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Chen ZX, Jia WN, Ma Y, Chen TH, Hong JH, Sun Y, Liu Y, Song LH, Jiang YX. Predicting axial length in patients with Marfan syndrome and ectopia lentis after modified capsular tension ring and intraocular lens implantation. J Cataract Refract Surg 2023; 49:571-577. [PMID: 36745849 DOI: 10.1097/j.jcrs.0000000000001155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 01/26/2023] [Indexed: 02/08/2023]
Abstract
PURPOSE To predict the growth of axial length (AL) in patients with Marfan syndrome (MFS) and ectopia lentis (EL). SETTING Eye and ENT Hospital of Fudan University, Shanghai, China. DESIGN Consecutive retrospective case series. METHODS Eyes were evaluated that had modified capsular tension ring and intraocular lens (IOL) implantation. The rate of AL growth (RALG) was calculated using AL divided by log10-transformed age. A multivariate linear regression model of RALG was developed after validation. RESULTS 128 patients with MFS and EL were enrolled with a median follow-up duration of about 3 years. RALG was independent of age between 3 years and 15 years old ( P = .799) and decreased to 0 thereafter ( P = .878). Preoperative AL was associated with RALG in patients under 15 years old ( P = .003). Beta values for the final model of RALG were as below: intercept (-9.794) and preoperative AL (0.664). The postoperative AL was predicted as: postAL = preAL + RALG × log 10 ([postAge + 0.6]/[preAge + 0.6]). The mean prediction error was -0.003 (95% CI, -0.386 to 0.3791) mm and the mean absolute percentage error was 1.93% (95% CI, 0.73% to 3.14%). A Python-based calculator was developed to use the predicted AL in selecting IOL power and setting undercorrection. CONCLUSIONS The AL growth of patients with MFS followed a logarithmic pattern and ceased at about age 15. A prediction model of postoperative AL was established for individual MFS patients between 3 and 15 years old, which could potentially optimize the IOL power selection.
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Chen M, Cavinato C, Hansen J, Tanaka K, Ren P, Hassab A, Li DS, Youshao E, Tellides G, Iyengar R, Humphrey JD, Schwartz MA. FN (Fibronectin)-Integrin α5 Signaling Promotes Thoracic Aortic Aneurysm in a Mouse Model of Marfan Syndrome. Arterioscler Thromb Vasc Biol 2023; 43:e132-e150. [PMID: 36994727 PMCID: PMC10133209 DOI: 10.1161/atvbaha.123.319120] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 03/20/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Marfan syndrome, caused by mutations in the gene for fibrillin-1, leads to thoracic aortic aneurysms (TAAs). Phenotypic modulation of vascular smooth muscle cells (SMCs) and ECM (extracellular matrix) remodeling are characteristic of both nonsyndromic and Marfan aneurysms. The ECM protein FN (fibronectin) is elevated in the tunica media of TAAs and amplifies inflammatory signaling in endothelial and SMCs through its main receptor, integrin α5β1. We investigated the role of integrin α5-specific signals in Marfan mice in which the cytoplasmic domain of integrin α5 was replaced with that of integrin α2 (denoted α5/2 chimera). METHODS We crossed α5/2 chimeric mice with Fbn1mgR/mgR mice (mgR model of Marfan syndrome) to evaluate the survival rate and pathogenesis of TAAs among wild-type, α5/2, mgR, and α5/2 mgR mice. Further biochemical and microscopic analysis of porcine and mouse aortic SMCs investigated molecular mechanisms by which FN affects SMCs and subsequent development of TAAs. RESULTS FN was elevated in the thoracic aortas from Marfan patients, in nonsyndromic aneurysms, and in mgR mice. The α5/2 mutation greatly prolonged survival of Marfan mice, with improved elastic fiber integrity, mechanical properties, SMC density, and SMC contractile gene expression. Furthermore, plating of wild-type SMCs on FN decreased contractile gene expression and activated inflammatory pathways whereas α5/2 SMCs were resistant. These effects correlated with increased NF-kB activation in cultured SMCs and mgR aortas, which was alleviated by the α5/2 mutation or NF-kB inhibition. CONCLUSIONS FN-integrin α5 signaling is a significant driver of TAA in the mgR mouse model. This pathway thus warrants further investigation as a therapeutic target.
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Ng B, Xie C, Su L, Kuthubudeen FF, Kwek XY, Yeong D, Pua CJ, Cook SA, Lim WW. IL11 (Interleukin-11) Causes Emphysematous Lung Disease in a Mouse Model of Marfan Syndrome. Arterioscler Thromb Vasc Biol 2023; 43:739-754. [PMID: 36924234 PMCID: PMC10125130 DOI: 10.1161/atvbaha.122.318802] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 02/27/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Marfan Syndrome (MFS) is an inherited connective tissue disorder caused by mutations in the FBN1 (fibrillin-1) gene. Lung abnormalities are common in MFS, but their pathogenesis is poorly understood. IL11 (interleukin-11) causes aortic disease in a mouse model of MFS and was studied here in the lung. METHODS We examined histological and molecular phenotypes in the lungs of Fbn1C1041G/+ mice (mouse model of Marfan Syndrome [mMFS]), an established mouse model of MFS. To identify IL11-expressing cells, we used immunohistochemistry on lungs of 4- and 16-week-old Fbn1C1041G/+:Il11EGFP/+ reporter mice. We studied the effects of IL11 inhibition by RT-qPCR, immunoblots and histopathology in lungs from genetic or pharmacologic models: (1) 16-week-old IL11 receptor (IL11RA) knockout mMFS mice (Fbn1C1041G/+:Il11ra1-/- mice) and (2) in mMFS mice administered IgG control or interleukin-11 receptor antibodies twice weekly from 4 to 24 weeks of age. RESULTS mMFS lungs showed progressive loss and enlargement of distal airspaces associated with increased proinflammatory and profibrotic gene expression as well as matrix metalloproteinases 2, 9, and 12. IL11 was increased in mMFS lungs and localized to smooth muscle and endothelial cells in young mMFS mice in the Fbn1C1041G/+:Il11EGFP/+ reporter strain and in fibroblasts, in older mice. In mMFS mice, genetic (Fbn1C1041G/+:Il11ra1-/-) or pharmacologic (anti-interleukin-11 receptor) inhibition of IL11 signaling reduced lung emphysema, fibrosis, and inflammation. This protective effect was associated with reduced pathogenic ERK1/2 signaling and lower metalloproteinase 2, 9, and 12 expression. CONCLUSIONS IL11 causes lung disease in mMFS. This reveals a shared IL11-driven disease mechanism in lung and aorta in MFS and suggests inhibition of IL11 signaling as a holistic approach for treating multiorgan morbidity in MFS.
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Hovan M, Mandler A. Lactobacillus rhamnosus endocarditis associated with dental procedure in a patient with Marfan's variant and prior aortic root replacement. BMJ Case Rep 2023; 16:e252699. [PMID: 36941016 PMCID: PMC10030545 DOI: 10.1136/bcr-2022-252699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2023] Open
Abstract
A man in his 60s with a medical history of Marfan's variant with remote valve sparing aortic root replacement presented for evaluation of subacute fevers, chills and night sweats. He had no significant preceding history other than a dental cleaning performed with antibiotic prophylaxis. Blood cultures grew Lactobacillus rhamnosus which was susceptible to penicillin and linezolid but resistant to meropenem and vancomycin. A transthoracic echocardiogram showed an aortic leaflet vegetation with chronic moderate aortic regurgitation but no reduction in his ejection fraction. He was discharged home and treated with gentamicin and penicillin G, initially with adequate response. However, he was subsequently readmitted for persistent fevers, chills, weight loss and dizziness, found to have multiple acute strokes secondary to septic thromboemboli. He underwent definitive aortic valve replacement with excised tissue confirming infective endocarditis.
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Avetisov KS, Chizhonkova EA, Avetisov SE, Narbut MN. [Endocapsular fixation of intraocular lens in patients with ectopia lentis and Marfan syndrome (case study)]. Vestn Oftalmol 2023; 139:59-64. [PMID: 37638573 DOI: 10.17116/oftalma202313904159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
Modern trends in advancement of phaco surgery techniques in patients with ectopia lentis (including patients with Marfan syndrome) are characterized by the transition from complete removal of the lens (lensectomy) to aspiration of the lens substance and attempts to preserve and reposition the capsular bag. This case study analyzes the results of surgical treatment of bilateral ectopia lentis in a 6-year-old patient with Marfan syndrome. The specifics of microinvasive phaco surgery consisted in capsular bag preservation and endocapsular fixation of the intraocular lens. The article presents the results of ophthalmological observation over a seven-year period.
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Sato I, Takeda A. Long-term survival case with severe infantile Marfan syndrome: A case report. Pediatr Int 2023; 65:e15571. [PMID: 37459280 DOI: 10.1111/ped.15571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 03/31/2023] [Accepted: 05/02/2023] [Indexed: 07/20/2023]
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Zhang Y, Shi C, Zhang D, Chen Q. Endovascular treatment of type Ia endoleak in a patient with Marfan syndrome: A case report. Asian J Surg 2023; 46:613-614. [PMID: 35843811 DOI: 10.1016/j.asjsur.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/06/2022] [Indexed: 12/15/2022] Open
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Udugampolage N, Caruso R, Magon A, Conte G, Callus E, Taurino J, Pini A. Describing post-traumatic stress disorder and its associations with depression, anxiety and insomnia: a descriptive study in Italian adults with Marfan syndrome during the COVID-19 third wave. BMJ Open 2022; 12:e067024. [PMID: 36523249 PMCID: PMC9748516 DOI: 10.1136/bmjopen-2022-067024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE The evaluation of post-traumatic stress disorder (PTSD), depression, anxiety and insomnia in patients with Marfan syndrome (MFS) during the third wave of the COVID-19 pandemic in a region of northern Italy (Lombardy) and the investigation of which mental health, sociodemographic and clinical factors were associated with PTSD. DESIGN Descriptive observational design with cross-sectional data collection procedure. SETTING A single Italian MFS-specific specialised and reference centre in Lombardy (Italy) between February and April 2021. PARTICIPANTS 112 adults with MFS. The majority of participants were female (n=64; 57.1%), with a high school diploma (n=52; 46.4%) and active workers (n=66; 58.9%). The mean age was 41.89 years (SD=14.00), and the mean time from diagnosis was 15.18 years (SD=11.91). PRIMARY AND SECONDARY OUTCOMES Descriptive statistics described PTSD, which was the primary outcome, as well as depression, anxiety and insomnia, which were the secondary outcomes. Four linear regression models described the predictors of PTSD total score and its three domains: avoidance, intrusion and hyperarousal. RESULTS One out of 10 patients with MFS had mild psychological symptoms regarding depression, anxiety and insomnia, and scores of PTSD that indicated clinical worries about the mental health status. The presence of PTSD was mainly predicted by anxiety (β=0.647; p<0.001), being older, taking psychoactive medication and being unemployed. CONCLUSION Depression, anxiety and insomnia should be monitored in patients with MFS in order to minimise PTSD insurgence. Specific psychosocial interventions should be developed and tested for this population and adopted in clinical practice, given the relevance of mental health outcomes during the pandemic.
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Selamet Tierney ES, Chung S, Stauffer KJ, Brabender J, Collins RT, Folk R, Li W, Murthy AK, Murphy DJ, Esfandiarei M. Can 10 000 Healthy Steps a Day Slow Aortic Root Dilation in Pediatric Patients With Marfan Syndrome? J Am Heart Assoc 2022; 11:e027598. [PMID: 36453629 PMCID: PMC9851465 DOI: 10.1161/jaha.122.027598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background Stiffer aortas are associated with a faster rate of aortic root (AoR) dilation and higher risk of aortic dissection in patients with Marfan syndrome. We have previously shown that mild aerobic exercise reduces aortic stiffness and rate of AoR dilation in a Marfan mouse model. In this study, we investigated if these results could be translated to pediatric patients with Marfan syndrome. Methods and Results We enrolled 24 patients with Marfan syndrome aged 8 to 19 years to participate in a 6-month physical activity intervention, excluding those with ventricular dysfunction or prior history of aortic surgery. We instructed patients to take 10 000 steps per day, tracked by an activity tracker. At baseline and 6 months, we measured AoR dimension, arterial stiffness, endothelial function, physical activity indices, inflammatory biomarkers, and coping scores. Controls consisted of 15 age-matched patients with Marfan syndrome. Twenty-four patients with Marfan syndrome (median age, 14.4 years [interquartile range {IQR}, 12.2-16.8], 14 male patients) were enrolled. Baseline assessment demonstrated that the majority of these patients were sedentary and had abnormal arterial health. Twenty-two patients completed the intervention and took an average of 7709±2177 steps per day (median, 7627 [IQR, 6344-9671]). Patients wore their Garmin trackers at a median of 92.8% (IQR, 84%-97%) of their intervention days. AoR Z score in the intervention group had a significantly lower rate of change per year compared with the controls (rate of change, -0.24 versus +0.008; P=0.01). Conclusions In this clinical intervention in pediatric patients with Marfan syndrome, we demonstrated that a simple physical activity intervention was feasible in this population and has the potential to decrease the AoR dilation rate. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03567460.
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Downey RT, Aron RA. Thoracic and Thoracoabdominal Aneurysms: Etiology, Epidemiology, and Natural History. Anesthesiol Clin 2022; 40:671-683. [PMID: 36328622 DOI: 10.1016/j.anclin.2022.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Thoracic aortic aneurysms and thoracoabdominal aneurysms are often found incidentally. Complications include dissection or rupture. Most of the thoracic aortic aneurysms and thoracoabdominal aneurysms develop in patients with risk factors for atherosclerosis. Younger patients without significant cardiovascular risk factors may have a genetic basis and include syndromes such as Marfan, Ehlers-Danlos, and Loeys-Dietz and bicuspid aortic valve. Most thoracic aneurysms grow slowly over time and factors that accelerate growth rate include dissection, aneurysm size, bicuspid valve disease, and Marfan syndrome. Size cutoffs where complications occur determine when surgery or intervention should be considered.
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DeVries JJ, Myers HA. Case Report: Effects of Sars-CoV-2 on Marfan syndrome with resulting acute aortic dissection. JOURNAL OF VASCULAR NURSING 2022; 40:181-183. [PMID: 36435601 PMCID: PMC9492500 DOI: 10.1016/j.jvn.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/16/2022] [Accepted: 09/16/2022] [Indexed: 12/14/2022]
Abstract
Marfan syndrome is one of the most common inherited connective tissue disorders that affects the heart, eyes, blood vessels, and bones. It occurs in approximately 1-2 per 10,000 individuals annually. Many patients with Marfan syndrome eventually develop aortic wall abnormalities, often resulting in aortic dilatation, which increases the risk of acute aortic dissection. Recent studies involving SARS-CoV-2 propose that individuals with connective tissue disorders such as Marfan syndrome can have additional associated conditions that could impose a higher risk for morbidity and mortality from SARS-CoV-2. The purpose of this article is to discuss the interrelationship between Marfan Syndrome, Acute Type A Aortic Dissection in a patient with Sars-CoV-2 infection. Pertinent review of these conditions, diagnostic findings, treatment, and the patient's clinical course will be discussed. There is minimal research focused on the connection between this novel virus, Marfan Syndrome, and compounding risk for aortic dissection.
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Taghizadeh Waghefi A, Petrov A, Wilbring M, Fajfrova Z, Fitze G, Matschke K, Kappert U. Combined Bentall and Modified Ravitch Procedures: A Case Report and Systematic Review of the Evidence. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58121774. [PMID: 36556976 PMCID: PMC9788579 DOI: 10.3390/medicina58121774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 12/05/2022]
Abstract
Background and Objectives: Marfan syndrome (MS) is a genetic disorder with autosomal dominant inheritance that affects the connective tissue and consequently many organ systems. The cardiovascular manifestations of MS are notorious and include aortic root dilatation or acute aortic dissection, which can cause morbidity and early mortality. However, surgical treatment of aortic pathology may be complicated by musculoskeletal deformity of the chest wall, as in pectus excavatum. In this regard, single-stage combined Bentall and Ravitch surgery is an extreme rarity that has also been scarcely reported in the literature. Patients and Methods: We present the medical history and single-stage Bentall and modified Ravitch surgical treatment of an 18-year-old male MS patient with symptomatic and severe pectus excavatum (PEX) in conjunction with a pear-shaped aortic root aneurysm. To discuss our case in the context of a synopsis of similar published cases, we present a systematic review of combined Bentall surgical aortic aneurysm repair and Ravitch correction of PEX. Results: A total of four studies (one case series and three case reports) and a case from our institution describing a single-stage combined Bentall and Ravitch operation were included. Patients were 22 ± 5.9 years of age (median = 22.5 years) and predominantly male (60%). All cases reported a midline vertical skin incision over the sternum. The most common surgical approach was midsternotomy (80%). In all cases metal struts were used to reinforce the corrected chest wall. Postoperative mortality was zero. Conclusions: Single-stage combined Bentall and Ravitch surgery is an underutilized surgical approach. Its use in MS patients with concomitant PEX and ascending aortic aneurysm that require surgical treatment warrants further investigation. Midsternotomy seems to be a viable access route that provides sufficient exposure in the single-stage surgical setting. Although operative time is long, the intraoperative and postoperative risks appear to be low and manageable.
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Kim KH, Kim TY, Kim SJ, Cho YG, Park J, Jang W. Targeted Panel Sequencing Identifies an Intronic c.5225-3C>G Variant of the FBN1 Gene Causing Sporadic Marfan Syndrome with Annuloaortic Ectasia. Genes (Basel) 2022; 13:2108. [PMID: 36421783 PMCID: PMC9690865 DOI: 10.3390/genes13112108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/03/2022] [Accepted: 11/11/2022] [Indexed: 08/29/2023] Open
Abstract
Marfan syndrome (MFS) is a hereditary connective tissue disease whose clinical severity varies widely. Mutations of the FBN1 gene encoding fibrillin-1 are the most common genetic cause of Marfanoid habitus; however, about 10% of MFS patients are unaware of their genetic defects. Herein, we report a Korean patient with MFS and annuloaortic ectasia caused by an intronic c.5225-3C>G variant of the FBN1 gene identified by targeted panel sequencing. The reverse transcription analysis of FBN1 revealed that the intron 43 sequence from positions c.5297-1516 to c.5297-1 was retained at the coding sequence as a consequence of the c.5225-3C>G variant enhancing a cryptic splice acceptor site (c.5297-1518_5297-1517AG) in intron 43. The retained sequence of the part of intron 43 caused the same effect as insertion mutation (NM_000138.5:c.5297_c.5298ins5297-1516_5297-1), resulting in a frameshift mutation resulting in p.Ile1767Trpfs*3. The patient underwent an urgent modified Bentall operation with a 29 mm mechanical valve for annuloaortic ectasia and severe aortic valve regurgitation. This report emphasizes the need for functional investigations into the diagnostic workflows of certain diseases or gene panels with suspected high rates of intronic variants and potential pathogenic effects. Hence, further descriptions of individuals with intronic variants causing alternative splicing expected to have pathogenic effects at different transcript levels are crucial for improving our understanding.
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Chotigavanichaya C, Vatidvarodom P, Ariyawatkul T, Ruangchainikom M, Wilartratsami S, Chotivichit A, Thanapipatsiri S, Santipas B, Adulkasem N, Luksanapruksa P. Surgical outcome of scoliosis in patients with Marfan syndrome. Spine Deform 2022; 10:1453-1460. [PMID: 35908146 DOI: 10.1007/s43390-022-00547-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 06/18/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE To evaluate clinical and radiographic outcomes after surgical scoliosis correction and posterior instrumented fusion in SMF patients. METHODS A single-center medical database was reviewed to identify MF patients who presented with scoliosis from 2000 to 2015. Patients who underwent spinal fusion surgery were included. Demographic, operative and clinical data were reviewed, and the preoperative, postoperative, and latest follow-up radiographic parameters were compared. RESULTS Twelve patients were identified (2 males, 10 females) with an average age at surgery of 14.4 ± 2.6 years. Comorbidities were found in 84.6%. Most patients (90.9%) presented with a right thoracic curve. The average preoperative Cobb angle was 75.6 ± 15.5 degrees. Posterior instrumented spinal fusion was performed in all patients (1 hook/pedicular screw and 11 pedicle screws only). The average follow-up period was 6.8 ± 3.1 years. The mean postoperative Cobb angle after surgery and at the final follow-up was 33.4 ± 18.0 degrees and 35.5 ± 18.4 degrees, respectively. There was a statistically significant difference among the preoperative and postoperative Cobb angles (p < 0.001), but no significant difference among the sagittal angles. Two perioperative complications including superficial wound infection and broken rods were observed. CONCLUSIONS Posterior scoliosis correction and instrumented spinal fusion resulted in a satisfactory outcome in MF patients. Perioperative complications are not uncommon; however, no neurological complication or spinal decompensation was observed in this study. LEVEL OF EVIDENCE IV.
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Colijn MA. The cooccurrence of psychosis and Marfanoid features: diagnostic considerations. Eur Arch Psychiatry Clin Neurosci 2022; 272:1389-1390. [PMID: 35366713 DOI: 10.1007/s00406-022-01404-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 03/25/2022] [Indexed: 11/25/2022]
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Ono R, Iwahana T, Kato H, Kobayashi Y. Steinberg sign and ectopia lentis: Marfan syndrome. QJM 2022; 115:617-618. [PMID: 35781828 DOI: 10.1093/qjmed/hcac156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Indexed: 11/14/2022] Open
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Pitcher A, Spata E, Emberson J, Davies K, Halls H, Holland L, Wilson K, Reith C, Child AH, Clayton T, Dodd M, Flather M, Jin XY, Sandor G, Groenink M, Mulder B, De Backer J, Evangelista A, Forteza A, Teixido-Turà G, Boileau C, Jondeau G, Milleron O, Lacro RV, Sleeper LA, Chiu HH, Wu MH, Neubauer S, Watkins H, Dietz H, Baigent C. Angiotensin receptor blockers and β blockers in Marfan syndrome: an individual patient data meta-analysis of randomised trials. Lancet 2022; 400:822-831. [PMID: 36049495 PMCID: PMC7613630 DOI: 10.1016/s0140-6736(22)01534-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/01/2022] [Accepted: 08/03/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Angiotensin receptor blockers (ARBs) and β blockers are widely used in the treatment of Marfan syndrome to try to reduce the rate of progressive aortic root enlargement characteristic of this condition, but their separate and joint effects are uncertain. We aimed to determine these effects in a collaborative individual patient data meta-analysis of randomised trials of these treatments. METHODS In this meta-analysis, we identified relevant trials of patients with Marfan syndrome by systematically searching MEDLINE, Embase, and CENTRAL from database inception to Nov 2, 2021. Trials were eligible if they involved a randomised comparison of an ARB versus control or an ARB versus β blocker. We used individual patient data from patients with no prior aortic surgery to estimate the effects of: ARB versus control (placebo or open control); ARB versus β blocker; and indirectly, β blocker versus control. The primary endpoint was the annual rate of change of body surface area-adjusted aortic root dimension Z score, measured at the sinuses of Valsalva. FINDINGS We identified ten potentially eligible trials including 1836 patients from our search, from which seven trials and 1442 patients were eligible for inclusion in our main analyses. Four trials involving 676 eligible participants compared ARB with control. During a median follow-up of 3 years, allocation to ARB approximately halved the annual rate of change in the aortic root Z score (mean annual increase 0·07 [SE 0·02] ARB vs 0·13 [SE 0·02] control; absolute difference -0·07 [95% CI -0·12 to -0·01]; p=0·012). Prespecified secondary subgroup analyses showed that the effects of ARB were particularly large in those with pathogenic variants in fibrillin-1, compared with those without such variants (heterogeneity p=0·0050), and there was no evidence to suggest that the effect of ARB varied with β-blocker use (heterogeneity p=0·54). Three trials involving 766 eligible participants compared ARBs with β blockers. During a median follow-up of 3 years, the annual change in the aortic root Z score was similar in the two groups (annual increase -0·08 [SE 0·03] in ARB groups vs -0·11 [SE 0·02] in β-blocker groups; absolute difference 0·03 [95% CI -0·05 to 0·10]; p=0·48). Thus, indirectly, the difference in the annual change in the aortic root Z score between β blockers and control was -0·09 (95% CI -0·18 to 0·00; p=0·042). INTERPRETATION In people with Marfan syndrome and no previous aortic surgery, ARBs reduced the rate of increase of the aortic root Z score by about one half, including among those taking a β blocker. The effects of β blockers were similar to those of ARBs. Assuming additivity, combination therapy with both ARBs and β blockers from the time of diagnosis would provide even greater reductions in the rate of aortic enlargement than either treatment alone, which, if maintained over a number of years, would be expected to lead to a delay in the need for aortic surgery. FUNDING Marfan Foundation, the Oxford British Heart Foundation Centre for Research Excellence, and the UK Medical Research Council.
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Pedroza AJ, Dalal AR, Shad R, Yokoyama N, Nakamura K, Cheng P, Wirka RC, Mitchel O, Baiocchi M, Hiesinger W, Quertermous T, Fischbein MP. Embryologic Origin Influences Smooth Muscle Cell Phenotypic Modulation Signatures in Murine Marfan Syndrome Aortic Aneurysm. Arterioscler Thromb Vasc Biol 2022; 42:1154-1168. [PMID: 35861960 PMCID: PMC9420801 DOI: 10.1161/atvbaha.122.317381] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Aortic root smooth muscle cells (SMC) develop from both the second heart field (SHF) and neural crest. Disparate responses to disease-causing Fbn1 variants by these lineages are proposed to promote focal aortic root aneurysm formation in Marfan syndrome (MFS), but lineage-stratified SMC analysis in vivo is lacking. METHODS We generated SHF lineage-traced MFS mice and performed integrated multiomic (single-cell RNA and assay for transposase-accessible chromatin sequencing) analysis stratified by embryological origin. SMC subtypes were spatially identified via RNA in situ hybridization. Response to TWIST1 overexpression was determined via lentiviral transduction in human aortic SMCs. RESULTS Lineage stratification enabled nuanced characterization of aortic root cells. We identified heightened SHF-derived SMC heterogeneity including a subset of Tnnt2 (cardiac troponin T)-expressing cells distinguished by altered proteoglycan expression. MFS aneurysm-associated SMC phenotypic modulation was identified in both SHF-traced and nontraced (neural crest-derived) SMCs; however, transcriptomic responses were distinct between lineages. SHF-derived modulated SMCs overexpressed collagen synthetic genes and small leucine-rich proteoglycans while nontraced SMCs activated chondrogenic genes. These modulated SMCs clustered focally in the aneurysmal aortic root at the region of SHF/neural crest lineage overlap. Integrated RNA-assay for transposase-accessible chromatin analysis identified enriched Twist1 and Smad2/3/4 complex binding motifs in SHF-derived modulated SMCs. TWIST1 overexpression promoted collagen and SLRP gene expression in vitro, suggesting TWIST1 may drive SHF-enriched collagen synthesis in MFS aneurysm. CONCLUSIONS SMCs derived from both SHF and neural crest lineages undergo phenotypic modulation in MFS aneurysm but are defined by subtly distinct transcriptional responses. Enhanced TWIST1 transcription factor activity may contribute to enriched collagen synthetic pathways SHF-derived SMCs in MFS.
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94
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Stanciu PE, O'Regan A, Cosgrave E. Late onset sclerotomy dehiscence in a patient with Marfan syndrome presenting as recurrent episodes of raised intraocular pressure. BMJ Case Rep 2022; 15:15/8/e249990. [PMID: 36041776 PMCID: PMC9438104 DOI: 10.1136/bcr-2022-249990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
A man in his 50s presented to the eye emergency department on three separate occasions complaining of blurred vision and discomfort in the left eye. He had a history of Marfan syndrome and had undergone bilateral 20-gauge (G) pars plana vitrectomy and lensectomy 20 years prior for ectopia lentis. On examination he had epithelial corneal oedema, raised intraocular pressure >40 mm Hg and conjunctival chemosis, which later appeared as a bleb-like conjunctival elevation. Acute treatment with oral acetazolamide and topical ocular hypotensive agents produced a marked reduction in intraocular pressure to 2–4 mm Hg. A presumed diagnosis of a leaking scleral wound was made. He underwent scleral exploration under general anaesthesia and a leaking sclerotomy was uncovered. The defect was repaired successfully using a scleral patch graft. Late dehiscence of a sclerotomy has been reported rarely in patients with Marfan syndrome. This is the first reported case to present atypically with intermittent episodes of raised intraocular pressure rather than with hypotony.
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95
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Fernandez Campos BA, Silversides CK. Marfan syndrome and pregnancy-related aortic complications: contemporary outcomes from two Spanish Marfan units. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2022; 75:542-544. [PMID: 35339410 DOI: 10.1016/j.rec.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 06/14/2023]
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96
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Kim JM, Kim JY, Sung JY, Hwang JY, Lee YH. Intercalary staphyloma after strabismus surgery in a patient with Marfan syndrome: A case report. Medicine (Baltimore) 2022; 101:e29468. [PMID: 35713458 PMCID: PMC9276189 DOI: 10.1097/md.0000000000029468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 04/26/2022] [Indexed: 11/26/2022] Open
Abstract
RATIONALE A few cases of intercalary staphyloma have been reported in patients with Marfan syndrome, but we believe that this is the first case of intercalary staphyloma in Marfan syndrome developing after strabismus surgery. PATIENT CONCERNS A 9-year-old girl diagnosed with Marfan syndrome visited a strabismus clinic for treatment of esotropia. Both eyes were aphakic and had 60 prism diopter esotropia at distance and 55 prism diopter esotropia at near. There were no corneal, conjunctival, or scleral abnormalities. Six millimeters of recession was performed on both medial rectus muscles via an inferonasal fornix approach under general anesthesia. 5 days after surgery, a dark gray protruding lesion was observed on the upper nasal side of the left eye. DIAGNOSES Intraocular ultrasonography showed no bleeding, retinal detachment, or other abnormal findings. Computed tomography showed a conical protrusion of the scleral wall which was diagnosed as intercalary staphyloma. INTERVENTIONS To reduce risk of progression of the staphyloma in the left eye and to reduce risk of development of a new staphyloma, intraocular pressure lowering eye drops were administered. OUTCOMES We just observed it without any intervention except the intraocular pressures lowering eye drops. It remained stable for 12 months. LESSONS Clinicians need to be alert to the possibility of this serious complication in Marfan syndrome patients after minor surgical trauma, which can occur during uneventful strabismus surgery.
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97
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Saiki M, Yunoki K, Takao K, Yokoyama S, Inoue T, Tateishi A, Tamura K, Ohshima Y, Hisamochi K. [Bentall Operation for Pregnant Women with Marfan's Syndrome]. KYOBU GEKA. THE JAPANESE JOURNAL OF THORACIC SURGERY 2022; 75:423-427. [PMID: 35618687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
A 35-years-old pregnant woman with Marfan's syndrome visited the emergent department. She had sudden severe back pain. She was at the 20th week of gestation. An emergent chest computed tomo-graphy scan showed Stanford type B acute aortic dissection. After admission, strict blood pressure control was started. According to aortic valve insufficiency and fluid retention with pregnancy, acute heart and respiratory failure was getting worse. It seemed risky for both mother and the fetus to continue pregnancy. After sincere and detailed discussion between the patient and our multidisciplinary medical team, the patient decided to continue pregnancy. An urgent Bentall operation was performed. A careful attention was paid for the fetus during and after the surgery. Strict blood pressure control was also continued. The mother and the 30-week-gestation newborn recovered uneventfully. During four years of follow-up, thoracic and thoraco-abdominal aortic replacement was performed. The patient survived all of these procedures without any complication.
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98
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Holmes KW, Markwardt S, Eagle KA, Devereux RB, Weinsaft JW, Asch FM, LeMaire SA, Maslen CL, Song HK, Milewicz DM, Prakash SK, Guo D, Morris SA, Pyeritz RE, Milewski RC, Ravekes WJ, Dietz HC, Shohet RV, Silberbach M, Roman MJ. Cardiovascular Outcomes in Aortopathy: GenTAC Registry of Genetically Triggered Aortic Aneurysms and Related Conditions. J Am Coll Cardiol 2022; 79:2069-2081. [PMID: 35618343 PMCID: PMC9205611 DOI: 10.1016/j.jacc.2022.03.367] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/14/2022] [Accepted: 03/15/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND The GenTAC (Genetically Triggered Thoracic Aortic Aneurysm and Cardiovascular Conditions) Registry enrolled patients with genetic aortopathies between 2007 and 2016. OBJECTIVES The purpose of this study was to compare age distribution and probability of elective surgery for proximal aortic aneurysm, any dissection surgery, and cardiovascular mortality among aortopathy etiologies. METHODS The GenTAC study had a retrospective/prospective design. Participants with bicuspid aortic valve (BAV) with aneurysm (n = 879), Marfan syndrome (MFS) (n = 861), nonsyndromic heritable thoracic aortic disease (nsHTAD) (n = 378), Turner syndrome (TS) (n = 298), vascular Ehlers-Danlos syndrome (vEDS) (n = 149), and Loeys-Dietz syndrome (LDS) (n = 121) were analyzed. RESULTS The 25% probability of elective proximal aortic aneurysm surgery was 30 years for LDS (95% CI: 18-37 years), followed by MFS (34 years; 95% CI: 32-36 years), nsHTAD (52 years; 95% CI: 48-56 years), and BAV (55 years; 95% CI: 53-58 years). Any dissection surgery 25% probability was highest in LDS (38 years; 95% CI: 33-53 years) followed by MFS (51 years; 95% CI: 46-57 years) and nsHTAD (54 years; 95% CI: 51-61 years). BAV experienced the largest relative frequency of elective surgery to any dissection surgery (254/33 = 7.7), compared with MFS (273/112 = 2.4), LDS (35/16 = 2.2), or nsHTAD (82/76 = 1.1). With MFS as the reference population, risk of any dissection surgery or cardiovascular mortality was lowest in BAV patients (HR: 0.13; 95% CI: 0.08-0.18; HR: 0.13; 95%: CI: 0.06-0.27, respectively). The greatest risk of mortality was seen in patients with vEDS. CONCLUSIONS Marfan and LDS cohorts demonstrate age and event profiles congruent with the current understanding of syndromic aortopathies. BAV events weigh toward elective replacement with relatively few dissection surgeries. Nonsyndromic HTAD patients experience near equal probability of dissection vs prophylactic surgery, possibly because of failure of early diagnosis.
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Zhang RM, Tiedemann K, Muthu ML, Dinesh NEH, Komarova S, Ramkhelawon B, Reinhardt DP. Fibrillin-1-regulated miR-122 has a critical role in thoracic aortic aneurysm formation. Cell Mol Life Sci 2022; 79:314. [PMID: 35606547 PMCID: PMC11072253 DOI: 10.1007/s00018-022-04337-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 04/08/2022] [Accepted: 04/28/2022] [Indexed: 11/30/2022]
Abstract
Thoracic aortic aneurysms (TAA) in Marfan syndrome, caused by fibrillin-1 mutations, are characterized by elevated cytokines and fragmentated elastic laminae in the aortic wall. This study explored whether and how specific fibrillin-1-regulated miRNAs mediate inflammatory cytokine expression and elastic laminae degradation in TAA. miRNA expression profiling at early and late TAA stages using a severe Marfan mouse model (Fbn1mgR/mgR) revealed a spectrum of differentially regulated miRNAs. Bioinformatic analyses predicted the involvement of these miRNAs in inflammatory and extracellular matrix-related pathways. We demonstrate that upregulation of pro-inflammatory cytokines and matrix metalloproteinases is a common characteristic of mouse and human TAA tissues. miR-122, the most downregulated miRNA in the aortae of 10-week-old Fbn1mgR/mgR mice, post-transcriptionally upregulated CCL2, IL-1β and MMP12. Similar data were obtained at 70 weeks of age using Fbn1C1041G/+ mice. Deficient fibrillin-1-smooth muscle cell interaction suppressed miR-122 levels. The marker for tissue hypoxia HIF-1α was upregulated in the aortic wall of Fbn1mgR/mgR mice, and miR-122 was reduced under hypoxic conditions in cell and organ cultures. Reduced miR-122 was partially rescued by HIF-1α inhibitors, digoxin and 2-methoxyestradiol in aortic smooth muscle cells. Digoxin-treated Fbn1mgR/mgR mice demonstrated elevated miR-122 and suppressed CCL2 and MMP12 levels in the ascending aortae, with reduced elastin fragmentation and aortic dilation. In summary, this study demonstrates that miR-122 in the aortic wall inhibits inflammatory responses and matrix remodeling, which is suppressed by deficient fibrillin-1-cell interaction and hypoxia in TAA.
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Dogăroiu AC, Dogăroiu C, Tătaru CP. Ectopia lentis surgery in Marfan’s syndrome: from “couching” to the use of intracapsular tension rings. Rom J Ophthalmol 2022; 66:2-7. [PMID: 35531445 PMCID: PMC9022145 DOI: 10.22336/rjo.2022.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2022] [Indexed: 11/23/2022] Open
Abstract
In the course of time, correction of the ectopia lentis in Marfan’s syndrome has been approached through quite many surgical techniques. They addressed the iris, or the lens and aimed at increasing the aphakic zone, the opacification or removal of the lens. Although associated to many complications, the first techniques proved the courage and imagination of pioneer surgeons and are worth mentioning. They were steps towards the invention of current techniques and devices that make surgery of ectopia lentis safe, easy, and having a favorable prognosis.
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