Mitral insufficiency in Marfan's syndrome. A case report of surgical correction

Marfan's syndrome. Broad spectral surgical treatment cardiovascular manifestations

Most patients with Marfan's syndrome have cardiovascular manifestations and complications of these abnormalities lead to death in 50% of patients by the age of 32. This report is concerned with the performance of 79 operations to control these problems in 41 patients during a 16-year period. There were 3 early deaths and 11 late deaths, with survival at 15 years in 62%. The cardiovascular manifestations assumed eight patterns of involvement, in brief, consisting of aneurysms of ascending aorta, mitral valve insufficiency, aortic dissection and dissecting aortic aneurysm, and degenerative distal fusiform aortic aneurysm. These lesions occurred in isolated form or in association with others, hence the larger number of patterns of involvement. Various methods were employed in treatment of aneurysms of the ascending aorta, which was associated with aortic valvular insufficiency in most. The most reliable method of controlling disease at this level was composite valve graft replacement of fusiform aneurysms and separate valve graft operation for dissections occurring in the previously uninvolved aorta. Isolated mitral valve insufficiency was relieved by standard mitral valve replacement and this operation could be safely combined with composite valve graft replacement of the ascending aorta. More distant aneurysms of the aorta, either degenerative or chronic dissections, were susceptible to reconstruction as employed in the nonMarfan patient. Treatment of multiple lesions was staged, treating the more symptomatic condition first. Regular follow-up examination is important in these patients to detect new lesions and to evaluate known lesions. An aggressive approach is suggested in their treatment because 63% of the 11 late deaths in this series were due to lesions that could be successfully treated by presently available methods.

Mitral valve dysfunction in the Marfan syndrome. Clinical and echocardiographic study of prevalence and natural history

Although mitral regurgitation and fibromyxomatous thickening of the mitral leaflets have long been recognized as such, mitral valve prolapse has only recently been added as one of the pleiotropic features of the Marfan syndrome. The prevalence, age of onset, and natural history of mitral valve dysfunction in this condition are uncertain. Therefore, all patients in one clinic who met strict diagnostic criteria for the Marfan syndrome and who had clinical and echocardiographic examinations before age 22 years were reviewed. Of the 166 patients (84 males, aged 11.9 +/- 0.6 years [mean +/- SEM]; and 82 females, 11.0 +/- 0.6 years), 52 percent had auscultatory and 68 percent had echocardiographic evidence of mitral valve dysfunction, generally mitral valve prolapse. Prevalence did not differ between the sexes. Follow-up in 115 patients averaged five examinations over a mean of four years; 17 percent were followed for more than six years. Criteria for progression of mitral valve dysfunction were: (1) on auscultation, the appearance of new systolic clicks or apical systolic murmurs, a mitral regurgitant murmur increased by two grades, or appearance of congestive heart failure not due to aortic regurgitation; and (2) on echocardiography, the new appearance of mitral valve prolapse or abnormally increased left atrial dimension. Nearly half the patients met at least one criterion and one quarter had both auscultatory and echocardiographic evidence of progressive mitral valve dysfunction. Twice as many females demonstrated worse mitral valve function with time. Eight of the 166 patients either died as a result of mitral valve dysfunction or required mitral valve replacement. Severe mitral regurgitation developed in an additional 15 patients. Rupture of chordae tendineae was uncommon. Antibiotic prophylaxis was routine, and no cases of bacterial endocarditis of the mitral valve occurred. These results suggest that mitral valve dysfunction is extremely common in young patients with Marfan syndrome and usually presents as mitral valve prolapse. Serious mitral regurgitation develops in one of every eight patients by the third decade. Thus, the prevalence and natural history of mitral valve prolapse in the Marfan syndrome appear distinct from mitral valve prolapse associated with other conditions, including idiopathic or familial mitral valve prolapse.

Maternal and fetal complications of pregnancy in the Marfan syndrome

The medical literature reports 32 women affected by the Marfan syndrome who had at least one pregnancy; 16 died of and four survived acute aortic dissection. Most of the women who suffered an aortic complication in association with pregnancy had pre-existing aortic regurgitation, aortic root dilatation or other severe cardiovascular problem. Because women with the Marfan syndrome usually desire children, our clinic records were reviewed and patients were contacted to determine a more representative estimate of maternal risks. The pregnancy histories of women with the Marfan syndrome were compared with those of spouses of men with the Marfan syndrome and those of mothers of a sporadic (new mutation) child with the Marfan syndrome. One of 26 women with the Marfan syndrome died shortly after pregnancy of endocarditis; she was the only woman to have a severe, pre-existing cardiovascular condition. The prevalences of milder pregnancy-associated cardiovascular and general complications did not differ among the study groups. The rate of early spontaneous abortion was higher in women with the Marfan syndrome than in either control group. These results suggest the risk of maternal death is low in women with the Marfan syndrome who have minimal cardiovascular disease. Women with the Marfan syndrome should be counseled regarding pregnancy risks only after review of their cardiovascular status, including an echocardiographically determined aortic root diameter.

The Marfan syndrome: surgical technique and follow-up in 50 patients

Fifty patients with Marfan's syndrome underwent operation at the National Heart Hospital because of cardiovascular complications. Forty-six had an aneurysm of the ascending aorta, 13 had chronic dissection, and 6 had acute dissection of the aortic wall. Forty-three aortic valves were incompetent, and five were stenotic and incompetent. One mitral valve had minor regurgitation. The Starr-Edwards prosthesis was used in 36 patients, homograft valves in 4, fascia lata valves in 2, and xenograft valves in 6. The ascending aorta was replaced with a Dacron tube in 40 patients and with an aortic homograft in 2. Three patients required Dacron patches over the aneurysm, and 1 patient had plication of the aortic wall. Early mortality totaled 12% (6 patients). Only 1 of these patients died in the last five years. Reoperations for homograft incompetence, periprosthetic leak, and acute dissection of an unreplaced aorta resulted in 1 hospital death (33%). Forty-three patients have been followed for up to 8.5 years (mean, 3.5 years), with 7 late deaths (46.2%). The improvement in recent surgical results with decreased operative mortality supports an aggressive surgical approach to Marfan's syndrome in view of the poor prognosis for the natural history of this disease.

Replacement of the mitral valve, aortic valve, and ascending aorta with coronary transplantation in a child with the Marfan syndrome

A girl with the Marfan syndrome is described who developed mitral regurgitation, an aneurysm of the ascending aorta, and severe aortic regurgitation. Complete surgical correction required mitral valve, aortic valve, and ascending aorta replacement with transplantation of the origin of the coronary arteries.

The cardiovascular complications of the Marfan syndrome are discussed and the previously described surgical techniques for dealing with aortic or mitral involvement are briefly reviewed. A simpler and safer method for replacement of the complete ascending aorta with coronary artery transplantation is described.