooding may be subtle in such cases. The proposed criteria using multiple echocardiographic cross sections (rather than the long-axis view alone) is more likely to provide a comprehensive visualization of several components of the leaflets and avoid errors of underdiagnosis of localized myxomatous prolapse abnormality. The criteria and discussion are based on the author's experience and interest in the diagnosis of this condition and clinical correlations with intraoperative findings. If the cardiac surgeons and the echocardiologists could agree on a common terminology and classification scheme, it could result in better anatomic correlations of the echocardiographic findings in this condition and potentially result in improved patient care.

Left ventricular function in children with the Marfan syndrome

Aortic dilatation and heart valve lesions are common in the Marfan syndrome but whether primary alterations occur in left ventricular (LV) function has not been studied hitherto. LV size, mass and systolic as well as diastolic function were studied by M-mode and Doppler echocardiography and cine magnetic resonance imaging in 22 Marfan children aged 3.0-15.4 years and in 22 age-matched healthy children. No child had significant valve disease. Heart rate and systolic blood pressure were comparable in the groups but diastolic blood pressure was higher in the controls (67 +/- 7 mmHg vs 62 +/- 8 mmHg, P = 0.030). No statistically significant differences were found in LV size, mass or systolic function. The Marfan children had slower LV peak diameter lengthening rates (106 +/- 27 mm.s-1 vs 132 +/- 29 mm.s-1, P = 0.004), prolonged relaxation times (155 +/- 22 ms vs 140 +/- 19 ms, P = 0.023), slower deceleration of the early transmitral velocity (580 +/- 144 cm.s-1 vs 720 +/- 160 cm.s-2, P = 0.006), and smaller early-to-late peak velocity ratios (1.99 +/- 0.40 vs 2.29 +/- 0.46, P = 0.031). These data indicate that LV early diastolic function (relaxation) is impaired in the Marfan syndrome. Weakened elastic recoil due to the underlying connective tissue abnormality may best explain this novel observation.

Aortic valve repair in patients with Marfan syndrome and ascending aorta aneurysms due to degenerative disease

Patients with Marfan syndrome may require aortic surgery because of aortic insufficiency, aortic root aneurysm, ascending aortic aneurysm, or acute type A aortic dissection. The aortic valve leaflets are often overstretched and the fibrosa layer is damaged in many patients, particularly in those with all the stigmata of Marfan syndrome. However, in some patients the leaflets are normal or only minimally stretched in spite of aortic insufficiency. In these patients the aortic valve can be satisfactorily repaired. When significant annuloaortic ectasia is present, the reconstructive procedure consists of excising all three aortic sinuses and reimplanting the aortic valve inside a Dacron graft. If the annuloaortic ectasia is mild and the principal problem is loss of the sinotubular junction because of aneurysmal dilatation of the sinuses of Valsalva, aortic valve repair is accomplished by replacing one, two, or all three aortic sinuses with a properly tailored Dacron graft. The first type of aortic valve repair has been performed in 18 patients with one early and one late failure. The other 16 patients remained well from 3 to 50 months. The second type of aortic valve repair has been performed in 15 patients during the past 3 years without any failure and all patients remain well. Therefore, in selected patients with aortic insufficiency due to aortic root and/or ascending aorta aneurysm secondary to degenerative disease, the aortic valve can be repaired with satisfactory results.

Bone mineral status of women with Marfan syndrome

PURPOSE

With effective surgical correction of vascular abnormalities, skeletal health is an important issue for patients with Marfan syndrome. Osteopenia has been radiographically described, yet no systematic evaluation of bone status has been published. The purpose of this study was to determine the bone mineral density (BMD, g/cm2) in women with Marfan syndrome.

PATIENTS AND METHODS

Seventeen women, 37.2 +/- 7.3 years old, with Marfan syndrome were studied. Dual energy x-ray absorptiometry (DXA) was used to measure BMD at the lumbar spine (L2-L4), proximal femur, and total body in all subjects. Scoliosis scores were assigned from 0 (no curvature) to 3 (severe curvature).

RESULTS

Highly significant deficits in BMD were observed at the proximal femur (p = 0.0001) as well as of the whole body (p < 0.05). Femoral neck BMD Z-score (mean +/- SD) = -1.36 +/- 0.94, trochanter Z = -1.07 +/- 0.80, and intertrochanter Z = -1.44 +/- 0.71; whole-body BMD Z-score = -0.30 +/- 0.16. BMD at L2-L4, however, did not differ from age-predicted values, Z = -0.48 +/- 1.16. There was no significant association between BMD and scoliosis, nor between BMD and fracture history. To correct for bone size, the bone mineral apparent density (BMAD, g/cm3) was calculated. The femoral neck BMAD values (mean +/- SD) were significantly lower than predicted (0.125 +/- 0.02 versus 0.147 +/- 0.001 g/cm3, p < 0.001). All subjects had normal menarche, and 15 reported regular menses. There was no history of nontraumatic fracture.

CONCLUSIONS

Women with Marfan syndrome have bone deficits at the proximal femur as well as of the whole body. This deficit is not related to scoliosis and persists when corrected for bone size. Women with Marfan syndrome may be at increased risk for proximal femoral fracture.

[Isolated proximal fibula fracture in Marfan syndrome]

An isolated fracture of the proximal fibular shaft without associated tibial or ankle injury and without resulting from direct violence is extremely rare. This report presents a case of an unusual isolated proximal fibular fracture (stress-fracture) in a female tennis-player with Marfan-syndrome. The literature is reviewed and diagnosis, treatment and etiology are discussed.

Marfan syndrome with myocarditis demonstrated by 99Tcm-HMPAO-labelled WBC and 201Tl scintigraphy: report of three cases in a Chinese family

Marfan syndrome is a heritable disorder of connective tissue in which the most prominent abnormalities occur in the ocular, cardiovascular and skeletal systems. Although cardiovascular complications are infrequent in patients under 20 years of age, whenever they do occur, they are the major cause of death. Here we report three cases in a Chinese family with clinical evidence of myocarditis associated with Marfan syndrome. The 99Tcm-hexamethylpropyleneamine oxime (HMPAO)-labelled white blood cell and 201Tl single photon emission computed tomographic heart scans show indications of an inflammatory process involving the myocardium. After comparison with the pathology results, the accuracy of these studies is seen to be 100%. We thus introduce these simple methods to evaluate myocardial viability in patients with Marfan syndrome.

The natural history of aortic dilatation in Marfan syndrome

OBJECTIVES

To determine the relationship between age and aortic dilatation in patients with Marfan syndrome and to define the rate of progression of aortic dilatation in these patients.

DESIGN

All patients were evaluated in a multidisciplinary clinic to establish a firm diagnosis of Marfan syndrome. Aortic dimensions were measured by echocardiography and patients with Marfan syndrome were followed up with annual physical and echocardiographic examinations to detect any change in aortic diameter over the subsequent four years.

PATIENTS

One hundred and fifty-seven patients were referred to the clinic for assessment, of whom 40 exhibited diagnostic features of Marfan syndrome. Only 24 of these patients had previously been diagnosed with Marfan syndrome, while 17 other patients, previously diagnosed with Marfan syndrome, had insufficient clinical features to justify the diagnosis.

RESULTS

Among the 40 patients (19 male, 21 female) with Marfan syndrome (mean age, 28 +/- 15 years), the prevalence of cardiovascular abnormalities was 90%. Aortic root dilatation was present in 78% of patients, aortic regurgitation in 28%, mitral valve prolapse in 65% and mitral regurgitation in 35%. Mean aortic root diameter in the Marfan patients (21.4 +/- 4.0 mm/m2 body surface area) markedly exceeded that of age and sex matched controls without Marfan syndrome (14.9 +/- 2.2 mm/m2) and that of first-degree relatives without Marfan syndrome (15.3 +/- 2.9 mm/m2). The occurrence of aortic dilatation in Marfan syndrome was variable, with patients as young as 20 years exhibiting severe dilatation. All patients with Marfan syndrome exhibiting aortic dilatation were advised to take beta-adrenergic blocking drugs, unless contraindicated, in an effort to retard the rate of aortic dilatation. Among 33 patients followed up for at least one year, 14 (42%) exhibited an increase in aortic diameter of at least 2 mm, while 16 of 23 patients (70%) followed up for at least three years exhibited similar progression of aortic dilatation. The overall mean rate of dilatation in the Marfan patients was 1.9 mm per year. Nine patients developed aortic dilatation of more than 50 mm diameter during four years' follow-up and required surgical repair of the aorta. Each of these patients is well at between three months' and four years' follow-up.

CONCLUSIONS

Aneurysmal dilatation of the aorta is a common complication of Marfan syndrome and may become manifest at an early age. Furthermore, aortic dilatation can progress rapidly, even in the absence of symptoms. Individuals with Marfan syndrome should have annual echocardiographic examinations to monitor aortic root dimensions, and those exhibiting rapid progression of aortic dilatation or an aortic root diameter in excess of 50 mm, should be considered for elective composite graft repair of the aorta.

Cardiovascular manifestations of Marfan's syndrome: improved evaluation by transoesophageal echocardiography

OBJECTIVES

To assess the value of transoesophageal echocardiography in patients with Marfan syndrome particularly those with suspected aortic pathology or where conventional transthoracic imaging was suboptimal.

DESIGN AND PATIENTS

Eleven patients with Marfan syndrome. Seven patients were studied because of suspected aortic dissection and four because of inadequate transthoracic imaging.

INTERVENTION

Transoesophageal echocardiography and colour Doppler flow mapping by a 5 MHz single plane transoesophageal probe.

RESULTS

Aortic dissection was identified in six patients with subsequent diagnostic confirmation in all six. No dissection was found in one patient in whom the diagnosis had been suspected clinically. Estimates of aortic root dimensions and assessment of aortic and mitral valve pathology were made in four other patients with inadequate transthoracic imaging.

CONCLUSIONS

Transoesophageal echocardiography provides rapid diagnostic information in patients with Marfan syndrome with suspected aortic dissection and enhances the assessment of cardiovascular manifestations of this condition.

Color flow and conventional echocardiography of the Marfan syndrome

Imaging and color flow Doppler echocardiography are an integral part of any evaluation of a patient with the Marfan syndrome. The major cardiovascular manifestations of this condition are aortic dilation, which may involve the proximal and distal aorta, aortic regurgitation, aortic dissection, mitral valve prolapse, and mitral regurgitation. Patients who have the Marfan syndrome should have serial echocardiograms to measure aortic root diameter carefully at the sinuses of Valsalva and subsequent levels (sinotubular junction, arch, descending and abdominal aorta). Additionally, color Doppler echocardiography assists in the diagnosis of aortic dissection and facilitates evaluation of the severity of aortic and mitral regurgitation that commonly complicate the Marfan syndrome. The risk of aortic dissection, which is the most serious manifestation of the Marfan syndrome, increases as the aorta enlarges. Therefore, elective composite graft surgery is recommended when the aortic root size reaches 60 mm, regardless of symptom status, or 55 mm in the presence of severe aortic regurgitation. Surgical replacement of the aortic root with a composite graft does not end the disease process. Color flow Doppler is useful in the diagnosis of dehiscence of the conduit sewing ring, coronary artery aneurysm, distal aortic dissections, and prosthetic valve dysfunction.