Mitral valve disease in patients with Marfan syndrome undergoing aortic root replacement

Frequency of Cardiac Valvulopathies in Patients With Marfan Syndrome: A Systematic Review and Meta-Analysis

Marfan syndrome (MFS) is a progressive connective tissue disease with a broad range of clinical manifestations. We sought to establish the spectrum of structural valvular abnormalities as cardiovascular involvement has been identified as the most life-threatening aspect of the syndrome. This was a systematic review with a meta-analysis of studies indexed in Medline from the inception of the database to November 7, 2022. Using the random-effects model, separate Forest and Galbraith plots were generated for each valvular abnormality assessed. Heterogeneity was assessed using the I2 statistics whilst funnel plots and Egger's test were used to assess for publication bias. From a total of 35 studies, a random-effects meta-analysis approximated the pooled summary estimates for the prevalence of cardiac valve abnormalities as mitral valve prolapse 65% (95% CI: 57%-73%); mitral valve regurgitation 40% (95% CI: 29%-51%); aortic valve regurgitation 40% (95% CI: 28%-53%); tricuspid valve prolapse 35% (95% CI: 15%-55%); and tricuspid valve regurgitation 43% (95% CI: 8%-78%). Only one study reported on the involvement of the pulmonary valve (pulmonary valve prolapse was estimated at 5.3% (95% CI: 1.9%-11.1%) in a cohort of 114 patients with MFS). We believe this study provides a description of the structural valvular disease spectrum and may help inform providers and patients in understanding the clinical history of MFS in the current treatment era with its increased life expectancy.

Marfan syndrome

Marfan syndrome (MFS) is an autosomal dominant, age-related but highly penetrant condition with substantial intrafamilial and interfamilial variability. MFS is caused by pathogenetic variants in FBN1, which encodes fibrillin-1, a major structural component of the extracellular matrix that provides support to connective tissues, particularly in arteries, the pericondrium and structures in the eye. Up to 25% of individuals with MFS have de novo variants. The most prominent manifestations of MFS are asymptomatic aortic root aneurysms, aortic dissections, dislocation of the ocular lens (ectopia lentis) and skeletal abnormalities that are characterized by overgrowth of the long bones. MFS is diagnosed based on the Ghent II nosology; genetic testing confirming the presence of a FBN1 pathogenetic variant is not always required for diagnosis but can help distinguish MFS from other heritable thoracic aortic disease syndromes that can present with skeletal features similar to those in MFS. Untreated aortic root aneurysms can progress to life-threatening acute aortic dissections. Management of MFS requires medical therapy to slow the rate of growth of aneurysms and decrease the risk of dissection. Routine surveillance with imaging techniques such as transthoracic echocardiography, CT or MRI is necessary to monitor aneurysm growth and determine when to perform prophylactic repair surgery to prevent an acute aortic dissection.

Mitral Valve Prolapse and Its Motley Crew-Syndromic Prevalence, Pathophysiology, and Progression of a Common Heart Condition

Mitral valve prolapse (MVP) is a commonly occurring heart condition defined by enlargement and superior displacement of the mitral valve leaflet(s) during systole. Although commonly seen as a standalone disorder, MVP has also been described in case reports and small studies of patients with various genetic syndromes. In this review, we analyzed the prevalence of MVP within syndromes where an association to MVP has previously been reported. We further discussed the shared biological pathways that cause MVP in these syndromes, as well as how MVP in turn causes a diverse array of cardiac and noncardiac complications. We found 105 studies that identified patients with mitral valve anomalies within 18 different genetic, developmental, and connective tissue diseases. We show that some disorders previously believed to have an increased prevalence of MVP, including osteogenesis imperfecta, fragile X syndrome, Down syndrome, and Pseudoxanthoma elasticum, have few to no studies that use up-to-date diagnostic criteria for the disease and therefore may be overestimating the prevalence of MVP within the syndrome. Additionally, we highlight that in contrast to early studies describing MVP as a benign entity, the clinical course experienced by patients can be heterogeneous and may cause significant cardiovascular morbidity and mortality. Currently only surgical correction of MVP is curative, but it is reserved for severe cases in which irreversible complications of MVP may already be established; therefore, a review of clinical guidelines to allow for earlier surgical intervention may be warranted to lower cardiovascular risk in patients with MVP.

Non-aortic cardiovascular disease in Marfan syndrome: a nationwide epidemiological study

OBJECTIVES

Studies indicate that other cardiovascular problems than aortic disease are a burden for patients with Marfan syndrome (MFS). The aim of the study was to assess the extent of this issue.

METHODS

A registry-based population study of patients with a Ghent II verified MFS diagnosis. Each patient was matched with up to 100 controls on age and sex. From the Danish healthcare system, we identified 407 MFS patients (from 1977 to 2014) and their cardiovascular events and compared them with those in 40,700 controls. Total follow-up time was 16,439 person years.

RESULTS

Mitral valve disease was significantly more common in MFS [HR: 58.9 (CI 38.1-91.1)] and happened earlier and more often in women than men with MFS [age at first registration: 22 vs. 38 years, HR: 2.1 (CI 1.0-4.4)]. Heart failure/cardiomyopathy was also more common in MFS [HR: 8.7 (CI 5.7-13.4)] and men were more affected than women, and at younger age [39 vs. 64 years, HR: 0.18 (CI 0.06-0.55)]. In all cases, atrioventricular block [HR: 4.9 (1.5-15.6)] was related to heart surgery. Supraventricular [HR: 9.7 (CI 7.5-12.7)] and ventricular tachycardia [HR: 7.7 (CI 4.2-14.3)] also occurred more often than in the control group. The risk of sudden cardiac death was increased [HR: 8.3 (CI 3.8-18.0)] but the etiology was unclear due to lack of autopsies.

CONCLUSION

Non-aortic cardiovascular disease in patients with MFS is exceptionally prevalent and the range of diseases varies between women and men. Physicians caring for MFS patients must be aware of this large spectrum of cardiovascular diseases.

Institutional Marfan syndrome surgical volume influences mitral valve surgical strategy in patients with Marfan syndrome

BACKGROUND/AIM

The goal of this study was to evaluate trends in mitral valve (MV) operations performed on patients with Marfan syndrome (MfS) and determine the influence of an institution's MfS and MV surgical volume on MV surgical strategy in the US.

METHODS

The Nationwide Inpatient Sample was queried from 1998 to 2011 and a total of 1126 patients with MfS were identified who underwent MV operations meeting our inclusion criteria. Linear regression was performed to assess trends of MV repair (MVr) rates over time. Patients were stratified into tertiles depending on the institution's annual MfS and MV surgical volumes. Multivariate analysis was used to determine the impact of institutional MV and MfS surgical volume on whether a patient received an MV replacement (MVR).

RESULTS

The MVR rate was 60% for the entire cohort. There was a decreasing trend of MVR rates during the study period (82% in 1998-99 vs 49% in 2010-2011, P < .05). Multivariate analysis revealed that patients operated on at high (odds ratio [OR], 0.65; P < .05) and medium (OR, 0.66; P < .05) volume MfS centers were less likely to undergo MVR when compared to lower-volume MfS centers. In contrast, MV volume was not a significant predictor of surgical strategy in this cohort.

CONCLUSION

The national MVR rate in the MfS population is higher than published reports. Data from this study suggest that MfS patients with indications for MV surgery should be referred to high-volume MfS surgical centers to have the best opportunity for MVr.

Mid-term outcomes of simultaneous mitral valve repair in patients with miral regurgitation and concomitant annulo-aortic ectasia

OBJECTIVE

This study investigated the mid-term outcomes of simultaneous mitral valve repair in patients with mitral regurgitation (MR) and concomitant annulo-aortic ectasia.

METHODS

The study included 26 patients with MR and annulo-aortic ectasia [mean age 46.0 ± 19.9 (10-86) years] who underwent simultaneous mitral valve repair between January 2007 and March 2018. Of these 26 patients, 11 (42.3%) were diagnosed with Marfan syndrome and 10 (38.5%) with Barlow's disease. All patients underwent complete ring annuloplasty; a semi-rigid ring was used in 14 (53.8%) and a semi-flexible ring (anterior-flexible) in 12 patients (46.2%). All patients underwent valve-sparing root replacement using the reimplantation technique.

RESULTS

The overall 3-year survival rate was 95.7 ± 4.3%. The 3-year freedom from > moderate MR rate was 94.7 ± 5.1%, and the 3-year freedom from > moderate aortic regurgitation (AR) rate was 86.7 ± 7.3%. The 3-year freedom from reoperation rate was 100%. The 3-year freedom from > moderate MR rate was 100% in the semi-rigid ring group and 85.7 ± 13.2% in the semi-flexible ring group (log-rank test, p = 0.5371). The 3-year freedom from > moderate AR rate was 100% in the semi-rigid ring group and 72.9 ± 16.5% in the semi-flexible ring group (log-rank test, p = 0.0815).

CONCLUSIONS

Simultaneous mitral valve repair in patients with MR and concomitant annulo-aortic ectasia showed favorable mid-term outcomes.

Valvular Disease in Marfan Syndrome: Surgical Considerations and Management

PURPOSE OF REVIEW

Detail the current strategies for the management of valve dysfunction in Marfan syndrome (MFS), understand the limitations of surgical interventions, and delineate the likely direction of future innovations.

RECENT FINDINGS

Significant advances in both medical and surgical management of MFS have been made over the last 50 years. This has resulted in improved overall outcomes. As MFS patients age, new clinical challenges that were once rare have emerged and can require complex care strategies. Medical management has seen advances and focuses on anti-impulse and molecular-based pharmacotherapy, along with close monitoring with serial imaging to minimize acute aortic dissection risk by selecting appropriate timing of prophylactic surgical intervention with increasing aortic dimensions. Ongoing trials are evaluating other potential drug therapies with the ultimate goal of targeted treatment. Over the last 50 years, significant advances have been made in the understanding and management of MFS. A move to prophylactic surgery for aortopathy and valve disease has progressed from a valve replacement to a valve-sparing strategy in many cases. However, the durability of these repairs is variable and the possibility of reintervention looms.

Mitral valve prolapse and Marfan syndrome

Marfan syndrome is a multisystemic genetic condition affecting connective tissue. It carries a reduced life expectancy, largely dependent on cardiovascular complications. More common cardiac manifestations such as aortic dissection and aortic valve incompetence have been widely documented in the literature. Mitral valve prolapse (MVP), however, has remained poorly documented. This article aims at exploring the existing literature on the pathophysiology and diagnosis of MVP in patients with Marfan syndrome, defining its current management and outlining the future developments surrounding it.

Surgery for mitral regurgitation in patients with aortic root aneurysm: Transaortic or transseptal approach?

OBJECTIVE

Mitral regurgitation is common in patients with aortic root aneurysm. Mitral valve repair (MVP) or replacement (MVR) can be performed for these patients through either a transverse aortotomy (TA) or transseptal approach (TS). This study sought to compare the early outcomes of mitral valve surgery through the TA and TS approaches and decide which is optimal for this subset of patients.

METHODS

Between March 2013 and April 2015, we operated on 99 patients (81 males, 81.8%) with aortic root aneurysm who developed mitral regurgitation. Mean age was 47.8±16.5years. MVR was performed in 66 patients (TAR=27; TSR=39) and MVP in 33 (TAP=8; TSP=25). The baseline and operative outcomes data were compared between patients with MVR and MVP through the TA vs TS approaches.

RESULTS

Preoperatively, the mitral regurgitation area was significantly larger in the MVR than MVP groups (8.9±2.0 vs 7.8±3.8 cm², p=0.0009), and in the TSP vs TAP groups (8.5±4.1 vs 5.6±1.3cm², p=0.0049), but no significant difference was found between the TAR and TSR groups (8.7±2.2 vs 9.0±1.8cm², p=0.4681); the aortic sinus size was significantly larger in the TAR than TSR group (66.7±15.8 vs 52.1±8.8mm, p=0.0061). Subvalvular structure was preserved in 12 MVR patients (18.2%). In MVP patients, Kay annuloplasty was used in 11 (33.3%) and annuloplastic ring in 22 (66.7%). The times of cardiopulmonary bypass (CPB) and cross-clamp in patients with TA approach were significantly shorter compared to those with the TS approach (139±34 vs 176±38min, p=0.0001; 101±26 vs 129±31min, p=0.0002). No cases of mortality, stroke and renal failure occurred in the whole series. The amount of transfusion, lengths of ICU and hospital stay did not differ between patients with MVR and MVP, and between the TA and TS approaches.

CONCLUSIONS

Both the TA and TS approaches achieved good early outcomes in MV surgery for patients with root aneurysm. The transverse aortotomy was associated with shorter CPB and cross-clamp times. Surgical approaches should be selected according to the underlying mitral valve etiology and the size of the aortic root.