Interact CardioVasc Thorac Surg 2008;7:1166. doi:10.1510/icvts.2008.183103A
© 2008 European Association of Cardio-Thoracic Surgery
eComment: Stabilizing aortic tissue after aortic root surgery in Marfan syndrome
Peter Matt and
Friedrich Eckstein
Division of Cardiac Surgery, Basel, Switzerland
Giant left coronary ostial aneurysm after modified Bentall procedure in a Marfan patient
We would like to congratulate Okamoto and colleagues for their interesting report [1]. Their case illustrates again how difficult it is to treat and manage patients with Marfan syndrome before and even after several aortic (root) surgeries.
Ostial aneurysm formation is a well known complication after aortic root surgery in Marfan syndrome [2]. We agree that it is crucial to excise as much aortic root tissue as possible when re-implanting the coronary arteries in the Dacron graft. We use felt or pericardial patches to strengthen the suture-line around the ostium and to prevent future aneurysm formation at this area. Unfortunately, progressive aortic dilatation can sometimes not be prevented, and it is clear that aneurysm formation of the left trunk itself cannot be prevented by a small, reinforced button technique alone.
Interestingly, it has recently been shown that losartan, an angiotensin II type 1 receptor blocker, and widely used medication to treat arterial hypertension, has the potential to stabilize the aortic root tissue in Marfan syndrome [3, 4]. Brooke and colleagues recently published from Johns Hopkins a small pediatric cohort study in which the use of angiotensin II type 1 receptor blocker therapy in patients with Marfan syndrome slowed the rate of progressive aortic root dilatation from 3.54±2.87 mm per year during previous medical therapy to 0.46±0.62 mm per year during angiotensin II type 1 receptor blocker therapy (P<0.001) [5].
These findings are incredibly encouraging for patients with Marfan syndrome, and we think that it might, therefore, be time to start patients with Marfan syndrome – before and after aortic root surgery – on losartan therapy. However, whether angiotensin II type 1 receptor blocker therapy is effective in preventing ostial and coronary dilatation after aortic root surgery in Marfan syndrome requires, of course, further studies.
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References
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- Okamoto K, Casselman FP, De Geest R, Vanermen H. Giant left coronary ostial aneurysm after modified Bentall procedure in a Marfan patient. Interact CardioVasc Thorac Surg 2008;7:1164–1166.[Abstract/Free Full Text]
- Grapow MT, Matt P, Zerkowski HR, Bernet F. Pseudoaneurysm in a Marfan patient 16 years after Bentall operation. Asian Cardiovasc Thorac Ann 2004;12:182–183.[Free Full Text]
- Habashi JP, Judge DP, Holm TM, Cohn RD, Loeys BL, Cooper TK, Myers L, Klein EC, Liu G, Calvi C, Podowski M, Neptune ER, Halushka MK, Bedja D, Gabrielson K, Rifkin DB, Carta L, Ramirez F, Huso DL, Dietz HC. Losartan, an AT1 antagonist, prevents aortic aneurysm in a mouse model of Marfan syndrome. Science 2006;312:117–121.[Abstract/Free Full Text]
- Matt P, Habashi J, Carrel T, Cameron DE, Van Eyk JE, Dietz HC. Recent advances in understanding Marfan syndrome: should we now treat surgical patients with losartan? J Thorac Cardiovasc Surg 2008;135:389–394.[Abstract/Free Full Text]
- Brooke BS, Habashi JP, Judge DP, Patel N, Loeys B, Dietz HC 3rd. Angiotensin II blockade and aortic-root dilation in Marfan's syndrome. N Engl J Med 2008;358:2787–2795.[Abstract/Free Full Text]
Related Article
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Giant left coronary ostial aneurysm after modified Bentall procedure in a Marfan patient
- Kazuma Okamoto, Filip P. Casselman, Raphael De Geest, and Hugo Vanermen
Interactive CardioVascular and Thoracic Surgery 2008 7: 1164-1166.
[Abstract]
[Full Text]
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