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The knowledge about Loeys-Dietz syndrome has evolved quickly since Hal Dietz, MD, and Bart Loeys, MD, at Johns Hopkins University, Baltimore, first reported on it in 2005.
Now, another team of Johns Hopkins investigators have reported that an aggressive approach with aortic root replacement coupled with valve-sparing whenever possible produces favorable results, but that clinicians must follow these patients closely with cardiovascular imaging.
“Growing experience with Loeys-Dietz syndrome has confirmed early impressions of its aggressive nature and proclivity toward aortic catastrophe,” Nishant D. Patel, MD, and his coauthors said in the February issue of the Journal of Thoracic and Cardiovascular Surgery (2017;153:406-12). They reported on results of all 79 patients with Loeys-Dietz syndrome (LDS) who had cardiovascular surgery at Johns Hopkins. There were two (3%) deaths during surgery and eight (10%) late deaths. Patients with LDS are at risk for dissection early when the aortic root reaches 4 cm. Despite what they termed “favorable” outcomes of surgery, Dr. Patel and his coauthors acknowledged that reintervention rates for this population are high – 19 patients (24%) had subsequent operations. That suggests cardiac surgeons must closely monitor these patients. “Meticulous follow-up with cardiovascular surveillance imaging remains important for management, particularly as clinical LDS subtypes are characterized and more tailored treatment is developed,” Dr. Patel and his coauthors reported.
They advise echocardiography every 3 to 6 months for the first year after surgery and then every 6 to 12 months afterward. Full-body imaging should occur at least every 2 years. “In particular, patients with type B dissections should be monitored aggressively for aneurysm growth,” Dr. Patel and his coauthors said. They recommend imaging at seven to 14 days after dissection, then repeat imaging at 1, 3, 6, and 12 months, and then yearly thereafter.
They noted that four LDS subtypes have been identified. Although those with LDS1 and 2 subtypes are prone to aortic rupture at an earlier age and at smaller aortic diameters than other connective tissue disorders, the medical and surgical management for all subtypes are similar, Dr. Patel and his coauthors indicated.
“Certain congenital heart defects are more common among patients with LDS, compared with the normal population, including patent ductus arteriosus and mitral valve prolapse/insufficiency,” they said. Genotype is one factor that determines the need for surgery in LDS patients, Dr. Patel and his coauthors said. Others are growth rate, aortic valve function, family history, and severity of noncardiac phenotype.
The 79 patients in the study were divided almost evenly between gender, and the average age at first operation was 24.9 years; 38 were children younger than 18 years and 20 had a previous sternotomy. Aortic root replacement represented the predominant operation in the group, accounting for 65 operations (82.3%), of which 52 (80%) were valve-sparing procedures and the remainder were composite valve-graft procedures. The other procedures the researchers performed were nine aortic arch replacements (11.4%), three open thoracoabdominal repairs (3.8%) and two ascending aorta replacements (2.5%).
“Valve-sparing root replacement has become a safe and reliable option for appropriately selected younger patients with LDS,” Dr. Patel and his coauthors wrote. Five patients needed a second operation on the aortic valve or root; three of them had a Florida sleeve procedure. “Based on these initial outcomes with the Florida sleeve at our institution, we have abandoned this procedure in favor of conventional valve-sparing root replacement,” Dr. Patel and his coauthors stated.
Dr. Patel and his coauthors had no financial relationships to disclose.
A rare disease such as Loeys-Dietz syndrome (LDS) seems more common now in vascular surgery, as we are the specialty making decisions on disorders of the descending thoracic aorta. Understanding not only the clinical presentation with the aortic root involvement but the fact that these patients require close surveillance is the key message.
Often we are consulted regarding or admit a patient with an acute type B dissection who usually has a history of poorly controlled hypertension but, also, has a history of “aneurysms” or a family member who passed away at a young age. These clues should lead us to explore the “molecular diagnosis” as well to see if patients have a connective tissue disorder such as LDS or vascular Ehlers-Danlos syndrome (vEDS). Because many of these syndromes have overlapping symptoms, understanding the type of connective tissue disorder will allow us to appreciate the differences, especially in a syndrome such as LDS, which was first reported in 2005 and is associated with more cardiac and aortic root pathologies than vEDS.
At the University of Washington, my colleague Dr. Sherene Shalhub heads a vascular genetics clinic in which she examines patients with potential connective tissue disorders in an attempt to make the molecular diagnosis and identify surveillance protocols and study the effect of open and endovascular repairs in these patients. Pooling data on these patients from around the country and collaborating within, as well as outside of, our specialty is imperative to increasing our understanding of these disorders. I believe we are seeing a trend in which we crave studies such as Dr. Patel’s to increase our knowledge on these rare (but now more common) entities.
Niten Singh, MD, is the director of the Limb Preservation Service at the Regional Vascular Center at Harborview Medical Center, Seattle, and an Associate Editor of Vascular Specialist.
A rare disease such as Loeys-Dietz syndrome (LDS) seems more common now in vascular surgery, as we are the specialty making decisions on disorders of the descending thoracic aorta. Understanding not only the clinical presentation with the aortic root involvement but the fact that these patients require close surveillance is the key message.
Often we are consulted regarding or admit a patient with an acute type B dissection who usually has a history of poorly controlled hypertension but, also, has a history of “aneurysms” or a family member who passed away at a young age. These clues should lead us to explore the “molecular diagnosis” as well to see if patients have a connective tissue disorder such as LDS or vascular Ehlers-Danlos syndrome (vEDS). Because many of these syndromes have overlapping symptoms, understanding the type of connective tissue disorder will allow us to appreciate the differences, especially in a syndrome such as LDS, which was first reported in 2005 and is associated with more cardiac and aortic root pathologies than vEDS.
At the University of Washington, my colleague Dr. Sherene Shalhub heads a vascular genetics clinic in which she examines patients with potential connective tissue disorders in an attempt to make the molecular diagnosis and identify surveillance protocols and study the effect of open and endovascular repairs in these patients. Pooling data on these patients from around the country and collaborating within, as well as outside of, our specialty is imperative to increasing our understanding of these disorders. I believe we are seeing a trend in which we crave studies such as Dr. Patel’s to increase our knowledge on these rare (but now more common) entities.
Niten Singh, MD, is the director of the Limb Preservation Service at the Regional Vascular Center at Harborview Medical Center, Seattle, and an Associate Editor of Vascular Specialist.
A rare disease such as Loeys-Dietz syndrome (LDS) seems more common now in vascular surgery, as we are the specialty making decisions on disorders of the descending thoracic aorta. Understanding not only the clinical presentation with the aortic root involvement but the fact that these patients require close surveillance is the key message.
Often we are consulted regarding or admit a patient with an acute type B dissection who usually has a history of poorly controlled hypertension but, also, has a history of “aneurysms” or a family member who passed away at a young age. These clues should lead us to explore the “molecular diagnosis” as well to see if patients have a connective tissue disorder such as LDS or vascular Ehlers-Danlos syndrome (vEDS). Because many of these syndromes have overlapping symptoms, understanding the type of connective tissue disorder will allow us to appreciate the differences, especially in a syndrome such as LDS, which was first reported in 2005 and is associated with more cardiac and aortic root pathologies than vEDS.
At the University of Washington, my colleague Dr. Sherene Shalhub heads a vascular genetics clinic in which she examines patients with potential connective tissue disorders in an attempt to make the molecular diagnosis and identify surveillance protocols and study the effect of open and endovascular repairs in these patients. Pooling data on these patients from around the country and collaborating within, as well as outside of, our specialty is imperative to increasing our understanding of these disorders. I believe we are seeing a trend in which we crave studies such as Dr. Patel’s to increase our knowledge on these rare (but now more common) entities.
Niten Singh, MD, is the director of the Limb Preservation Service at the Regional Vascular Center at Harborview Medical Center, Seattle, and an Associate Editor of Vascular Specialist.
The knowledge about Loeys-Dietz syndrome has evolved quickly since Hal Dietz, MD, and Bart Loeys, MD, at Johns Hopkins University, Baltimore, first reported on it in 2005.
Now, another team of Johns Hopkins investigators have reported that an aggressive approach with aortic root replacement coupled with valve-sparing whenever possible produces favorable results, but that clinicians must follow these patients closely with cardiovascular imaging.
“Growing experience with Loeys-Dietz syndrome has confirmed early impressions of its aggressive nature and proclivity toward aortic catastrophe,” Nishant D. Patel, MD, and his coauthors said in the February issue of the Journal of Thoracic and Cardiovascular Surgery (2017;153:406-12). They reported on results of all 79 patients with Loeys-Dietz syndrome (LDS) who had cardiovascular surgery at Johns Hopkins. There were two (3%) deaths during surgery and eight (10%) late deaths. Patients with LDS are at risk for dissection early when the aortic root reaches 4 cm. Despite what they termed “favorable” outcomes of surgery, Dr. Patel and his coauthors acknowledged that reintervention rates for this population are high – 19 patients (24%) had subsequent operations. That suggests cardiac surgeons must closely monitor these patients. “Meticulous follow-up with cardiovascular surveillance imaging remains important for management, particularly as clinical LDS subtypes are characterized and more tailored treatment is developed,” Dr. Patel and his coauthors reported.
They advise echocardiography every 3 to 6 months for the first year after surgery and then every 6 to 12 months afterward. Full-body imaging should occur at least every 2 years. “In particular, patients with type B dissections should be monitored aggressively for aneurysm growth,” Dr. Patel and his coauthors said. They recommend imaging at seven to 14 days after dissection, then repeat imaging at 1, 3, 6, and 12 months, and then yearly thereafter.
They noted that four LDS subtypes have been identified. Although those with LDS1 and 2 subtypes are prone to aortic rupture at an earlier age and at smaller aortic diameters than other connective tissue disorders, the medical and surgical management for all subtypes are similar, Dr. Patel and his coauthors indicated.
“Certain congenital heart defects are more common among patients with LDS, compared with the normal population, including patent ductus arteriosus and mitral valve prolapse/insufficiency,” they said. Genotype is one factor that determines the need for surgery in LDS patients, Dr. Patel and his coauthors said. Others are growth rate, aortic valve function, family history, and severity of noncardiac phenotype.
The 79 patients in the study were divided almost evenly between gender, and the average age at first operation was 24.9 years; 38 were children younger than 18 years and 20 had a previous sternotomy. Aortic root replacement represented the predominant operation in the group, accounting for 65 operations (82.3%), of which 52 (80%) were valve-sparing procedures and the remainder were composite valve-graft procedures. The other procedures the researchers performed were nine aortic arch replacements (11.4%), three open thoracoabdominal repairs (3.8%) and two ascending aorta replacements (2.5%).
“Valve-sparing root replacement has become a safe and reliable option for appropriately selected younger patients with LDS,” Dr. Patel and his coauthors wrote. Five patients needed a second operation on the aortic valve or root; three of them had a Florida sleeve procedure. “Based on these initial outcomes with the Florida sleeve at our institution, we have abandoned this procedure in favor of conventional valve-sparing root replacement,” Dr. Patel and his coauthors stated.
Dr. Patel and his coauthors had no financial relationships to disclose.
The knowledge about Loeys-Dietz syndrome has evolved quickly since Hal Dietz, MD, and Bart Loeys, MD, at Johns Hopkins University, Baltimore, first reported on it in 2005.
Now, another team of Johns Hopkins investigators have reported that an aggressive approach with aortic root replacement coupled with valve-sparing whenever possible produces favorable results, but that clinicians must follow these patients closely with cardiovascular imaging.
“Growing experience with Loeys-Dietz syndrome has confirmed early impressions of its aggressive nature and proclivity toward aortic catastrophe,” Nishant D. Patel, MD, and his coauthors said in the February issue of the Journal of Thoracic and Cardiovascular Surgery (2017;153:406-12). They reported on results of all 79 patients with Loeys-Dietz syndrome (LDS) who had cardiovascular surgery at Johns Hopkins. There were two (3%) deaths during surgery and eight (10%) late deaths. Patients with LDS are at risk for dissection early when the aortic root reaches 4 cm. Despite what they termed “favorable” outcomes of surgery, Dr. Patel and his coauthors acknowledged that reintervention rates for this population are high – 19 patients (24%) had subsequent operations. That suggests cardiac surgeons must closely monitor these patients. “Meticulous follow-up with cardiovascular surveillance imaging remains important for management, particularly as clinical LDS subtypes are characterized and more tailored treatment is developed,” Dr. Patel and his coauthors reported.
They advise echocardiography every 3 to 6 months for the first year after surgery and then every 6 to 12 months afterward. Full-body imaging should occur at least every 2 years. “In particular, patients with type B dissections should be monitored aggressively for aneurysm growth,” Dr. Patel and his coauthors said. They recommend imaging at seven to 14 days after dissection, then repeat imaging at 1, 3, 6, and 12 months, and then yearly thereafter.
They noted that four LDS subtypes have been identified. Although those with LDS1 and 2 subtypes are prone to aortic rupture at an earlier age and at smaller aortic diameters than other connective tissue disorders, the medical and surgical management for all subtypes are similar, Dr. Patel and his coauthors indicated.
“Certain congenital heart defects are more common among patients with LDS, compared with the normal population, including patent ductus arteriosus and mitral valve prolapse/insufficiency,” they said. Genotype is one factor that determines the need for surgery in LDS patients, Dr. Patel and his coauthors said. Others are growth rate, aortic valve function, family history, and severity of noncardiac phenotype.
The 79 patients in the study were divided almost evenly between gender, and the average age at first operation was 24.9 years; 38 were children younger than 18 years and 20 had a previous sternotomy. Aortic root replacement represented the predominant operation in the group, accounting for 65 operations (82.3%), of which 52 (80%) were valve-sparing procedures and the remainder were composite valve-graft procedures. The other procedures the researchers performed were nine aortic arch replacements (11.4%), three open thoracoabdominal repairs (3.8%) and two ascending aorta replacements (2.5%).
“Valve-sparing root replacement has become a safe and reliable option for appropriately selected younger patients with LDS,” Dr. Patel and his coauthors wrote. Five patients needed a second operation on the aortic valve or root; three of them had a Florida sleeve procedure. “Based on these initial outcomes with the Florida sleeve at our institution, we have abandoned this procedure in favor of conventional valve-sparing root replacement,” Dr. Patel and his coauthors stated.
Dr. Patel and his coauthors had no financial relationships to disclose.
Key clinical point: Outcomes for aortic surgery in Loeys-Dietz syndrome are favorable, but reintervention rates are high.
Major finding: Patients require close postoperative follow-up with cardiovascular imaging.
Data source: Retrospective review of 79 patients who had cardiovascular surgery for LDS over 26 years at Johns Hopkins University.