Marfan syndrome in children and adolescents: predictive and prognostic value of aortic root growth for screening for aortic complications

OBJECTIVE

To assess and measure the diagnostic and prognostic value of individual aortic root growth in children and adolescents with Marfan syndrome.

DESIGN

From 1983 to 1996, 250 children were screened for Marfan syndrome. Serial echocardiographic aortic root measurements of 123 children (57 Marfan, 66 control) were available for evaluation of aortic root growth. Aortic root diameters were correlated with body surface area. Based on individual growth of the aortic root a discrimination formula was derived to distinguish Marfan patients from control subjects.

RESULTS

Sensitivity and specificity of this method, which were dependent on the number of measurements, were 84% and 73%, respectively, for three serial measurements. The discrimination score also predicted a five year complication free survival in all patients.

CONCLUSIONS

In children and adolescents with Marfan syndrome, aortic root growth differs significantly from subjects in whom Marfan syndrome was definitely ruled out during screening. Measurement of individual aortic root growth may serve to establish diagnosis at an early stage and is of prognostic value for occurrence of aortic complications.

Interleukin-1beta in plasma and synovial fluid in relation to radiographic changes in arthritic temporomandibular joints

The aim of this study was to investigate the level of the cytokine IL-1beta in plasma and temporomandibular joint (TMJ) synovial fluid of patients with arthropathies, and to study the relation between IL-1beta levels of synovial fluid and plasma as well as radiographic changes of the TMJ. 31 patients with general disease, 14 with rheumatoid arthritis (RA) and 17 with various arthritides were included in the study. Synovial fluid and blood samples were collected, and an individualized tomography of the TMJ was performed. Detectable levels of IL-1beta were found in 5 out of 39 synovial fluids and in 10 out of 27 plasma samples. The presence of IL-1beta in both plasma and synovial fluid was more frequent in RA patients than in the non-RA group. The extension of radiographic erosion was significantly greater in joints with IL-1beta than in those without. Both the extension of erosion and grade of radiographic changes of the TMJ were greater in patients with detectable IL-1beta level of plasma than in patients without. Our study indicates that presence of IL-1beta in plasma and synovial fluid is related to radiographic changes of the TMJ.

Marfan syndrome in children and adolescents: an adjusted nomogram for screening aortic root dilatation

OBJECTIVE

To construct an adjusted nomogram for the echocardiographic screening of aortic root diameter in children with possible Marfan disease.

DESIGN

In 91 children (42 boys, 49 girls, age range 3.2 to 18.4 years) undergoing Marfan screening from 1983 until 1996, the diagnosis Marfan syndrome and any other aortic pathology was definitely ruled out. These served as a control population to set appropriate reference standards.

RESULTS

Compared with a standard Dutch reference population, body surface area of the control subjects (mean (SD)) was above the 50th centile (boys 0.09 (0.20) m2, range -0.28 to 0.69 m2; girls 0.09 (0.17) m2, range -0.17 to 0.69 m2). Echocardiographically determined aortic root diameter and body surface area showed a linear relation and a greater variability of aortic root diameter in these relatively tall subjects (n = 91, R2 = 0.62) than in the standard nomogram (n = 56, R2 = 0.93). In 24% of cases (n = 22), the aortic root exceeded the upper limit of normal in the standard nomogram, by 2.2 (2.0) mm. An adjusted nomogram was constructed with a higher upper limit.

CONCLUSIONS

A Marfan screening population differs from the unselected population in body surface area and aortic root size variability. An adjusted nomogram should therefore be used to detect a truly enlarged aortic root.

Left midcardiac border of frontal chest radiographs of patients with annulo-aortic ectasia

The utility of the frontal chest radiograph for the diagnosis of annulo-aortic ectasia (AAE) was evaluated in 12 patients with Marfan's syndrome and five patients with incomplete stigmata (forme fruste). Prominence of the left midcardiac border was seen in 11 patients: the upper midsegment in one, the lower midsegment in two, and the whole midsegment in eight patients. Either a linear or an arcuate contour was seen. The contours of the prominent left midcardiac border in three patients who had moderate to marked aortic regurgitation and a cardiothoracic ratio (CTR) over 59% were nonspecific. In the remaining eight patients (47%), the contour was considered to be characteristic of AAE, as suggested by the displacement of either all or part of the right ventricular outflow tract, main pulmonary artery and left atrial appendage. Six patients showed only left midcardiac border prominence. The contour of the left midcardiac border on the conventional frontal chest radiograph is characteristic and of paramount importance for the diagnosis of AAE in Marfan' s syndrome or its forme fruste, particularly in patients whose CTRs are within the normal range.

Hiatus/paraesophageal hernias in neonatal Marfan syndrome

We report on an infant with neonatal Marfan syndrome (NMS) and hiatus/paraesophageal hernia who presented to a university hospital with an unusual early complication of this connective tissue disorder. An abnormal course of the nasogastric tube was noted on the first day of life by a radiograph of the chest and abdomen performed for bloody gastric drainage. The question of esophageal perforation was raised. Subsequent contrast study demonstrated a large hiatus/paraesophageal hernia with pronounced gastroesophageal reflux (GER). A part of the hernia was positioned posterior and to the right of the gastroesophageal junction (GEJ), presumably the location of the nasogastric tube as noted on the initial films. Although characterized by cardiac/aortic abnormalities, NMS can be a difficult diagnosis and should be considered in any infant with hiatus/ paraesophageal hernia with or without GER.

Metacarpophalangeal pattern profile in Marfan syndrome and Marfan-like patients

Marfan syndrome (MFS) is an autosomal dominant trait due to mutations in the fibrillin gene (FBN1). The MFS expressivity is variable, and its diagnosis relies completely on clinical criteria. Atypical cases and Marfan-like (marfanoid) clinical presentations are commonly found. The metacarpophalangeal pattern profile (MCPP), a radiological method in which the 19 tubular hand bones are assessed, has been used in the diagnosis of various syndromes. To investigate whether the MCPP was adequate to discriminate between MFS and Marfan-like subjects, we studied 38 patients who were referred to our service because they had an MFS diagnosis, diagnostic hypothesis, or differential diagnosis or had arachnodactyly with dolichostenomelia. Two groups were formed: 1) MFS: 21 patients with a mean age of 18.3 (10.8 S.D.) years and 2) Marfan-like syndromes: 16 patients who did not meet the current criteria, with a mean age of 14.6 (4.6 S.D.) years. The MCPP was performed in each case following the classical technique, and a characteristic mean profile was obtained for group I (MFS), with Z scores ranging from 0.69 to 2.73 (1.80+/-0.50; mean+/-S.D.). In group I, three cases had no correlation with the typical MFS pattern. In group II, three cases had an MFS pattern. The correlation with the mean MCPP of MFS permitted the differential diagnosis of MFS and marfanoid syndromes with 86% sensitivity, 81% specificity, and 86% positive and 81% negative predictive values. The results suggest that MCPP can be used effectively as an auxiliary tool in the nosology of these conditions and, because there is no change in MCPP with age, can be helpful in early diagnosis.

Protrusio acetabuli and bilateral basicervical femoral neck fractures in a patient with Marfan syndrome

A 22-year-old man with Marfan syndrome and bilateral protrusio acetabuli presented with bilateral femoral neck stress fractures after vigorous stretching exercises for hip "stiffness." Fifteen years later, his fractures, which were treated with internal fixation, have healed, his acetabular protrusion has not worsened, and his perceived hip "stiffness" persists. This case demonstrates a rare manifestation of Marfan syndrome, protrusio acetabuli, and a possible side effect of vigorous stretching in the face of abnormal joint mechanics.

The cervical spine in Marfan syndrome

STUDY DESIGN

Prospective radiographic and clinical analysis of a consecutive unselected population of persons with Marfan Syndrome.

OBJECTIVES

To determine cervical spine abnormalities present in the Marfan population compared with that seen in the general population.

SUMMARY OF BACKGROUND DATA

In the treatment of a large population of patients with Marfan Syndrome, three serious cervical spine disorders were noted. To the authors' knowledge, no report of cervical abnormalities in patients with Marfan Syndrome exists in the literature. Therefore, the cervical spine in these patients was studied in a systematic fashion.

METHODS

An unselected group of 104 consecutive patients with Marfan Syndrome seen at a medical genetics follow-up examination underwent lateral neutral and flexion-extension cervical spine radiographs. Parameters of alignment, size, and stability were measured. Patients with Marfan Syndrome aged 35-45 years and matched controls were given a pain questionnaire to complete.

RESULTS

The prevalence of focal kyphosis was 16%. A large number of patients with Marfan Syndrome (54%) had increased atlantoaxial translation. The preadolescent Marfan population has a greater range of motion than either the adolescent or adult populations. The Marfan population has an increased radiographic prevalence of basilar impression (36%), and the odontoid height (3.69 +/- 0.53 cm) was larger than reported norms (2.34 +/- 0.22 cm). Cervical stenosis was rare, with 3% having a critical Torg ratio at C3 and 2% having a critical Torg ratio at C6. Neck pain frequency did not differ significantly from that of age-matched controls.

CONCLUSION

Based on the increased prevalence of several cervical bony and ligamentous abnormalities, patients with Marfan Syndrome were recommended to avoid sports with risks of high-impact loading of the cervical spine. Given the rarity of actual neurologic injuries in the Marfan population, however, radiographs for all patients with Marfan Syndrome undergoing general anesthesia is not recommended.

[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.

Abnormal ambulatory electrocardiographic findings in patients with the Marfan syndrome

OBJECTIVES

The aim of this study was to assess the prevalence of cardiac dysrhythmias and abnormalities of conduction and repolarization in the Marfan-syndrome (MFS).

SUBJECTS AND METHODS

Forty-five adult MFS patients (25 men) and healthy age and sex matched controls. A 24-h ambulatory electrocardiogram was recorded.

RESULTS

There was no difference in heart rates between the two groups. Two MFS patients had atrial fibrillation. The median number of premature atrial beats was 12/24 h in the MFS group vs. 6/24 h in the controls (P < 0.05), and the respective medians of premature ventricular beats were 17/24 h vs. 1/24 h (P < 0.001). Five patients but no healthy person had salvos of > or = 3 premature ventricular complexes (P < 0.05). Ventricular premature beats with R on T configuration were recorded in nine patients but in none of the control subjects (P < 0.05). Both PQ and QT intervals at heart rates of 60, 80 and 100 beats min-1 were longer in the MFS group compared with healthy persons (P < 0.005). Also ST segment depression was seen more often in the MFS group (17/43 vs. 6/45; P < 0.05). In patients with MFS, the findings at ambulatory electrocardiography showed no association with echocardiographically determined aortic root diameter, left atrial diameter or left ventricular diameters, wall thickness and systolic function. Nor did the electrocardiographic findings correlate with the presence of mitral or tricuspid valve prolapse.

CONCLUSIONS

Patients with MFS have a higher prevalence of cardiac dysrhythmias than healthy persons. Likewise they have prolonged atrio-ventricular conduction time and disturbed depolarization as suggested by longer QT intervals and more common ST segment depression.

Marfan's syndrome: a family affair

Marfan's syndrome (MFS), a heritable connective tissue disorder, may result in cardiac valvular insufficiency, aortic aneurysm or dissection, dislocated lens, and musculoskeletal abnormalities. During a 20-month period (1994-96), an interdisciplinary health care team at a central Virginia medical center evaluated the histories of 112 persons from 15 different families for the presence of MFS-related traits. Seventy-five had at least one MFS-related trait, and 27 subjects underwent echocardiography to evaluate for aortic root dilatation and valvular lesions. Forty-three patients (57.3%) in the above cohort demonstrated significant cardiovascular lesions, with 20 undergoing cardiac surgery. Thirty-one patients (41.3%) were initially seen with significant ocular lesions, and 38 (50.7%) displayed orthopedic deformities. The health care team developed strategies for long-term management of persons with MFS, including antihypertensive therapy, periodic testing, risk-factor modification, genetic counseling, and surgery for appropriate patients. Proactive, consistent management of MFS families will improve long-term health outcomes for this patient population.

Protrusio acetabuli: its occurrence in the completely expressed Marfan syndrome and its musculoskeletal component and a procedure to arrest the course of protrusion in the growing pelvis

Protrusio acetabuli [center-edge (C/E) angle > 60 degrees, teardrop collapsed, and pelvis invaded by acetabulum beyond ilioischial line (Köhler's)] was identified in 22 patients with classic Marfan syndrome. All had a preponderance of the syndrome's cardinal features (positive pedigree and musculoskeletal, ocular, and cardiovascular manifestations). Fifty-two immature patients with the syndrome's skeletal expressions predominating were studied for deep acetabuli. Half of these individuals (26 patients) had true protrusio acetabuli. Thirty-one percent (16 patients) had abnormal acetabular deepening (C/E angle > 50 degrees; teardrop partially collapsed without acetabular protrusion); 19% (10 patients) had normal pelves with C/E angle < 40 degrees and normal teardrop. To arrest the protrusio, the triradiate physis was closed surgically in 11 patients (21 hips), one unilaterally. In 19 operated-on hips followed-up to maturity by using teardrop, C/E angle, and acetabular relation to the ilioischial line as criteria, architecture was restored to normal in 12 hips and reduced from true protrusio to simply acetabular deepening in four. Three were unchanged. The youngest child operated on was 8; the oldest was 12 years. Laboratory examination of the physes was unrewarding.

Radiographic findings in Shprintzen-Goldberg syndrome

We report the case of a Japanese boy whose dysmorphic features were consistent with those of Shprintzen-Goldberg syndrome. The radiological features were characterized by late-onset craniosynostosis, arachnodactyly, undermodeling of short tubular bones, mildly undermodeled and slightly bowed long bones, twisted ribs and tall vertebral bodies with elongated neural arches. Apart from the craniosynostosis, these skeletal changes resembled those of frontometaphyseal dysplasia, a well-known craniotubular dysplasia. Shprintzen-Goldberg syndrome also shares many clinical features with frontometaphyseal dysplasia.

Craniosynostosis with Marfan syndrome, hand and foot anomalies

We report a patient with various connective tissue abnormalities suggesting a distinctive connective tissue disorder combining some features of the Marfan syndrome with craniosynostosis and hand and feet anomalies.

Aortic root complications in Marfan's syndrome: identification of a lower risk group

OBJECTIVES

The purpose of this study was to examine clinical and echocardiographic predictors of outcome in a cohort of patients with Marfan's syndrome.

BACKGROUND

Serial echocardiographic measurements of aortic root dimensions are an important clinical method for monitoring patients with Marfan's syndrome. However, there are few data on the prognostic importance of echocardiographic variables for risk stratification and timing of aortic root replacement.

METHODS

In 89 consecutive patients with Marfan's syndrome (age range 1-54 years) clinical and serial echocardiographic data (n = 62) were evaluated as potential predictors of outcome (mean (range) follow up 4 (< 1-16) years). Aortic sinus diameter and an aortic ratio normalised for age and body surface area were examined using Kaplan-Meier life table and Cox regression analysis, with the end point defined as death or surgery for ascending aortic dissection and events defined as an end point or surgery for ascending aortic aneurysm.

RESULTS

Overall actuarial survival at two and five years was 96% and 92% and event free survival was 85% and 76%, respectively. There were five deaths due to aortic dissection, four patients survived surgery for ascending dissection, and nine underwent root replacement with a composite graft for ascending aneurysm. Those with aortic events were older (35 (12) v 25 (13) years, P = 0.007) and had greater initial aortic root dimensions (47 (14) v 33 (8) mm, P < 0.0001) and ratios (1.6 (0.5) v 1.3 (0.2), P < 0.0001). In the 62 patients with serial echocardiographic follow up, the rate of aortic root dilatation was more rapid in those with events (15 (17) v 0 (3)%/year, P < 0.0001). Utilising a Cox proportional hazards model, the groups with an initial aortic ratio > or = 1.3 or an annual change in aortic ratio > or = 5% had a relative risk of an aortic complication of 2.7 and 4.1, respectively (95% confidence limits 1.5 to 4.8 and 1.8 to 9.3). Only one of 31 patients with an initial aortic ratio of < 1.3 and a rate of change of < 5% had an event (five year event free survival 97%).

CONCLUSIONS

A low risk subgroup of patients with Marfan's syndrome can be identified as those with an aortic ratio < 1.3 and an annual change in aortic ratio of < 5%. These findings are helpful in optimising echocardiographic monitoring and risk stratification of patients with Marfan's syndrome.

Detection of abnormal aortic elastic properties in asymptomatic patients with Marfan syndrome by combined transoesophageal echocardiography and acoustic quantification

OBJECTIVE

To evaluate the potential value of transoesophageal echocardiography combined with automated border detection and acoustic quantification for the assessment of elastic properties of the thoracic aorta in patients with Marfan syndrome.

SUBJECTS

16 patients with Marfan syndrome and 12 age matched normal controls.

METHODS

Transoesophageal echocardiography was performed in all subjects. Minimum and maximum diameters of the descending thoracic aorta were obtained from M mode images and acoustic quantification was used for the on-line evaluation of cross sectional aortic area and peak positive area changes over time. Compliance, distensibility, and stiffness index were calculated using M mode data and non-invasively measured blood pressure and were compared with the indices derived from acoustic quantification.

RESULTS

Aortic dimensions normalised for body surface area were not statistically different between patients and normal controls, but there were significant differences for all elasticity indices except compliance. Marfan patients had a lower distensibility [4.2 (SD 1.8) v 5.8 (2.1) cm2/dyn, P < 0.05] and a higher stiffness index [9.7 (3.0) v 7.1 (1.8), P < 0.05]. The dynamic indices derived from the acoustic quantification were significantly smaller in Marfan patients [peak positive area change: 5.1 (1.0) v 7.7 (1.7) cm2/s; P < 0.001; and normalised peak positive area change: 2.5 (1.2) v 4.0 (0.8) cm2/s respectively, P < 0.001] and were suitable to discriminate between normal and abnormal elastic properties.

CONCLUSIONS

In Marfan syndrome elastic properties of the descending aorta are significantly different from normal controls, even in the absence of vessel dilatation. In addition to established static indices, indices derived from acoustic quantification reflect dynamic changes of the cross sectional area for the evaluation of regional vessel mechanics. The on-line assessment of peak positive area change allows differentiation from normal individuals and may be more accurate than standard M mode measurements.

Composite graft in annulo-aortic ectasia. Nineteen years' experience without graft inclusion

OBJECTIVE

The original Bentall procedure for the surgery of annulo-aortic ectasia (AAE) includes the risk of leakage and pseudo-aneurysm formation in the coronary anastomosis. To avoid the complications mentioned above we have used the open technique without the graft inclusion. In this study we evaluate our early and late results.

MATERIAL AND METHODS

One hundred consecutive patients with annuloaortic ectasia underwent surgical repair with composite graft between December 1975 and February 1994. In all cases the aneurysmal tissue was radically resected and the origins of the coronary arteries were directly reimplanted to the tube prosthesis. No wrapping was used. Twenty-two patients met the clinical criteria of Marfan syndrome. Thirteen of the patients underwent an emergency operation, because of a rupture of aneurysm in 2 cases and an acute dissection in 11 cases. Additional procedures were performed in 16 patients: mitral valve replacement in 2, coronary artery bypass grafting in 12 patients and in 2 cases the tube prosthesis included aortic arch, too.

RESULTS

The overall hospital mortality was 3.0% (3/100). In the elective group there was one hospital death (1/87; 1.1%). In the emergency group two patients died in the operation room (2/13; 16.7%). There have been 13 late deaths among the 97 hospital survivors (13.4%). Four of the late deaths were surgery related. Routine control angiography was performed in all patients 6 months after surgery. Sixty patients who had lived at least 3 years after surgery were called to reangiography and 53 of them came. No pseudo-aneurysm or leakage at distal anastomosis or coronary anastomosis could be seen. A slight dilatation of one or both coronary origins was observed on 15 patients; 9 of whom had Marfan syndrome.

CONCLUSIONS

The open technique is simple and can be used in all anatomical variations of the annulo-aortic ectasia. The early and late results are at least comparable with those achieved by other techniques.

Lumbar spine in Marfan syndrome

Lumbar spine radiographs of 28 patients with Marfan syndrome and a gender and age-matched control group were evaluated for scoliosis and morphologic changes of the L2, L3, and L4 vertebrae. No patient or control subject had any serious low back problems. The Marfan patients showed a high incidence of scoliosis (64%). The incidence of lumbosacral transitional vertebra was also high (18%). The end plates of the vertebral bodies in the Marfan patients were more biconcave than in the control group. In addition, the transverse processes were longer in relation to the vertebral body width in the Marfan group than in the controls. These findings indicate that biconcave vertebral bodies can be added to the list of skeletal manifestations of the Marfan syndrome, and Marfan syndrome to the list of differential diagnoses for biconcave vertebrae ("codfish vertebrae").

The thoracolumbar spine in Marfan syndrome

We analyzed the prevalence, inheritance, progression, and functional implications of spinal deformity in Marfan syndrome using four different groups of patients. We studied 113 patients who had Marfan syndrome, eighty-two of whom were skeletally immature, in order to characterize the alignment and function of the spine. The patients were selected from a clinic that provides total care with no bias toward the presence of orthopaedic conditions. Scoliosis was identified in fifty-two of the eighty-two patients, and the prevalences for the sexes were equal. The thoracic portion of the curve was convex to the right in all but two patients. The mean kyphosis was greater than that in the general population. Five distinct sagittal profiles were identified on the basis of whether the thoracic kyphosis was within, greater than, or less than normal limits and whether the transition between the kyphosis and lordosis occurred at or caudad to the normal level or whether the curves were reversed. Spondylolisthesis was present in five patients (6 per cent), with a mean slip of 30 per cent. Fourteen pedigrees were studied in depth. There was no familial pattern of the scoliosis. A separate group of fifty-six patients with scoliosis, for whom serial follow-up radiographs were available, was studied for progression. Patients who had a curve of more than 30 degrees had mild progression, and those who had a curve of more than 50 degrees had marked progression (mean, 3 +/- 4 degrees per year). Pain and function of the back were studied in thirty patients who were thirty-five to forty-five years old; these patients were found to be more impaired than matched controls. The presence of scoliosis was associated with pain in the region of the curve in these patients.

Aortic distensibility and stiffness index measured by magnetic resonance imaging in patients with Marfan's syndrome

OBJECTIVES

To use magnetic resonance imaging to measure the elastic properties of the aorta of adults with Marfan's syndrome and to compare these results with those obtained by echocardiography.

PATIENTS AND METHODS

12 patients with Marfan's syndrome and 12 controls matched for age. Transverse luminal areas of the ascending and descending aorta were measured using electrocardiographic gated magnetic resonance imaging. Echocardiography was used to measure the diameter of the ascending aorta and aortic arch in patients with Marfan's syndrome. Blood pressure was measured during both scans.

RESULTS

In diastole, transverse luminal areas of the ascending and descending aorta were significantly greater in patients with Marfan's syndrome when measured by magnetic resonance imaging and corrected for body surface area; P < 0.02 and P < 0.05 respectively. Patients with Marfan's syndrome had a higher stiffness index (112.77 v 5.78, P < 0.05) and a lower distensibility (0.0066 v 0.0105, P < 0.05) than controls. Results produced by MRI and echocardiography were not significantly different.

CONCLUSIONS

Magnetic resonance imaging gives good quality reproducible images of the ascending and descending aorta. In patients with Marfan's syndrome, aortic distensibility and stiffness index measured by magnetic resonance imaging were abnormal (but did not always relate directly to the size of the aorta.