Prevalence and factors associated with masked hypertension in chronic kidney disease

OBJECTIVES

Optimal blood pressure (BP) control is key to prevent cardiovascular complications in patients with chronic kidney disease (CKD). We described the prevalence and factors associated with masked hypertension in CKD.

METHODS

We analyzed 1113 ambulatory 24-h BP monitoring (ABPM) records of 632 patients referred for kidney function evaluation. Masked hypertension was defined as office BP less than 140/90 mmHg but daytime BP at least 135/85 mmHg or nighttime BP at least 120/70 mmHg. Factors associated with masked hypertension were assessed with mixed logistic regression models.

RESULTS

At inclusion, 424 patients (67%) had controlled office BP, of whom 56% had masked hypertension. In multivariable analysis conducted in all visits with controlled office BP ( n  = 782), masked hypertension was positively associated with male sex [adjusted OR (95% confidence interval) 1.91 (1.16-3.27)], sub-Saharan African origin [2.51 (1.32-4.63)], BMI [1.11 (1.01-1.17) per 1 kg/m 2 ], and albuminuria [1.29 [1.12 - 1.47] per 1 log unit), and was negatively associated with plasma potassium (0.42 [0.29 - 0.71] per 1 mmol/L) and 24-h urinary potassium excretion (0.91 [0.82 - 0.99] per 10 mmol/24 h) as well as the use of renin-angiotensin-aldosterone (RAAS) blockers (0.56 [0.31 - 0.97]) and diuretics (0.41 [0.27 - 0.72]).

CONCLUSION

Our findings support the routine use of ABPM in CKD, as more than half of the patients with controlled office BP had masked hypertension. Weight control, higher potassium intake (with caution in advanced CKD), correction of hypokalemia, and larger use of diuretics and RAAS blockers could be potential levers for better out-of-office BP control.

Evaluation of the Specificity of the 2023 Duke-International Society of Cardiovascular Infectious Diseases Classification for Infective Endocarditis

BACKGROUND

The 2023 Duke-ISCVID (International Society of Cardiovascular Infectious Diseases) classification is a new diagnostic tool for infective endocarditis, updating the 2000 modified Duke and the 2015 European Society for Cardiology (ESC) classifications. In comparison, its sensitivity is higher; however, its specificity remains to be evaluated and compared to that of the 2 other classifications in endocarditis suspected patients.

METHODS

We retrospectively collected the characteristics of patients hospitalized in Bichat University's Hospital, Paris, in 2021, who had been evaluated for clinical suspicion of endocarditis, have had at least a transthoracic echocardiography, 2 pairs of blood cultures, 3-month follow-up and in whom endocarditis diagnosis was finally rejected. All patients were classified by 2000 modified Duke, 2015 ESC and 2023 Duke-ISCVID, as though the endocarditis diagnosis had not been rejected.

RESULTS

In total, 130 patients' charts were analyzed. Mean age was 62 years, 84 (64.6%) were male, 39 (30.0%) had prosthetic cardiac valve or valve repair, 21 (16.2%) cardiac implanted electronic device, and 30 (23.1%) other cardiac conditions. Overall, 5, 2, and 5 patients were falsely classified as definite endocarditis with the 2000 modified Duke, 2015 ESC, and 2023 Duke-ISCVID classifications, respectively. The corresponding specificities were 96.2% (95% confidence interval [CI] [90.8%, 98.6%]), 98.5% (95% CI [93.9%, 99.7%]), and 96.2% (95% CI [90.8%, 98.6%]). The rates of possible endocarditis were of 38%, 35%, and 35% in the 3 classifications, respectively.

CONCLUSIONS

The 2023 Duke-ISCVID classification is highly specific for ruling out the diagnosis of definite infective endocarditis in patients who had been evaluated for IE.

Association between nocturnal blood pressure dipping and chronic kidney disease

Introduction

Management of blood pressure (BP) in chronic kidney disease (CKD) is critical for preventing cardio-renal complications. While increasing attention has been given to discrepancies between office and ambulatory BP control in this population, information on nocturnal BP decrease patterns (dipping) in CKD is still scarce.

Purpose

We aimed at describing nocturnal BP dipping patterns and its predictors in patients with CKD.

Methods

We analysed data from patients with CKD stages 1 to 5 referred for kidney function testing from September 2006 to January 2022, including 24-hour urine collection, gold-standard measurement of glomerular filtration rate (GFR) using clearance of a radioisotopic tracer, as well as ambulatory BP measurement (ABPM) in a single tertiary hospital in Paris, France. A total of 1177 ABPM were available in 642 participants. The magnitude of dipping was calculated as the difference between day- and night-time systolic BP (SBP), in percentage of daytime SBP. Participants were then categorized as extreme-dippers (≥20%), dippers (10% to <20%), non-dippers (0% to <10%), or reverse-dippers (<0%). Factors associated with a less than 10% dipping were analysed with crude and adjusted logistic regression models including a random intercept to deal with clustering of measurements within patients.

Results

Participants (mean age 56±15 years; 35% female, mean GFR 49±21 mL/min per 1.73 m2) consisted of 8% extreme-dippers, 37% dippers, 40% non-dippers, and 15% reverse-dippers. The prevalence of non- or reverse-dipping increased with CKD severity, from 36% in CKD stage 1 to 65% in CKD stages 4–5 (Figure). In crude analyses, African origin, a lower measured GFR, a higher daytime SBP, diabetes, a higher number of antihypertensive medications and a higher 24-hour urinary sodium to potassium ratio (24h Na/K) were associated with abnormal dipping status. In the multivariable adjusted regression, non or reverse dipping was independently associated with measured GFR (odds ratio [OR, 95% confidence interval] per 10 ml/min/1.73 m2 decrease = 1.16 [1.06–1.26], p=0.001), daytime ambulatory SBP (OR per 10 mmHg decrease = 1.17 [1.06–1.28], p=0.001), African origin (OR= 1.56 [1.04–2.34], p=0.03) and 24h Na/K (OR per 1-unit increase = 1.20 [1.06–1.37], p=0.006).

Conclusions

The prevalence of nocturnal non-or reverse dipping BP profiles increases substantially across the spectrum of CKD. Measured GFR, ambulatory daytime SBP, African origin and 24-hour urinary sodium to potassium ratio are independent predictors of abnormal nocturnal BP decrease and thus may help in cardiovascular risk stratification in this population. More research is needed on whether nocturnal dipping may be a treatment target to reduce cardiorenal complications.

Funding Acknowledgement

Type of funding sources: None.

Neurologic Outcomes of Survivors of COVID-19-Associated Acute Respiratory Distress Syndrome Requiring Intubation

OBJECTIVES

To describe 3-6-month neurologic outcomes of survivors of COVID-19-associated acute respiratory distress syndrome, invasively ventilated in the ICU.

DESIGN

A bicentric prospective study during the two first waves of the pandemic (March to May and September to December, 2020).

SETTING

Two academic hospital ICUs, Paris, France.

PATIENTS

Adult COVID-19-associated acute respiratory distress syndrome survivors, invasively ventilated in the ICU, were eligible for a neurologic consultation between 3 and 6 months post ICU discharge.

INTERVENTIONS

Follow-up by face-to-face neurologic consultation.

MEASURES AND MAIN RESULTS

The primary endpoint was favorable functional outcome defined by a modified Rankin scale score less than 2, indicating survival with no significant disability. Secondary endpoints included mild cognitive impairment (Montreal Cognitive Assessment score < 26), ICU-acquired weakness (Medical Research Council score < 48), anxiety and depression (Hospital Anxiety and Depression score > 7), and posttraumatic stress disorder (posttraumatic stress disorder checklist for Diagnostic and Statistical Manual of Mental Disorders 5 score > 30). Of 54 eligible survivors, four non-French-speaking patients were excluded, eight patients were lost-to-follow-up, and one died during follow-up. Forty-one patients were included. Time between ICU discharge and neurologic consultation was 3.8 months (3.6-5.9 mo). A favorable functional outcome was observed in 16 patients (39%) and mild cognitive impairment in 17 of 33 patients tested (52%). ICU-acquired weakness, depression or anxiety, and posttraumatic stress disorder were reported in six of 37 cases (16%), eight of 31 cases (26%), and two of 27 cases (7%), respectively. Twenty-nine patients (74%) required rehabilitation (motor, cognitive, or psychologic). ICU and hospital lengths of stay, tracheostomy, and corticosteroids were negatively associated with favorable outcome. By contrast, use of alpha-2 agonists during ICU stay was associated with favorable outcome.

CONCLUSIONS

COVID-19-associated acute respiratory distress syndrome requiring intubation led to slight-to-severe functional disability in about 60% of survivors 4 months after ICU discharge. Cognitive impairment, muscle weakness, and psychologic symptoms were frequent. A large multicenter study is warranted to allow identification of modifiable factors for improving long-term outcome.

Exercise Limitation in Survivors of Severe Acute Respiratory Syndrome associated with novel coronavirus

Aim

There are increasing reports of persisting exertional dyspnea several months after acute SARS-CoV-2 infection. The aim of this study was to evaluate pulmonary, cardiac, and functional capacity of SARS-CoV-2 survivors at 3 months after initial diagnosis by performing cardio-pulmonary exercise testing (CPET).

Methods

CPET was proposed to all patients who were treated both in and out of hospital settings at a tertiary university hospital at 3 months (± 1 month) after the diagnosis of SARS-CoV-2 infection.

Results

A total of 114 patients were included in the study. The median age was 57 [48–66] and 30% were women. 91% required in-hospital treatment during the initial SARS-CoV-2 infection and 22% needed intensive care unit (ICU) admission. At 3-month follow-up, 51% of patients were still symptomatic and 40% reported dyspnea at exertion. During CPET, 71% of patients had impairment of exercise capacity, mostly due to muscle deconditioning (43%) and/or hyperventilation (16%). In multivariable-adjusted analysis, age (β= 0.4, P = 0.002), ICU stay (β= −10.27, P = 0.017), endotracheal intubation and mechanical ventilation (β= −12.63, P = 0.004) and total hospital length of stay (β= −0.24, P = 0.009) were independently associated with % predicted oxygen uptake (peak VO₂) (Fig. 1).

Conclusion

The majority of SARS-CoV-2 survivors had impairment of exercise capacity at 3 months after initial illness, mostly due to muscle deconditioning and exercise hyperventilation. Age and factors related to initial disease severity such as ICU stay and mechanical ventilation were predictive of worse performance during CPET.

Aortic tortuosity is related to aortic phenotype in patients with bicuspid aortic valve: a CT scan study of 83 cases

Background

Although the incidence of aortic dissection is higher in patients with bicuspid aortic valve (BAV) compared to tricuspid aortic valve (TAV), risk stratification remains unclear. Guidelines focus on ascending aorta diameters, regardless of the location, and do not take into account the morphology of the aorta. Aortic tortuosity (AT) is emerging as a novel biomarker associated with more severe aortopathy in patients with Marfan syndrome. AT has not been accuretely assessed in BAV.

Our aim is to describe the relationship between AT and ascending aortic phenotype in patients with BAV.

Methods

83 patients (43±16 years, 19 women) diagnosed with BAV and without significant aortic valve disease nor prior aortic intervention were included. CT scans were retrospectively analysed with measurements of aortic diameters and aortic tortuosity. For 61 patients with abdominal images available, descending and total aortic length and tortuosity were measured.

Results

In our cohort, 62 (75%) patients presented a typical BAV. Pathological aorta (Root and/or tubular Z-score &gt;2) was found in 80 patients (96%) and 67 (81%) presented a tubular dilatation. The aortic phenotype, the maximal aortic diameters and aortic tortuosity index were similar in typical and atypical BAV.

Total aortic tortuosity index was correlated to Z-score tubular diameter (r=0.31; p=0,014) but not with Z-score Valsalva diameter (p=0,55). In patients with tubular dilatation (Z score &gt;2), total aortic tortuosity index was higher than in patient without tubular dilatation (2.01 vs 1.85; p=0,015).

Conclusion

Total aortic tortuosity is associated with tubular dilatation but not with root dilatation in BAV patients suggesting that tubular phenotype may be at higher risk of complication in BAV. Further studies evaluating the association between aortic tortuosity and clinical outcomes in BAV are needed.

Funding Acknowledgement

Type of funding sources: None.

Genotype-phenotype correlations in Marfan syndrome patients with FBN1 mutations: a cohort study on 1575 patients

Background

Marfan syndrome (MFS) is a connective tissue disorder in which several systems are affected with great phenotypic variability. Although known to be associated with pathogenic variants in the FBN1 gene, few genotype-phenotype correlations have been found in probands' studies only.

Purpose

The aim of this study is to provide survival curves and genotype-phenotype correlations in all patients with FBN1 mutations, probands and relatives.

Methods

We established survival curves and sought genotype–phenotype correlations in a population of 1575 consecutive MFS patients with pathogenic class 4 or 5 variants in the FBN1 gene. This population represents the most comprehensive clinical database worldwide on MFS.

Results

Global survival was 90% at 60 years. However, lifelong aortic event rate (either dissection or surgery) and survival were impacted by the genotype. Premature termination codons (PTC), resulting in haploinsufficiency, were associated with a shorter life expectancy and a high lifelong risk of an aortic event (83%). Interestingly, these variants were also associated with the highest risk of severe scoliosis (52%) and with a lower risk for ectopia lentis (EL) surgery (13%). Dominant negative in-frame pathogenic variants could be subdivided according to their impact on the cysteine content of fibrillin-1: cysteine loss (–Cys) was associated with high aortic risk (73%) and a higher frequency of EL surgery (43%); cysteine addition was associated with moderate aortic risk (29%) and the highest frequency of EL surgery (48%); unchanged cysteine content was associated with high aortic risk (61%) and lower frequency of EL surgery (23%). No gene-region effect was observed, except for a more severe phenotype for in-frame variants with cysteine loss within the “neonatal region”. Aortic risk was greater for males in all subgroups, and probands were more severely affected.

Conclusions

MFS genotype-phenotype correlations related to pathogenic FBN1 variants exist for aortic and extra-aortic features. This leads us to propose new tools to refine the prognosis in this population. Preventive therapy with β-blockers and restricted exercise should be proposed regardless of the aortic diameter in the high aortic risk groups (PTC and –Cys variants). These results have major consequences on genetic counseling and personalized medicine for patients carrying a FBN1 mutation. This study also improves the overall understanding of the role of FBN1 in various organs.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Fondation Coeur et Recherche, Paris, FranceFédération Française de Cardiologie, Paris, France Patients with PTC vs. in-frame mutationsDifferences within in-frame mutations

Pregnancy in women with bicuspid aortic valve

Background

Aortic dissection during pregnancy is uncommon, however, the risk of aortic dissection is increased if there is underlying aortopathy. Bicuspid aortic valve (BAV) is common in the general population and is associated with the presence of an aortic aneurysm, but this condition is mostly asymptomatic and ignored in women of childbearing age. Data on pregnancy in patients with BAV are scarce, and guidelines on this topic are based on the consensus opinion of experts. The risk of occurrence of aortic dissection as a function of aortic diameter during pregnancy remains poorly known in women with BAV.

Purpose

To investigate demographic and echocardiographic characteristics and aortic events associated with pregnancy in women with BAV and to estimate ascending aortic diameter at the time of pregnancy.

Methods

We performed a retrospective study using data from our tertiary centre. All women seen at our centre between 1996 and 2020 with BAV, at least 1 pregnancy, and no genetic syndrome were included. We have collected data from echocardiograms performed in and out of our centre and aortic events.

Assuming from the literature an annual aortic dilation rate of 0.2 mm at the sinus of Valsalva and 0.4 mm at the tubular ascending aorta, we estimated ascending aortic size and Z-score at the time of pregnancy.

Results

We identified 47 women with BAV with occurrence of 103 pregnancies. The median age of BAV diagnosis was 43 years. The aorta was measured at a median of 13.3 years since the last delivery. At BAV diagnosis, the median largest ascending aortic diameter was 44mm, and the median Z-score was +4.3. Ascending aortic diameter was ≥40mm in 37/47 (79%) and Z-score ≥2 in 44/47 (94%).

No aortic dissection was observed during pregnancy and postpartum in all 103 pregnancies.

At the time of pregnancy, the estimated median diameter of the ascending aorta was 37mm and the estimated median Z-score was +3.3. The largest aortic diameter during pregnancy was estimated to be ≥40mm in 36/103 pregnancies, ≥45mm in 13/103, and ≥50mm in 1/103; Z-score was estimated to be ≥2 in 81/103 and ≥4 in 40/103.

Type A aortic dissection occurred in 1 woman, 13 years after pregnancy, and type B aortic dissection in 1 woman, 14 years after pregnancy. Planned surgery was performed in 8 women at a median of 17.5 years after the last pregnancy: 1 isolated aortic valve replacement and 7 prophylactic aortic surgeries associated with aortic valve surgery.

Conclusions

In our population of women with BAV, pregnancy is not associated with the occurrence of aortic dissection even though, when estimating aortic diameter at the time of pregnancy, the rate of aortic dilation was high (Z-score ≥2 in 81/103 pregnancies). Prospective studies of a large population of women with BAV are needed to assess the risk of aortic complication during pregnancy according to aortic diameter.

Funding Acknowledgement

Type of funding sources: None.

Hyperventilation as one of the mechanisms of persistent dyspnoea in SARS-CoV-2 survivors

There are increasing reports of persistent dyspnoea several months after the onset of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection [1]. In most cases, functional disability seems out of proportion compared to residual pulmonary function impairment [2]. To date, knowledge about the functional limitations following a SARS-CoV-2 infection remains limited.

Inadequate exercise hyperventilation should not be overlooked while exploring the causes of exertional dyspnoea in SARS-CoV-2 survivorshttps://bit.ly/3AxOiDh

Alteration of Diffusion Capacity After SARS-CoV-2 Infection: A Pathophysiological Approach

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has affected millions of people worldwide, and pneumonia affects 90% of patients. This raises the possibility of millions of people with altered lung function. Few data exist to date on pulmonary function after SARS-CoV-2 infection, but alteration of diffusion capacity of CO (D_LCO) is the most frequently described abnormality. First, we present original data on lung function at 3 months after SARS-CoV-2 infection and discuss the effect of using European Coal and Steel Community (ECSC) or Global Lung Function Initiative (GLI) reference equations to diagnose diffusion capacity. Second, we review existing data on D_LCO alteration after SARS-CoV-2 infection and discuss the implication of restrictive disorder in D_LCO alteration. Last, we discuss the pathophysiology of D_LCO alteration and try to disentangle vascular damage and fibrosis.

Hyperventilation: A Possible Explanation for Long-Lasting Exercise Intolerance in Mild COVID-19 Survivors?

Since the outbreak of the coronavirus (COVID-19) pandemic, most attention has focused on containing transmission and addressing the surge of critically ill patients in acute care settings. As we enter the second phase of the pandemic, emphasis must evolve to post-acute care of COVID-19 survivors. Persisting cardiorespiratory symptoms have been reported at several months after the onset of the infection. Information is lacking on the pathophysiology of exercise intolerance after COVID-19. Previous outbreaks of coronaviruses have been associated with persistent dyspnea, muscle weakness, fatigue and reduced quality of life. The extent of Covid-19 sequelae remains to be evaluated, but persisting cardiorespiratory symptoms in COVID-19 survivors can be described as two distinct entities. The first type of post-Covid symptoms are directly related to organ injury in the acute phase, or the complications of treatment. The second type of persisting symptoms can affect patients even with mild initial disease presentation without evidence of organ damage. The mechanisms are still poorly qualified to date. There is a lack of correlation between initial symptom severity and residual symptoms at exertion. We report exercise hyperventilation as a major limiting factor in COVID-19 survivors. The origin of this hyperventilation may be related to an abnormality of ventilatory control, by either hyperactivity of activator systems (automatic and cortical ventilatory control, peripheral afferents, and sensory cortex) or failure of inhibitory systems (endorphins) in the aftermath of pulmonary infection. Hyperventilation-induced hypocapnia can cause a multitude of extremely disabling symptoms such as dyspnea, tachycardia, chest pain, fatigue, dizziness and syncope at exertion.

Pathogenic FBN1 Genetic Variation and Aortic Dissection in Patients With Marfan Syndrome

BACKGROUND

Aortic risk has not been evaluated in patients with Marfan syndrome and documented pathogenic variants in the FBN1 gene.

OBJECTIVES

This study sought to describe aortic risk in a population with Marfan syndrome with pathogenic variants in the FBN1 gene as a function of aortic root diameter.

METHODS

Patients carrying an FBN1 pathogenic variant who visited our reference center at least twice were included, provided they had not undergone aortic surgery or had an aortic dissection before their first visit. Aortic events (aortic surgery or aortic dissection) and deaths were evaluated during the 2 years following each patient visit. The risk was calculated as the number of events divided by the number of years of follow-up.

RESULTS

A total of 954 patients were included (54% women; mean age 23 years). During follow-up (9.1 years), 142 patients underwent prophylactic aortic root surgery, 5 experienced type A aortic dissection, and 12 died (noncardiovascular causes in 3, unknown etiology in 3, post-operative in 6). When aortic root diameter was <50 mm, risk for proven type A dissection (0.4 events/1,000 patient-years) and risk for possible aortic dissection (proven aortic dissection plus death of unknown cause, 0.7 events/1,000 patients-years) remained low in this population that was treated according to guidelines. Three type A aortic dissections occurred in this population during the 8,594 years of follow-up, including 1 in a patient with a tubular aortic diameter of 50 mm, but none in patients with a family history of aortic dissection. The risk for type B aortic dissection in the same population was 0.5 events/1,000 patient-years.

CONCLUSIONS

In patients with FBN1 pathogenic variants who receive beta-blocker therapy and who limit strenuous exercise, aortic risk remains low when maximal aortic diameter is <50 mm. The risk of type B aortic dissection is close to the remaining risk of type A aortic dissection in this population, which underlines the global aortic risk.

Electrocardiographic and echocardiographic abnormalities associated with mitral valve prolapse in patients with Marfan syndrome

Introduction

Marfan syndrome (MFS) is responsible for cardiovascular disorders such as aortic aneurism and mitral valve prolapse (MVP).

A malignant MVP phenotype combining clinical, electrical and morphological features has been described in symptomatic patients who have experienced sudden cardiac death or complex ventricular arrhythmias.

We have taken advantage of the high prevalence of MVP in MFS patient to study the clinical, electrical and echocardiographic abnormalities associated with MVP.

Purpose

The aim of this study is to describe the clinical, electrical and morphological cardiac abnormalities associated with MVP in a cohort of MFS patients with FBN1 mutations with a high prevalence of MVP and who did not suffer from severe ventricular arrhythmias.

Methods

All consecutive patients coming to the National Reference Center for Marfan syndrome were evaluated prospectively i.e. clinical examination, 12-lead electrocardiogram, standard transthoracic echocardiography study and molecular genetic screening.

Results

352 consecutive patients were included from April 2015 to October 2016 [250 FBN1 mutation carriers (MFS) and 102 healthy relatives (HR)]. None of the patients had a history of sudden cardiac death or complex ventricular arrhythmia.

MFS vs HR: MFS patients were younger (33 vs 41yo p&lt;0.001) and 2/3 were women in both groups. In the MFS group, abnormal T waves repolarization in lateral leads were more common [172 MFS (70.2%) vs. 87 HR (86.14%) p&lt;0,0012], as was MVP [38.37% vs 1.96%; p&lt;0,0001], and diastolic hypertrophy of the basal segment of the inferolateral wall (thickness &gt;11mm) [22.31% vs. 9.18%; p&lt;0.0001].

In MFS, MVP affected either one valve (21.22%), or both (17.14%), and was not associated with electric abnormalities. However, diastolic basal inferolateral wall hypertrophy was associated with mitral valve prolapse (p&lt;0,0001), QTc interval prolongation (p&lt;0.0229), abnormal T waves repolarization in the inferior leads (p=0.004), and higher aortic Z-Score (p=0.274).

Conclusion

In MFS patients, the prevalence of MVP is high and no significant association between MVP and electrical abnormalities was found. In contrast, basal inferolateral wall hypertrophy is associated with MVP and repolarization disorders in inferior leads and QTc interval prolongation, i.e, electrocardiographic abnormalities described in malignant MVP.

QTc and basal inferolateral hypertrophy

Funding Acknowledgement

Type of funding source: None

Clinical Significance of Aortic Root Modification Associated With Bicuspid Aortic Valve in Marfan Syndrome

BACKGROUND

Both bicuspid aortic valve (BAV) and Marfan syndrome have been associated with aortic dissection risk, but it is unknown whether the presence of BAV is associated with an increased aortic risk in patients with an FBN1 gene mutation. We evaluated aortic diameters, aortic valve function, and aortic shape in Marfan syndrome patients with and without BAV and reported aortic events during follow-up.

METHODS

All patients with an FBN1 gene mutation evaluated in our clinic were included. Aortic root diameters were measured, and the aortic valve was studied using echocardiography at each visit.

RESULTS

Of the 1437 patients with an FBN1 gene mutation, 26 patients (1.8%) had a BAV. Both aortic root maximal diameter and normalized Z score were larger at all ages, in patients with BAV when compared with patients with tricuspid aortic valve. Prophylactic aortic root surgery tended to be performed in younger patients when BAV was present, although aortic diameter threshold was similar in the 2 populations. No aortic dissection was observed in Marfan syndrome patients with BAV.

CONCLUSIONS

In patients with a FBN1 mutation, BAV is associated with larger aortic root diameter, with no difference in evolution of Z score with age. We found a trend towards prophylactic aortic root surgery at younger ages but similar aortic diameter thresholds without occurrence of aortic dissection. We did not find any evidence for lowering aortic diameter thresholds used to propose preventive aortic root surgery in the presence of BAV in patients with FBN1 mutations.

Incidence of cardiovascular events and risk markers in a prospective study of children diagnosed with Marfan syndrome

BACKGROUND

Little is known about the incidence of cardiovascular events (CVEs) and their associated risk markers in children with Marfan syndrome (MFS).

AIMS

To assess the incidence of CVEs and determine risk markers in a cohort diagnosed with Marfan syndrome during childhood and followed for several years.

METHODS

From a French multicentre nationwide database, 462 patients with MFS diagnosed during childhood were included prospectively. Patients' files were screened for a period of 20 years (1993-2013). CVEs (e.g. death, aortic dissection, cardiac valve or aortic root surgery) were assessed during the prospective follow-up.

RESULTS

Median (interquartile range) age at the end of follow-up was 17.2 (11.1-21.3) years. CVEs were reported for 35 participants (7.6%; 95% confidence interval [CI] 5.3-10.4%). First CVEs were prophylactic aortic root surgery (n=29), aortic dissection (n=4; two aged <18 years) and death (n=2). Kaplan-Meier cumulative incidence of CVEs was 5.3% (95% CI 3.3-8.7%) during childhood (aged≤18 years) and 19.4% (95% CI 13.3-27.9%) at 25years of age. The cumulative rate of CVEs was higher in case of Valsalva sinus Z-score increase of≥0.1 per year (P=0.0003), maximal Valsalva sinus diameter growth speed ≥5mm per year (P=0.03), aortic regurgitation≥2 (P=0.0005) and maximal Valsalva sinus Z-score≥3 before 16 years of age (P<0.0001). In a multivariable Cox proportional analysis, the Valsalva sinus Z-score remained significantly related to outcome. Considering aortic root evolution, aortic regurgitation, age at diagnosis and beta-blocker therapy were related to Valsalva sinus Z-score evolution during follow-up.

CONCLUSIONS

CVEs in children with MFS are mainly related to prophylactic aortic root surgery. Aortic dissections are rarely observed in children. The Valsalva sinus Z-score is a strong indicator of subsequent CVEs in children with MFS. Attention to follow-up and beta-blocker observance may be warranted in high-risk children.

P3375The parasternal long axis ultrasound view does not allow the maximum diameter of the aortic root to be measured in atypical BAV

Background

Following guidelines, maximal aortic root diameter have to be measured in parasternal long axis view (PLA TTE) in trans-thoracic echocardiography (TTE). However, asymmetry of the aortic root is common in BAV and the larger diameter might be missed when using PLA TTE, depending on the asymmetric root orientation.

Purpose

Assess whether the maximum aortic diameter measured with PLA TTE and CT differs according to the type of BAV.

Methods

86 patients with BAV without significant valvulopathy (aortic regurgitation <2 and no more than mild stenosis with mean gradient <10mmHg) referred for aortic aneurysm assessment and who had benefited from TTE and CT were studied.

Definition: Typical BAVs have a horizontal valve opening (type I L-R and type 0 anteroposterior) while atypical BAVs have a vertical valve opening (type I N-R and type 0 lateral). (Figure) We compared: – using CT, the orientation of the largest diameter of the aortic root in typical and atypical BAVs using the sagittal plane as a reference (Figure). – the difference of the maximal aortic root diameter measured with PLA TTE and CT in typical and atypical BAVs.

Results

Patients with typical and atypical BAVs were comparable for age, sex, weight, height, aortic root surface area and maximum diameter of the aoric root.

When comparing maximal aortic root diameter measured in PLA TTE and CT:

– in the whole cohort, PLA TTE underestimates the maximal aortic root diameter with a mean difference of 3 mm.

– in atypical BAVs, the difference between CT and PLA TTE is 6,0 mm significantly different from the 2,3 mm found in typical BAVs p=0.0008 (Figure)

The orientation of the maximal aortic diameter is correlated with the type of BAV: Using the sagittal plan as a reference, this angle is 64.3° for the typical BAV and 143,1° for the atypical BAV p<0.0001 (Figure).

The use of a blue arrow (figure) to show the ultrasound beam direction in PLA ETT helps to understand that, in typical BAVs, the maximal aortic root diameter has the same direction that ultrasound beam while in atypical BAVs, the ultrasound beam direction is perpendicular to the direction of the maximum aortic diameter.

Figure 1

Conclusion

The difference in maximal diameter of the aortic root measured with CT and PLA TTE is significantly greater in atypical BAVs than in typical BAVs (6.0 mm vs 2.3mm). This difference can be explained by the fact that in the atypical BAV, the orientation of the maximal diameter of the aortic root differs from the typical BAV: using the sagittal plane as a reference, in the atypical BAV, the mean angle is around 140° and this orientation is perpendicular to the direction of the ultrasonic beam, explaining the inability to measure the maximum aortic diameter in PLA TTE for the atypical BAVs.

P1816Aortic root morphology in bicuspid aortic valve is related to the type of BAV

Background

Dilatation of the ascending aorta associated with bicuspid aortic valve (BAV) is common and has been associated with an increased risk of aortic dissection. However, the causal links between BAV types, aortic valve dysfunction and aorta phenotype are still poorly understood. Our hypothesis is that aortic root dilatation in BAV is an anatomic modification related to the BAV type.

Purpose

To assess whether the morphology and orientation of the aortic root can be predicted by the type of BAV.

Methods

86 patients with BAV without significant valvulopathy (aortic regurgitation <2 and no more than mild stenosis with mean gradient <10mmHg) referred for aortic aneurysm assessment and who had benefited from TTE and CT were studied.

Definitions

Results

Patients with typical and atypical BAVs were comparable for age, sex, weight, height, aortic root surface area and maximum aortic root diameter.

Aortic root asymmetric modifications were related to the type of BAV with: – a predominant non coronary sinus dilatation in type I L-R (Non coronary sinus to commissure normalized diameter = 1.02 in Type I l-R vs 0.98 in type I R-N; p=0.0004). – a predominant left coronary sinus dilatation in type I L-N (left coronary sinus to commissure normalized diameter = 1.07 in type I R-N vs 1.01 in type I L-R; p<0.0001). – a significantly larger anteroposterior diameter in type 0 typical BAVs (45mm vs 40mm p=0.02) and a significantly larger lateral diameter in type 0 atypical BAVs (48mm vs 39mm p=0.0003). The orientation of the aortic valve opening is correlated with the type of BAV: Using the sagittal plan as a reference, this angle is 144,9° for the typical BAVs vs 56,6° for the atypical BAVs p<0.0001 (Figure). The orientation of the maximal aortic diameter is correlated with the type of BAV: Using the sagittal plan as a reference, this angle is 64.3° for the typical BAVs and 143,1° for the atypical BAVs p<0.0001 (Figure 1).

Figure 1

Conclusion

The morphology and orientation of the aortic root in BAVs are strongly correlated with the type of BAV, suggesting anatomical modifications rather than aortopathy.

Risk of Ascending Aortic Aneurysm in Patients With Autosomal Dominant Polycystic Kidney Disease

In recent years, simple renal cysts have been associated with an increased risk of aortic aneurysms. There is little data regarding aortic dilation in patients with autosomal dominant polycystic kidney disease (ADPKD). The aim of this study was to compare Sinuses of Valsalva (SoV) and tubular ascending aorta diameters in ADPKD patients with matched controls. From 2008 to 2016, 61 consecutive ADPKD patients who had an echocardiogram performed in our institution were matched 1:1 with controls for sex, age, blood pressure, and β-blocker therapy use. SoV and tubular ascending aorta were measured at end-diastole, using the leading-edge to leading-edge convention. Paired t Tests were used for quantitative variables and McNemar-tests for qualitative variables. The mean age of patients was 56 ± 12 years, 54% were men, 38% received β-blockers, and mean systolic and diastolic BP were 137 ± 25 and 78 ± 19 mm Hg. SoV diameters were significantly larger in ADPKD patients than in controls (36.4 ± 4.1 vs 34.0 ± 3.7 mm, p <0.0001). The Z-scores (normalized for sex, age, and body surface area) were significantly higher in ADPKD patients, both for SoV and tubular ascending aorta. Moreover, aortic aneurysms, as defined by a Z score >2 standard deviations, were present in 27 ADPKD patients (44%) versus 9 controls (15%, p <0.001). In conclusion, there is an increased prevalence of aortic aneurysms in ADPKD patients as compared with controls matched for common confounding factors for aortic dilation.

Brain MRI findings in neurologically asymptomatic patients with infective endocarditis

BACKGROUND AND PURPOSE

Neurologic complications in infective endocarditis are frequent and affect patient prognosis negatively. Additionally, detection of asymptomatic lesions by MR imaging could help early management of this condition. The objective of our study was to describe MR imaging characteristics of cerebral lesions in a neurologically asymptomatic population with infective endocarditis.

MATERIALS AND METHODS

One hundred nine patients at the acute phase of a definite or possible infective endocarditis according to the Duke modified criteria and without neurologic manifestations according to the NIHSS were prospectively included. Each patient underwent cerebral MR imaging and MRA within 7 days of admission.

RESULTS

MR imaging showed abnormalities in 78 patients (71.5%). Acute ischemic lesions (40 patients, 37%) and cerebral microbleeds (62 patients, 57%) were the most frequent lesions. Eight patients had an acute SAH, 3 patients had brain microabscesses, 3 had a small cortical hemorrhage, and 3 had a mycotic aneurysm. Acute ischemic lesions mostly appeared as multiple small infarcts disseminated in watershed territories (25/40, 62.5%) and as lesions of different ages (21/40, 52.5%). Cerebral microbleeds were preferentially distributed in cortical areas (362/539 cerebral microbleeds, 67%). No significant correlation was found among lesions, in particular between acute ischemia and cerebral microbleeds.

CONCLUSIONS

Occult cerebral lesions, in particular cerebral microbleeds and acute ischemic lesions, are frequent in infective endocarditis. The MR imaging pattern of acute small infarcts of different ages predominating in watershed territories and cortical cerebral microbleeds may represent a surrogate imaging marker of infective endocarditis.

Surgical management of patients with Marfan syndrome: evolution throughout the years

AIM

To evaluate the evolution of surgical management in a large population of patients with Marfan syndrome.

METHODS

This is a retrospective study of patients fulfilling the Ghent criteria for Marfan syndrome, who visited the Centre de référence national pour le syndrome de Marfan et apparentés and underwent a surgical event before or during follow-up in the centre.

RESULTS

One thousand and ninety-seven patients with Marfan syndrome, according to international criteria, came to the clinic between 1996 and 2010. Aortic surgery was performed in 249 patients (22.7%; 20 children and 229 adults), including the Bentall procedure in 140 patients (56%) and valve-sparing surgery in 88 patients (35%); a supracoronary graft was performed in 19 patients (7.6%), usually for aortic dissection. During the past 20 years, the predominant reason for aortic surgery has switched from aortic dissection to aortic dilatation, while age at surgery has tended to increase (from 32.4 ± 11.9 years to 35.2 ± 12.4 years; P=0.075). Mitral valve surgery was performed in 61 patients (5.6%; six children and 55 adults), including 37 valvuloplasties (60.6%) and 18 mitral valve replacements (29.5%). No significant difference was observed when comparing mitral valve surgery before and after 2000.

CONCLUSION

Surgery performed in patients with Marfan syndrome has switched from emergency surgery for aortic dissection to elective surgery for aortic dilatation; this is associated with surgery performed at an older age despite the indication for surgery having decreased from 60mm to 50mm. No significant evolution was observed for mitral valve surgery.

Aortic Event Rate in the Marfan Population

Background—

Optimal management, including timing of surgery, remains debated in Marfan syndrome because of a lack of data on aortic risk associated with this disease.

Methods and Results—

We used our database to evaluate aortic risk associated with standardized care. Patients who fulfilled the international criteria, had not had previous aortic surgery or dissection, and came to our center at least twice were included. Aortic measurements were made with echocardiography (every 2 years); patients were given systematic β-blockade and advice about sports activities. Prophylactic aortic surgery was proposed when the maximal aortic diameter reached 50 mm. Seven hundred thirty-two patients with Marfan syndrome were followed up for a mean of 6.6 years. Five deaths and 2 dissections of the ascending aorta occurred during follow-up. Event rate (death/aortic dissection) was 0.17%/y. Risk rose with increasing aortic diameter measured within 2 years of the event: from 0.09%/y per year (95% confidence interval, 0.00–0.20) when the aortic diameter was <40 mm to 0.3% (95% confidence interval, 0.00–0.71) with diameters of 45 to 49 mm and 1.33% (95% confidence interval, 0.00–3.93) with diameters of 50 to 54 mm. The risk increased 4 times at diameters ≥50 mm. The annual risk dropped below 0.05% when the aortic diameter was <50 mm after exclusion of a neonatal patient, a woman who became pregnant against our recommendation, and a 72-year-old woman with previous myocardial infarction.

Conclusions—

Risk of sudden death or aortic dissection remains low in patients with Marfan syndrome and aortic diameter between 45 and 49 mm. Aortic diameter of 50 mm appears to be a reasonable threshold for prophylactic surgery.