[Surgical strategy for Stanford type A aortic dissection with Marfan syndrome]

Between January 1979 and May 1996, 23 Marfan patients underwent surgeries for type A aortic dissection; 8 patients with localized type dissection and 15 with extensive type. All of the 23 patients suffered from annuloaortic ectasia (AAE) which was treated by composite graft replacement, 10 of these patients had a concomitant replacement of the aortic arch. The operative mortality rate was 8.7%, and the causes were associated with the methods of coronary artery reattachment to the graft. Of the 15 patients with the extensive type dissection, there were 11 patients who had a non-thrombotic communicating false lumen in the untreated segments of the distal dissected aorta after the first operation and from this group there were seven patients who had anastomotic leakage around the distal suture line of the graft replacement that was demonstrated by aortography. Extensive graft replacement ranging from the entire thoracic aorta to the total aorta were performed in 10 (43.5%). Late deaths occurred in three patients (13.0%) and these causes were LOS and graft infection after the second operation and prosthetic valve endcarditis 6 months after the first operation. The present data indicate that Stanford type A aortic dissection with Marfan syndrome should be undertaken on the basis of a prior achievable plan to perform an entire aortic replacement. The dissection should also be performed using a procedure which doesn't leave distal anastomotic leakage.

Atrio-ventricular valve dysplasia in 22 newborn infants

We retrospectively studied the experience of our institution with isolated dysplasia of one or both atrio-ventricular valves in 22 newborn infants. All patients with associated cardiac malformations were excluded. Ten patients exhibited isolated tricuspid valve dysplasia. One patient had tricuspid valve dysplasia and a dysplastic pulmonary valve. In 10 patients, both atrio-ventricular valves were affected. Finally, mitral valve dysplasia was associated with pulmonary valve stenosis in 1 case. Associated syndromes and/or chromosomal anomalies were: Down syndrome (n=2), trisomy 18 (n=1), Noonan syndrome (n=1), Marfan syndrome (n=3), Ehlers-Danlos and Cutis laxa (n=2). Mortality was 27.2% during follow-up (mean 51 months): 3 patients with chromosomal aneuploidies, 2 patients with severe neonatal Marfan syndrome and 1 with Ehlers-Danlos. Complications were: sustained supra-ventricular tachycardia in 3, neonatal staphylococcal tricuspid valve endocarditis in 1, persistent significant valvular disease in 8. In the remaining 9 survivors, the dysplasia of the atrio-ventricular valves persists with absent or mild incompetence. Beside obvious chromosomal anomalies, newborn infants with dysplastic valves should be investigated for manifestations of connective tissue disorders. This may help to identify new pleiotropic syndromes which include valvular dysplasia as one manifestation.

Genetics of intracranial aneurysms

The etiology and pathogenesis of intracranial aneurysms are clearly multifactorial, with genetic factors playing an increasingly recognized role. Intracranial aneurysms have been associated with numerous heritable connective tissue disorders, which account for at least 5% of cases. Of these disorders, the most important are Ehlers-Danlos syndrome Type IV, Marfan's syndrome, neurofibromatosis Type 1, and autosomal dominant polycystic kidney disease; the association with intracranial aneurysms, however, has been firmly established only for polycystic kidney disease. Familial intracranial aneurysms are not rare but account for 7 to 20% of patients with aneurysmal subarachnoid hemorrhage and are generally not associated with any of the known heritable connective tissue disorders. First-degree relatives of patients with aneurysmal subarachnoid hemorrhage are at an approximately fourfold increased risk of suffering ruptured intracranial aneurysms, compared to the general population. Various possible modes of inheritance have been identified in families with intracranial aneurysms, suggesting genetic heterogeneity. Although the benefits have never been quantified, screening for asymptomatic intracranial aneurysms should be considered in families with two or more affected members. The yield of such a screening program may approximate 10%. Although it is unlikely that there is a single gene with major effect, much effort is currently being directed at locating intracranial aneurysm genes.

[Total proximal reconstruction of chronic aortic dissection in patients with Marfan syndrome]

Authors present two patients suffering from Marfan syndrome. Asymptomatically developed serious cardiovascular complications being characteristic of the syndrome itself were revealed at both cases. Type "A" aortic dissection was found at the first, and type "B" aortic dissection involving even the arch as well revealed at the other patient. They were operated on an elective base. Total proximal aortic reconstructions (aortic root-ascending aorta-arch) were performed under deep hypothermia using total circulatory arrest (35 and 87 min). Both patients are doing well without complaints 3-4 months following the surgical interventions. Control angiographic imagination has found normal anatomic conditions at one of the patients. Anastomosis stenosis at the borderline of the arch and descending aorta was revealed at the other case which should be necessary to operate at an later occasion.

Bentall operation for a child with Marfan syndrome: a case report

Children with Marfan syndrome rarely undergo surgery for annuloaortic ectasia and aortic regurgitation in the first decade. A 7-year-old girl presented with congestive heart failure due to severe aortic regurgitation associated with annuloaortic ectasia (6 cm). She also had funnel chest. She underwent a Bentall operation and sternal turn-over with a satisfactory result. Since the aortic valve cusps had rolled edges, the aortic valve was not spared. Histology of the aortic valve cusps showed myxoid degeneration and fragmentation of elastic fibers.

Infantile scoliosis in Marfan syndrome

STUDY DESIGN

A retrospective review of clinical data was conducted.

OBJECTIVES

To determine the characteristics of infantile scoliosis in Marfan syndrome and the response to treatment of patients with this condition.

SUMMARY OF BACKGROUND DATA

No previous study has reported the features of this condition nor the effect of treatment on patients with this syndrome.

METHODS

The data on all patients seen at one institution who had Marfan syndrome and scoliosis by age three were reviewed. Fourteen of the 600 patients from the group examined who had Marfan syndrome fit the above criteria. Skeletal and general features were studied.

RESULTS

Thirteen of the 14 patients had no family history of Marfan syndrome, a finding which does not fit the usual autosomal dominant inheritance pattern. All 14 patients had exaggeration of the Marfan. All but one patient had cardiac valvular insufficiency that required repair by age 11. Thirteen patients had thoracic aortic aneurysm, 10 had lens dislocation, and eight had sternal deformity. Three patients had hip dislocations, two had pyloric stenosis, and two had dural ectasia. Motor delay was evidenced by onset of walking past 18 months in nine patients; three of these patients were never able to walk independently. One patient each died at ages 1, 3, 4, and 8 years; all others have survived to present (mean age, 13 years). The mean curve of the patients' spines at presentation was 38 degrees. Eleven curves were double major, two were thoracolumbar, and one was double thoracic. Brace wear did not halt curve progression in any of the nine patients for whom it was used. Instrumentation without fusion was used in three patients for a mean of 3 years, with best results in one nonkyphotic curve. Nine patients underwent instrumented fusion at a mean age of 6.6 years (range, 3-13 years). Mean curve correction was 51% (from 72 degrees to 34 degrees). Final mean curve was 54 degrees for a mean correction of 20% at the 5-year (average, 5.4 years) follow-up examination. Acute complications occurred in three patients, and five patients needed a second surgery for late complications. Causes for curve increase after surgery included growth and loss of fixation.

CONCLUSIONS

In this most severe form of Marfan syndrome, bracing has a limited role and is only to be used if the curve is less than 40 degrees. Surgery should not be performed on a patient younger than four years of age because many patients with large curves before this age will succumb spontaneously to cardiac complications. Instrumentation without fusion should be considered only for patients with no significant kyphosis. Results of fusion are better for patients who are older than five years of age.

[Abdominal aortic aneurysm and annuloaortic ectasia in siblings with Marfan syndrome]

A combination of annuloaortic ectasia (AAE) and abdominal aortic aneurysm (AAA) appeared in siblings with Marfan syndrome is presented. The patients were a 53-year-old female and her younger brother. The brother died of arrhythmia twenty years before while waiting for surgical repair of AAE. His AAA and Marfan syndrome were ascertained at autopsy. The female patient received surgical repair for AAA and AAE subsequently. Pathologic study of the resected aneurysm revealed cystic medial necrosis. A combination of AAE and AAA developed in two members of a family with Marfan syndrome is extremely rare.

[Marfan syndrome]

The author describes three forms of Marfan's syndrome which have only the skeletal symptoms in common. In all instances also ophthalmological symptoms are present but of different types. A familial case was observed only in one family; in the remaining two frust forms of Marfan's syndrome are involved.

Repair of a ruptured sinus of Valsalva aneurysm. Associated with annuloaortic ectasia and coarctation of the aorta in a patient with Marfan syndrome

We report the case of a 16-year-old boy with Marfan syndrome who presented in severe congestive heart failure secondary to rupture of an aneurysm of the sinus of Valsalva into the right atrium, a condition that was aggravated by coarctation of the aorta. The patient also had a large aneurysm of the ascending aorta with the characteristics of annuloaortic ectasia. The patient underwent successful surgical correction and is asymptomatic 3 years after the repair.

Corneal wrinkling in a hydrogel contact lens wearer with Marfan syndrome

BACKGROUND

Corneal distortion in contact lens wear can be produced by epithelial wrinkles, compression rings, and anterior corneal surface mosaic. True corneal wrinkling can also occur but is an extremely rare phenomenon. These conditions can be manifested as alterations in keratometry and corneal topography.

METHODS

A case report is presented of a 17-year-old patient with Marfan syndrome. Central corneal wrinkling developed in his right eye while he was wearing low-water-content hydrogel contact lenses. No visual discomfort or distortions were noted.

RESULTS

The patient was refitted with a non-HEMA hydrogel polymer contact lens, with no further episodes of corneal wrinkling observed during subsequent care of the patient.

CONCLUSIONS

This case represents an example of corneal wrinkling in a patient wearing hydrogel contact lenses. It is unlikely this finding is related to Marfan syndrome.

[Preventive concomitant aortic root replacement for annuloaortic ectasia in a patient with Marfan syndrome undergoing mitral valve replacement for mitral regurgitation]

A 28-year-old woman presented with Marfan syndrome combined with severe mitral regurgitation and annuloaortic ectasia. The ascending aorta was dilated to 48 mm in diameter without aortic regurgitation. Considering the increased operative risk due to complication with aortic dissection, simultaneous replacement of the mitral valve and aortic root were performed. Her postoperative course was uneventful. Several options of the surgical treatment for Marfan syndrome are discussed.

Marfan's syndrome and surgical repair of ascending aortic aneurysms

Marfan's syndrome is an inherited, degenerative connective tissue disorder that affects many body systems (eg, skeletal, ocular, cardiovascular, cutaneous, pulmonary, abdominal, neurologic). The cause of Marfan's syndrome is unknown, but recent genetic studies have linked this disorder to chromosome 15q15-q21.3. The characteristics associated with Marfan's syndrome require a multidisciplinary approach to patient care. This article discusses one serious complication of Marfan's syndrome-aortic root dilatation- and composite graft repairs of ascending aortic aneurysms. Physicians and nurses must be more aware of Marfan's syndrome so that life-threatening medical conditions can be evaluated and followed by health care providers.

Recurrent aortic dissection after orthotopic heart transplantation

A patient with Marfan's syndrome and previous Bentall repair for aortic dissection required orthotopic cardiac transplantation for end-stage cardiomyopathy. Postoperatively he suffered recurrent aortic dissection involving the transverse and descending aorta leading to tracheal and esophageal compression. He underwent successful surgical replacement of his ascending aorta, transverse arch, and descending aorta.

Defective expression of HLA class I and CD1a molecules in boy with Marfan-like phenotype and deep skin ulcers

We report the case of a boy with low expression of HLA class I molecules on peripheral blood mononuclear cells, which is associated with immunodeficiency. The patient, who had a Marfan-like phenotype, had chronic deep skin ulcers and sinobronchiectasis. Immunohistologic examination of the ulcerated skin showed a dense perivascular infiltrate composed of normal mature lymphocytes and macrophages. All cells in the infiltrate showed an apparently normal expression of HLA class I molecules, but intraepidermal dendritic Langerhans' cells were negative for CD1a, an antigen that is a highly specific marker for these cells and is abundantly expressed in some self-healing forms of cutaneous lesions. It is therefore speculated that a defective expression of CD1a molecules can contribute to the chronic persistence of deep skin ulcers, which have already been reported in association with defective expression of HLA class I molecules.

[Perforation and localized dissection of the left common iliac artery during the modified Bentall procedure: a case report]

We performed the modified Bentall procedure for annuloaortic ectasia in a 41-year-old man with Marfan's syndrome. Approximately 15 minutes after initiation of cardiopulmonary bypass with an arterial delivery via the left common femoral artery, perfusion volume gradually decreased and the abdomen of the patient was distended. Retrograde dissection was strongly suggested. Perforation and localized dissection of the left common iliac artery were recognized. Following repair of the lesion, the modified Bentall operation was carried out. Postoperative course was uneventful. The patient has been well for 22 months after the operation.

[Neonatal heart failure and Marfan syndrome]

We report the case of a neonate admitted to the hospital in the 4th day of life in severe heart failure due to aortic and mitral regurgitation with a largely dilated aortic root. The associated skeletal features involving the superior and inferior limbs as well as the thorax, and joint hypermobility, allowed the clinical diagnosis of Marfan syndrome. Despite favorable initial response to medical therapy, sudden deterioration led to death two weeks after birth. Typical necroscopic findings were confirmed and the case is considered the most severe clinical manifestation possible to be found in this syndrome.

Influence of maxillary constriction on nasal resistance and sleep apnea severity in patients with Marfan's syndrome

BACKGROUND

Marfan's syndrome is associated with a high prevalence of obstructive sleep apnea (OSA). As this syndrome is associated with a characteristic constricted maxilla and high-arched palate, we reasoned that nasal airway constriction and resultant high nasal airway resistance (NAR) may contribute to the development of OSA. Therefore, the aim of this study was to measure NAR in patients with Marfan's syndrome. In addition, we aimed to examine the influence of maxillary morphology on both NAR and the severity of OSA.

METHOD

We measured NAR in 13 consecutive patients with Marfan's syndrome and 13 control subjects. NAR was measured by posterior rhinomanometry, and expressed as the inspiratory resistance at a flow of 0.5 L/s. Dental impressions were taken to evaluate maxillary arch morphology, allowing measurement of the following distances: intercuspid (ICD), interpremolar (IPD), intermolar (IMD), and maximum hard palate height (MPH). Ten of the patients and four of the control subjects had previously undergone nocturnal polysomnography.

RESULTS

Mean NAR for the Marfan group was more than twice that in the control group (7.7 +/- 1.2 vs 2.9 +/- 0.4 cm H2O/L/s; p < 0.005). The patients also had marked constriction of the maxillary arch compared with control subjects. Two of the lateral maxillary measurements were significantly inversely correlated with NAR. There were significant correlations between various maxillary arch measurements (MPH/ICD, MPH/IPD, MPH/IMD) and the apnea/hypopnea index.

CONCLUSION

These data suggest that high NAR is a common feature of Marfan's syndrome. Maxillary constriction with a relatively high hard palate appears to be a major reason for the high NAR. The significant correlations between indexes of maxillary constriction and sleep apnea severity suggest that maxillary morphology may play an important role in the pathophysiology of OSA in Marfan's syndrome.

[Subtotal aortic replacement in a patient with Marfan's syndrome--replacement of the ascending aorta and entire aortic arch for acute type I aortic dissection 4 years after the thoracoabdominal replacement]

We report a patient with Marfan's syndrome who underwent replacement of the ascending aorta and the entire aortic arch for acute type I aortic dissection 4 years after the thoracoabdominal replacement. As a result, she underwent subtotal aortic replacement from the ascending aorta to the bilateral common iliac arteries in three stages. A 48-years-old female was admitted to our service because of acute heart failure and cardiogenic shock caused by acute DeBakey type I aortic dissection. She had undergone replacement of the descending thoracic aorta at the age of 44 and replacement of the remaining thoracoabdominal aorta with reimplantation of the four major abdominal branches at the age of 46 for a chronic expanding DeBakey type IIIb dissecting aneurysm. She successfully underwent replacement of the ascending aorta and the entire aortic arch with an aortic prosthesis provided with four branch grafts for reconstruction of the arch vessels. Considering the high incidence of new aortic lesion, extensive aortic replacement and careful postoperative follow-up are necessary in patients with Marfan's syndrome.

Delay in diagnosis of homocystinuria: retrospective study of consecutive patients

OBJECTIVE

To assess the causes for delay in the diagnosis of homocystinuria.

DESIGN

Clinical and laboratory data were collected from patients diagnosed as having homocystinuria due to cystathionine synthase deficiency, with special reference to the ages at which the patients had their first major signs of the disease, ectopia lentis was established, and homocystinuria was diagnosed.

SETTING

University hospital in the Netherlands.

SUBJECTS

34 patients (18 males) in whom homocystinuria due to cystathionine synthase deficiency was diagnosed in the period 1970-94.

RESULTS

Among 34 consecutively detected homocystinuria patients the mean age at diagnosis of homocystinuria was 24 (range 1-61) years. Despite frequent ocular manifestations, serious complications in the vascular, skeletal, and central nervous systems, and repeated examinations performed in these patients by clinicians of various disciplines, there was a mean delay of 11 (0-43) years between the first major signs of the disease (at mean age 13 (1-40) years) and the ultimate diagnosis of homocystinuria. Even when ectopia lentis was diagnosed (in 26 (76%) patients, mean age 18 (1-50) years), this did not lead to adequate biochemical analysis for homocystinuria at the time of detection, causing a mean diagnostic delay of 8 (0-24) years in these patients.

CONCLUSIONS

Three factors should have precipitated the diagnosis of homocystinuria: early recognition that unusual myopia (high, very high, abnormal progressive, or at young age) was caused by subluxation of the ocular lenses; awareness that the occurrence of myopia combined with systemic complications ("myopia plus") might be due to homocystinuria; and appropriate biochemical investigations carried out in patients with ectopia lentis and in their siblings.

[Pathology of aortic dissection]

Aortic dissection is not a popular disease but it should be listed in the disease to be excluded especially in acute emergent cases, because of its serious and protean clinical manifestations. While DeBakey classification was used over 30 years. Stanford classification is now widely accepted for its clinical availabilities. The features of the aortic dissection are 1) presence of the intimal tear at the proximal end in almost all cases, 2) its frequent location in the ascending aorta and aortic segment just distal to the left subclavian artery, and 3) the dissected plane at the outer media or medial-adventitial border. Systemic hypertension is frequently noticed in cases with aortic dissection. These features suggest hemodynamic effect as a pathogenic factor in addition to mural fragility of the aorta. Aortic dissection is frequently encountered in Marfan syndrome and other heritable diseases of connective tissue. Concerning Marfan syndrome, mutation of fibrillin gene was confirmed. Fibrillin is a microfibril consisting of glycoprotein closely bound to elastin. Therefore, traditional "cystic medial necrosis" which was referred as a principal morphological change corresponding to aortic dissection is now thought to be a secondary change to the aortic injuries occurred in the aortic wall.

Management of ectopia lentis in a family with Marfan syndrome

OBJECTIVE

To determine the effectiveness of combined pars plana vitrectomy-lensectomy and open-loop anterior chamber lens implantation for the management of ectopia lentis associated with Marfan syndrome.

METHODS

Retrospective review of the medical records of 4 consecutive patients with Marfan syndrome who underwent combined pars plana lensectomy-vitrectomy and anterior chamber lens implantation at our institution between August 1994 and July 1995.

RESULTS

All patients demonstrated postoperative visual acuity of 20/25 or better during an average follow-up period of 6 months (range, 4-9 months). Two patients developed pseudophakic pupillary block and required YAG laser iridotomy postoperatively.

CONCLUSIONS

Pars plana lensectomy-vitrectomy and anterior chamber intraocular lens implantation appears to be an excellent technique for the management of ectopia lentis associated with Marfan syndrome. A bimanual, closed-system endosurgical technique avoids many of the complications previously associated with surgery for ectopia lentis.