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Is Obstructive Sleep Apnea Associated With Greater Thoracic Aortic Size?
Correspondence
JACC Vol. 53, No. 9, 2009 March 3, 2009:812–6
Stavros Kounas, MD *Perry Elliott, MD, FACC, FESC *The Heart Hospital University College London 16-18 Westmoreland Street London, W1G 8PH United Kingdom E-mail: [email protected] doi:10.1016/j.jacc.2008.11.027 REFERENCES
1. Kounas S, Demetrescu C, Pantazis AA, et al. The binary endocardial appearance is a poor discriminator of Anderson-Fabry disease from familial hypertrophic cardiomyopathy. J Am Coll Cardiol 2008;51: 2058 – 61. 2. Pieroni M, Chimenti C, De Cobelli F, et al. Fabry’s disease cardiomyopathy: echocardiographic detection of endomyocardial glycosphingolipid compartmentalization. J Am Coll Cardiol 2006;47:1663–71. 3. Vedder AC, Strijland A, van den Bergh Weerman MA, Florquin S, Aerts JM, Hollak CE. Manifestations of Fabry disease in placental tissue. J Inherit Metab Dis 2006;29:106 –11. 4. Linhart A, Kampmann C, Zamorano JL, et al. Cardiac manifestations of Anderson-Fabry disease: results from the international Fabry outcome survey. European FOS Investigators. Eur Heart J 2007;28:1228 –35.
Is Obstructive Sleep Apnea Associated With Greater Thoracic Aortic Size? In a recent issue of the Journal, Serizawa et al. (1) reported that thoracic aortic size was significantly greater in patients with obstructive sleep apnea (OSA) syndrome than in those without OSA syndrome. Whether OSA impacts aortic root size has not been yet fully investigated. We recently assessed thoracic aortic size in an observational single group of 76 consecutive patients with documented OSA (mean age 52.7 ⫾ 9.5 years, 70 men [92%], apnea-hypopnea index 56.5/h) referred in our institution between March 2005 and March 2007 (2). Of note, 51% had hypertension. The aortic root diameter was measured by transthoracic echocardiography (TTE) at sinuses of Valsalva level, in the parasternal long-axis view, at end-diastole, according to Roman’s recommendations (3). We found that mean aortic root diameter was 35.3 ⫾ 3.8 mm (range 26.9 to 44.6 mm), as compared with 36.8 ⫾ 3.6 mm in the study of Serizawa et al. (1). Aortic root diameter was significantly associated with age and male sex but not with arterial hypertension, in agreement with Serizawa et al. (1). In contrast, we did not find any correlation between aortic root diameter and OSA’s characteristics (apnea-hypopnea index, time spent with oxygen desaturation ⬍90%, Epworth Sleepiness Scale score, or treatment with continuous positive airway pressure). In addition, we did not find any correlation between carotid-femoral pulse wave velocity (aortic stiffness) and aortic root diameter. We would like to draw attention to the different mean body mass index in the 2 populations studied (24.7 ⫾ 3.1 kg/m2 in the study of Serizawa et al. [1] in Japanese patients vs. 31.5 ⫾ 5.8 kg/m2 in the French population studied). Determinants of thoracic
815
aortic size are still a matter of debate; however, age, weight, height, and body surface area are considered the main determinants of aortic dilation (3,4). However, in our study including obese OSA patients, body mass index did not influence aortic root size. As depicted in Roman’s normograms (3), aortic root size should be indexed to body surface area and age when using TTE. Another difference with the study of Serizawa et al. (1) is the method of measurement of thoracic aortic size: TTE in our study while computed tomography was used in their group of patients (1). However, the agreement for ascending aortic diameter measured by echocardiography and computed tomography has been evaluated to be as high as 95% (5). Finally, using Roman’s normograms and TTE in our study, we did not find a high proportion of aortic dilation reported when aortic root diameter at the sinus of Valsalva level was considered as mean values ⬎2 SDs above the regression line (3.9%). In the near future, additional trials should be performed to confirm the observation that a greater aortic root size is associated with OSA and, if confirmed, to examine its determinants and underlying mechanisms. There is also a need for evaluating the impact of OSA therapy with continuous positive airway pressure on heart geometry including aortic root size and ventricular function in large clinical trials. Catherine Meuleman, MD Franck Boccara, MD Stephane Ederhy, MD Ghislaine Dufaitre, MD Bernard Fleury, MD *Ariel Cohen, MD, PhD *Hopital Saint Antoine Cardiology 184 rue du faubourg Saint Antoine Paris, 75571 France E-mail: [email protected] doi:10.1016/j.jacc.2008.10.052 REFERENCES
1. Serizawa N, Yumino D, Takagi A, et al. Obstructive sleep apnea is associated with greater thoracic aortic size. J Am Coll Cardiol 2008;52: 885– 6. 2. Meuleman C, Boccara N, Guyen XL, et al. Is the aortic root dilated in obstructive sleep apnea syndrome? Arch Cardiovasc Dis 2008;101: 391–7. 3. Roman MJ, Devereux RB, Kramer-Fox R, et al. Two-dimensional echocardiographic aortic root dimensions in normal children and adults. Am J Cardiol 1989;64:507–12. 4. Vasan RS, Larson MG, Levy D. Determinants of echocardiographic aortic root size. The Framingham Heart study. Circulation 1995;91: 734 – 40. 5. Kaplan S, Aronow WS, Ahn C, et al. Prevalence of an increased ascending thoracic aorta diameter diagnosed by two-dimensional echocardiography versus 64-multislice cardiac computed tomography. Am J Cardiol 2008;101:119 –21.
Reply We appreciate the sincere comments of Dr. Meuleman and colleagues regarding our recent study (1). The authors argued that the presence of obstructive sleep apnea (OSA) is associated with thoracic aortic dilation. It was interesting that they also found that
JACC Vol. 53, No. 9, 2009 March 3, 2009:812–6
Stavros Kounas, MD *Perry Elliott, MD, FACC, FESC *The Heart Hospital University College London 16-18 Westmoreland Street London, W1G 8PH United Kingdom E-mail: [email protected] doi:10.1016/j.jacc.2008.11.027 REFERENCES
1. Kounas S, Demetrescu C, Pantazis AA, et al. The binary endocardial appearance is a poor discriminator of Anderson-Fabry disease from familial hypertrophic cardiomyopathy. J Am Coll Cardiol 2008;51: 2058 – 61. 2. Pieroni M, Chimenti C, De Cobelli F, et al. Fabry’s disease cardiomyopathy: echocardiographic detection of endomyocardial glycosphingolipid compartmentalization. J Am Coll Cardiol 2006;47:1663–71. 3. Vedder AC, Strijland A, van den Bergh Weerman MA, Florquin S, Aerts JM, Hollak CE. Manifestations of Fabry disease in placental tissue. J Inherit Metab Dis 2006;29:106 –11. 4. Linhart A, Kampmann C, Zamorano JL, et al. Cardiac manifestations of Anderson-Fabry disease: results from the international Fabry outcome survey. European FOS Investigators. Eur Heart J 2007;28:1228 –35.
Is Obstructive Sleep Apnea Associated With Greater Thoracic Aortic Size? In a recent issue of the Journal, Serizawa et al. (1) reported that thoracic aortic size was significantly greater in patients with obstructive sleep apnea (OSA) syndrome than in those without OSA syndrome. Whether OSA impacts aortic root size has not been yet fully investigated. We recently assessed thoracic aortic size in an observational single group of 76 consecutive patients with documented OSA (mean age 52.7 ⫾ 9.5 years, 70 men [92%], apnea-hypopnea index 56.5/h) referred in our institution between March 2005 and March 2007 (2). Of note, 51% had hypertension. The aortic root diameter was measured by transthoracic echocardiography (TTE) at sinuses of Valsalva level, in the parasternal long-axis view, at end-diastole, according to Roman’s recommendations (3). We found that mean aortic root diameter was 35.3 ⫾ 3.8 mm (range 26.9 to 44.6 mm), as compared with 36.8 ⫾ 3.6 mm in the study of Serizawa et al. (1). Aortic root diameter was significantly associated with age and male sex but not with arterial hypertension, in agreement with Serizawa et al. (1). In contrast, we did not find any correlation between aortic root diameter and OSA’s characteristics (apnea-hypopnea index, time spent with oxygen desaturation ⬍90%, Epworth Sleepiness Scale score, or treatment with continuous positive airway pressure). In addition, we did not find any correlation between carotid-femoral pulse wave velocity (aortic stiffness) and aortic root diameter. We would like to draw attention to the different mean body mass index in the 2 populations studied (24.7 ⫾ 3.1 kg/m2 in the study of Serizawa et al. [1] in Japanese patients vs. 31.5 ⫾ 5.8 kg/m2 in the French population studied). Determinants of thoracic
815
aortic size are still a matter of debate; however, age, weight, height, and body surface area are considered the main determinants of aortic dilation (3,4). However, in our study including obese OSA patients, body mass index did not influence aortic root size. As depicted in Roman’s normograms (3), aortic root size should be indexed to body surface area and age when using TTE. Another difference with the study of Serizawa et al. (1) is the method of measurement of thoracic aortic size: TTE in our study while computed tomography was used in their group of patients (1). However, the agreement for ascending aortic diameter measured by echocardiography and computed tomography has been evaluated to be as high as 95% (5). Finally, using Roman’s normograms and TTE in our study, we did not find a high proportion of aortic dilation reported when aortic root diameter at the sinus of Valsalva level was considered as mean values ⬎2 SDs above the regression line (3.9%). In the near future, additional trials should be performed to confirm the observation that a greater aortic root size is associated with OSA and, if confirmed, to examine its determinants and underlying mechanisms. There is also a need for evaluating the impact of OSA therapy with continuous positive airway pressure on heart geometry including aortic root size and ventricular function in large clinical trials. Catherine Meuleman, MD Franck Boccara, MD Stephane Ederhy, MD Ghislaine Dufaitre, MD Bernard Fleury, MD *Ariel Cohen, MD, PhD *Hopital Saint Antoine Cardiology 184 rue du faubourg Saint Antoine Paris, 75571 France E-mail: [email protected] doi:10.1016/j.jacc.2008.10.052 REFERENCES
1. Serizawa N, Yumino D, Takagi A, et al. Obstructive sleep apnea is associated with greater thoracic aortic size. J Am Coll Cardiol 2008;52: 885– 6. 2. Meuleman C, Boccara N, Guyen XL, et al. Is the aortic root dilated in obstructive sleep apnea syndrome? Arch Cardiovasc Dis 2008;101: 391–7. 3. Roman MJ, Devereux RB, Kramer-Fox R, et al. Two-dimensional echocardiographic aortic root dimensions in normal children and adults. Am J Cardiol 1989;64:507–12. 4. Vasan RS, Larson MG, Levy D. Determinants of echocardiographic aortic root size. The Framingham Heart study. Circulation 1995;91: 734 – 40. 5. Kaplan S, Aronow WS, Ahn C, et al. Prevalence of an increased ascending thoracic aorta diameter diagnosed by two-dimensional echocardiography versus 64-multislice cardiac computed tomography. Am J Cardiol 2008;101:119 –21.
Reply We appreciate the sincere comments of Dr. Meuleman and colleagues regarding our recent study (1). The authors argued that the presence of obstructive sleep apnea (OSA) is associated with thoracic aortic dilation. It was interesting that they also found that