Sleep disordered breathing in Marfan syndrome: Value of standard screening questionnaires

Marfan syndrome

ABSTRACT

This article provides a comprehensive review of Marfan Syndrome (MFS), covering its epidemiology, etiology, clinical presentations, diagnostics, complications, and treatment modalities. The Ghent II Nosology of MFS criteria are crucial in MFS diagnosis, guiding clinicians in identifying high-risk patients. Nursing implications underscore the importance of screenings, assessments, and close follow-ups to optimize the continuum of care for individuals with MFS.

Snoring and aortic dimension in Marfan syndrome

Recent reports suggest that self-reported snoring, which is a feature of obstructive sleep apnea, is associated with aortic enlargement in Marfan syndrome (MFS). Objective assessment of snoring although lacking, could provide a rational for OSA screening in MFS patients. Our goal in this study was to examine the association between objective measurements of snoring with OSA and aortic size in persons with MFS. Consecutive persons with MFS who reported snoring were recruited at Johns Hopkins, completed the Epworth Sleepiness Scale (ESS) and underwent overnight polysomnography during which inspiratory sound was captured. We measured breath-by-breath peak decibel levels and snoring was defined as flow limitation with sound ≥ 40 dB(A). OSA was defined as an apnea-hypopnea-index (AHI) ≥ 15 or AHI: 5-15 and ESS > 10. Participants' aortic data were collated to ascertain aortic root diameter. Regression models were used to determine the relationship of snoring breath% with OSA and aortic root diameter. In our cohort (M|F:13|16, Age: 37.0 ± 15.5 years, Aortic diameter; 38.9 ± 4.8 mm), a 1-unit increase in snoring breath percentage increased the odds of having OSA by 5% in both the unadjusted (OR = 1.05, p = 0.040) model, and a model adjusted for age and sex (OR = 1.05, p = 0.048). Similarly, a 10-unit increase in snoring breath percentage was associated with a 1 mm increase in contemporaneous aortic-root-diameter in both unadjusted (β = 0.09, p = 0.007), and adjusted (β = 0.08, p = 0.023) models. Objective snoring assessment could provide a means for identifying persons with MFS who need sleep studies, who may also be at risk for more severe aortic disease.

Assessment of pleural pressure during sleep in Marfan syndrome

STUDY OBJECTIVES

Patients with Marfan syndrome (MFS) have a high risk for aortic aneurysms. They are also susceptible to sleep-disordered breathing that may expose them to highly negative intrathoracic pressures known to increase aortic transmural pressure which may accelerate aortic dilatation. Our objective was to quantify overnight intrathoracic pressure changes during sleep in snoring patients with MFS, and the therapeutic effect of continuous positive airway pressure (CPAP).

METHODS

We used a questionnaire to identify self-reported snoring patients with MFS. In these patients, we monitored intrathoracic pressure using esophageal pressure (Pes) during overnight baseline and CPAP sleep studies. We defined a peak inspiratory Pes (Pes_peak-insp) < - 5 cmH₂O as greater than normal, and examined the distribution of Pes_peak-insp during baseline and CPAP studies.

RESULTS

In our sample of 23 MFS snorers, we found that 70% of sleep breaths exhibited Pes_peak-insp < -5 cmH₂O, with apneas/hypopneas accounting for only 12%, suggesting prevalent stable flow-limited breathing and snoring. In a subset (n=12) with Pes monitoring during CPAP night, CPAP lowered the mean proportion of breaths with Pes_peak-insp < -5 cmH₂O from 83.7±14.9% to 3.6±3.0% (p<0.001). In addition, contemporaneous aortic root diameter was associated with the mean Pes_peak-insp during IFL and apneas/hypopneas (β= -0.05, r=0.675, p=0.033).

CONCLUSIONS

The sleep state in MFS revealed prolonged exposure to exaggerated negative inspiratory Pes, which was reversible with CPAP. Since negative intrathoracic pressure can contribute to thoracic aortic stress and aortic dilatation, snoring may be a reversible risk factor for progression of aortic pathology in MFS.

Association of sleep apnoea risk and aortic enlargement in Marfan syndrome

Background

Marfan syndrome (MFS) is a connective tissue disorder characterised by complex aortic pathology and a high prevalence of obstructive sleep apnoea (OSA). OSA produces intrathoracic transmural stresses that may accelerate aortic injury. The current study was designed to examine the associations between OSA risk and markers of aortic enlargement in MFS.

Method

Consecutive patients with MFS were recruited at Johns Hopkins if they completed a STOP-BANG survey. Composite survey scores were categorised into those with low OSA risk (STOP-BANG <3) and high OSA risk (STOP-BANG ≥3). Participants’ aortic data were collated to ascertain aortic root diameter, dilatation and prior aortic root replacement. Regression analyses were used to examine associations between OSA risk strata and these aortic parameters.

Results

Of the 89 participants studied, 28% had a high OSA risk and 32% had aortic grafts. Persons with high OSA risk had greater aortic root diameter (mm) (ß=4.13, SE=1.81, p=0.027) and aortic root dilatation (ß=2.80, SE=1.34, p=0.046) compared with those with low OSA risk. In addition, the odds of prior aortic root replacement was three times greater in those with high OSA risk compared with those with low OSA risk.

Conclusion

In MFS, high OSA risk is associated with aortic enlargement and a threefold increased risk of having had prior aortic root replacement. These findings invite further exploration of the relationship between OSA and aortic disease in MFS, and studies to clarify whether targeted interventions for OSA might mitigate aortic disease progression in MFS.

Registration number

IRB00157483.

Sleep disordered breathing in Marfan syndrome: Value of standard screening questionnaires

Background

A high prevalence of sleep disordered breathing (SDB) has been reported in persons with Marfan syndrome (MFS), a single gene disorder of connective tissue resulting in premature death from aortic rupture. The burden of SDB and accompanying hemodynamic stress could warrant broad screening in this population. Our goal was to assess the utility of traditional SDB screening tools in our sample of persons with MFS.

Methods

Participants were recruited during an annual Marfan Foundation meeting and Marfan status confirmed using the Ghent criteria. Screening questionnaires were administered and SDB assessed by home sleep testing. We assessed accuracy of screening tools using receiver‐operating characteristic curve analyses.

Results

The prevalence of moderate‐severe SDB was 32% in our sample of 31 MFS participants. The Stop‐Bang questionnaire had the highest positive predictive value (PPV) of 60% and the highest negative predictive value (NPV) of 100% using the high‐ and moderate‐risk cut‐offs, respectively, and the Berlin questionnaire had a PPV of 50% and an NPV of 92.3% at the high‐risk cut‐off. When those with mild SDB were included, the Stop‐Bang and the Sleep Apnea Clinical Score (SACS) questionnaires demonstrated useful screening accuracies with PPVs of 94.7% and 92.9%, and NPVs of 63.6% and 47.1%, respectively, at the moderate‐risk cut‐offs.

Conclusion

A survey of SDB in a sample of persons with MFS reveals not only a high burden of SDB but also that conventional screening instruments have utility if adapted appropriately. Future studies should validate the utility of these screening tools given concerns that SDB may contribute to progression of aortic pathology in MFS.