Left Ventricular Apical Aneurysm in Fabry Disease: Implications for Clinical Significance and Risk Stratification

Background A previously underrecognized phenotype of left ventricular apical aneurysm (LVAA) has been increasingly identified in Fabry disease. This study explored LVAA's clinical prevalence and its prognostic implications over a long-term follow-up. Methods and Results We retrospectively analyzed 268 consecutive patients with Fabry disease at a tertiary medical center. Patients with increased left ventricular mass index were recognized as having left ventricular hypertrophy (LVH). LVAA was identified using either echocardiography or cardiovascular magnetic resonance imaging. Two patients with ischemic LVAA were excluded. The primary end point was a composite of cardiovascular events, including heart failure hospitalization, sustained ventricular tachycardia, ischemic stroke, and all-cause mortality. Of 266 enrolled patients, 105 (39.5%) had LVH (age 58.5±11.9 years, 48.6% men), and 11 (10.5%) had LVAA. Over 49.3±34.8 months of follow-up, 25 patients with LVH experienced composite events, including 9 heart failure hospitalizations, 4 sustained ventricular tachycardia, 6 ischemic strokes, and 15 mortalities. In patients with LVH, those with LVAA had a significantly higher risk of composite events and lower event-free survival than those without LVAA (8 [72.7%] versus 17 [18.1%], log-rank P<0.001). LVAA was independently associated with an increased risk of composite events (hazard ratio, 3.59 [95% CI, 1.30-9.91]; P=0.01) after adjusting for age, sex, advanced heart failure, renal function, dyslipidemia, atrial fibrillation, left ventricular ejection fraction, left ventricular diastolic function, and left ventricular mass index. Conclusions LVAA is present in approximately 10% of patients with Fabry disease and LVH. It is associated with an increased risk of adverse cardiovascular events and may necessitate aggressive treatment.

Incidentally identified left ventricular apical aneurysm in a patient with Fabry disease

Fabry disease is a rare X-linked lysosomal storage disorder caused by a deficiency in the lysosomal enzyme, galactosidase A, that can result in a progressive increase in the left ventricle (LV) wall thickness from glycosphingolipid deposition leading to myocardial fibrosis, conduction abnormalities, arrhythmias, and heart failure. We present a case of a patient with advanced Fabry cardiomyopathy, in whom a small LV apical aneurysm was incidentally discovered on abdominal imaging, which could have easily evaded detection on standard transthoracic echocardiography. The LV apex should be thoroughly interrogated in patients with Fabry cardiomyopathy, as the finding of LV aneurysm could have important management implications with respect to the prevention of stroke and sudden cardiac death.

Surgical septal myectomy for relief of dynamic obstruction in Anderson-Fabry Disease

Patients with Anderson-Fabry Disease (AFD) and severe left ventricular hypertrophy complicated by left ventricular outflow tract (LVOT) obstruction may benefit from surgical septal myectomy (SSM). Mid- and late outcomes following surgery have not been established, and we sought to better characterize postoperative outcomes following septal myectomy. Between January 2011 and June 2017, 7 patients (6 females) with AFD underwent SSM. The median (range) age at the time of surgery was 53 (37-72) years; 4 patients had a positive family history of AFD and a preoperative diagnosis of AFD. Extracardiac features suggestive of AFD were present in 3 patients and all but 1 (female) had reduced α-galactosidase A activity. All patients had severe left ventricular hypertrophy and LVOT obstruction on transthoracic echocardiography. Preoperatively, all patients were severely symptomatic with New York Heart Association (NYHA) class III symptoms. There was no early mortality following surgery. The median in-hospital length of stay was 5 (4-7) days with 6 patients reporting NYHA class II or less symptoms at 3 month follow-up. Long-term outcomes were favorable with 4 patients reporting sustained NYHA class II or less symptoms, but 2 patients had recurrence of NYHA class III symptoms without evidence of recurrent LVOT obstruction. In conclusion, SSM appears to provide favorable short- and long-term relief of severe, symptomatic LVOT obstruction but may not alter progression of Fabry cardiomyopathy.