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Weyland CN, Salciccioli KB, Beecroft T, Soludczyk EN, Morris SA. Evaluating Variation in the Cardiac Management of Children with Hereditary Thoracic Aortic Disease in the United States. Pediatr Cardiol 2024; 45:133-142. [PMID: 37755470 DOI: 10.1007/s00246-023-03305-8] [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: 06/22/2023] [Accepted: 09/12/2023] [Indexed: 09/28/2023]
Abstract
Hereditary thoracic aortic diseases (HTAD) such as Marfan syndrome (MFS), Loeys-Dietz syndrome (LDS), and vascular Ehlers-Danlos syndrome (VEDS) frequently result in complex cardiovascular pathology that can lead to premature death. However, given limited research and lack of detailed pediatric management guidelines, practice in the U.S. is largely guided by personal experience and/or advice from other professionals. A REDCap survey was composed that covered topics including genetic testing, imaging, and medication choice (all in children), among others. After piloting, the survey was distributed via email and advertised on PediHeartNet. Email addresses of providers were obtained through an established aortic research collaborative and a clinic directory offered through The Marfan Foundation. There were 64 survey responses (pediatric cardiologists 66%; geneticists 13%, genetic counselors 6%; the remaining 15% was comprised of a combination of cardiothoracic surgeons, adult cardiologists, adult congenital specialists, combined cardiology and genetics specialist, nurse practitioners, physician assistants, and nurse coordinators). The most supported indication for genetic evaluation in a child with mild aortic root dilation was family history of thoracic aortic dissection (100%), in contrast to mild root dilation with no other HTAD features (39% supported, 45% did not, 15% saying it would depend on other factors). The majority would start medical therapy in MFS at an aortic root z-score of 2, however differences existed regarding medication preferences for initiation (47% angiotensin receptor blockers, 36% beta blockers, 17% would not or cannot prescribe medication/defer medication choice to another provider). Variation existed for cross-sectional imaging indications and modality and for exercise restrictions, although on average respondents were more lenient than the Bethesda guidelines. While there are areas of general agreement in the cardiac management of children with HTAD, there are also several areas of considerable variation. This highlights the need for additional study in these areas with the ultimate goal of creating consensus guidelines.
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Affiliation(s)
| | - Katherine B Salciccioli
- Baylor College of Medicine, Houston, TX, USA
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Houston, TX, USA
| | - Taylor Beecroft
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Houston, TX, USA
| | - Emily N Soludczyk
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Houston, TX, USA
| | - Shaine A Morris
- Baylor College of Medicine, Houston, TX, USA
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Houston, TX, USA
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Klemenzdottir EO, Arnadottir GA, Jensson BO, Jonasdottir A, Katrinardottir H, Fridriksdottir R, Jonasdottir A, Sigurdsson A, Gudjonsson SA, Jonsson JJ, Stefansdottir V, Danielsen R, Palsdottir A, Jonsson H, Helgason A, Magnusson OT, Thorsteinsdottir U, Bjornsson HT, Stefansson K, Sulem P. A population-based survey of FBN1 variants in Iceland reveals underdiagnosis of Marfan syndrome. Eur J Hum Genet 2024; 32:44-51. [PMID: 37684520 PMCID: PMC10772070 DOI: 10.1038/s41431-023-01455-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 08/18/2023] [Accepted: 08/30/2023] [Indexed: 09/10/2023] Open
Abstract
Marfan syndrome (MFS) is an autosomal dominant condition characterized by aortic aneurysm, skeletal abnormalities, and lens dislocation, and is caused by variants in the FBN1 gene. To explore causes of MFS and the prevalence of the disease in Iceland we collected information from all living individuals with a clinical diagnosis of MFS in Iceland (n = 32) and performed whole-genome sequencing of those who did not have a confirmed genetic diagnosis (27/32). Moreover, to assess a potential underdiagnosis of MFS in Iceland we attempted a genotype-based approach to identify individuals with MFS. We interrogated deCODE genetics' database of 35,712 whole-genome sequenced individuals to search for rare sequence variants in FBN1. Overall, we identified 15 pathogenic or likely pathogenic variants in FBN1 in 44 individuals, only 22 of whom were previously diagnosed with MFS. The most common of these variants, NM_000138.4:c.8038 C > T p.(Arg2680Cys), is present in a multi-generational pedigree, and was found to stem from a single forefather born around 1840. The p.(Arg2680Cys) variant associates with a form of MFS that seems to have an enrichment of abdominal aortic aneurysm, suggesting that this may be a particularly common feature of p.(Arg2680Cys)-associated MFS. Based on these combined genetic and clinical data, we show that MFS prevalence in Iceland could be as high as 1/6,600 in Iceland, compared to 1/10,000 based on clinical diagnosis alone, which indicates underdiagnosis of this actionable genetic disorder.
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Affiliation(s)
| | - Gudny Anna Arnadottir
- deCODE Genetics/Amgen, Inc., Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | | | | | | | | | | | | | | | - Jon Johannes Jonsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Genetics, Landspitali Universtity Hospital, Reykjavik, Iceland
| | | | - Ragnar Danielsen
- Department of Cardiology, Landspitali University Hospital, Reykjavik, Iceland
| | - Astridur Palsdottir
- Institute for Experimental Pathology at Keldur, University of Iceland, Reykjavik, Iceland
| | | | - Agnar Helgason
- deCODE Genetics/Amgen, Inc., Reykjavik, Iceland
- Department of Anthropology, University of Iceland, Reykjavik, Iceland
| | | | - Unnur Thorsteinsdottir
- deCODE Genetics/Amgen, Inc., Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Hans Tomas Bjornsson
- Department of Pediatrics, Landspitali University Hospital, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Genetics, Landspitali Universtity Hospital, Reykjavik, Iceland
- McKusick-Nathans Institute of Genetic Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kari Stefansson
- deCODE Genetics/Amgen, Inc., Reykjavik, Iceland.
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.
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Pavasini R, Sanguettoli F, Deserio MA, Bianchi N, Zanarelli L, Fabbri G, Tonet E, Passarini G, Serenelli M, Campo G. Drug-based cardiovascular prevention in patients with Marfan Syndrome: a systematic review. Minerva Cardiol Angiol 2023; 71:611-621. [PMID: 36939732 DOI: 10.23736/s2724-5683.23.06184-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
INTRODUCTION Marfan Syndrome (MFS) is a rare and complex genetic disorder associated with increased aortic growth and aortic disease. The effectiveness of cardiovascular medical therapies aiming to slow down aortic growth has been tested in several trials, particularly beta-blockers and angiotensin receptor blockers, however showing conflicting results. EVIDENCE ACQUISITION We conducted a systematic review on PubMed (Medline), Cochrane library, Google Scholar, and Biomed Central databases between January and February 2022. We selected relevant articles focusing on patients with MFS treated with beta-blockers, angiotensin receptors blockers, or both, and reporting data on the effect of the drugs on 1) slowing down aortic dilatation; 2) the reduction of aortic complication (aortic dissection, mortality, aortic surgery); and with a 3) follow-up length of at least two years. A total of 16 studies were selected. EVIDENCE SYNTHESIS Beta-blockers remain the mainstay of therapy as they have proven to slow aortic enlargement. Angiotensin receptor blockers are a useful alternative and with proven benefit as an add-on therapy to limit aortic growth. Neither beta-blockers, nor angiotensin receptor blockers have shown meaningful results on clinical aortic endpoints. CONCLUSIONS The current evidence of pharmacological treatment for MFS patients is conflicting due to the lack of large, randomized clinical trials with adequate follow-up studies and homogeneous age grouping. Beta-blockers and angiotensin receptor blockers are the only available treatments to reduce aortic growth. A recently published patient-level meta-analysis confirmed that angiotensin receptor blockers and beta-blockers have a similar effect on reducing the rate of increase of the aortic root Z score, used singularly or as add-on therapy. Considering the current evidence on new features related with MFS (such as mitral annular disjunction - MAD) bearing a potential additional increased arrhythmic risk, it is of paramount importance to establish the role of beta-blockers and angiotensin receptor blockers in clinical endpoints of this population as well.
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Affiliation(s)
- Rita Pavasini
- Unit of Cardiology, University Hospital of Ferrara, Ferrara, Italy
| | | | - Maria A Deserio
- Unit of Cardiology, University Hospital of Ferrara, Ferrara, Italy
| | - Nicola Bianchi
- Unit of Cardiology, University Hospital of Ferrara, Ferrara, Italy
| | - Luca Zanarelli
- Unit of Cardiology, University Hospital of Ferrara, Ferrara, Italy
| | - Gioele Fabbri
- Unit of Cardiology, University Hospital of Ferrara, Ferrara, Italy
| | - Elisabetta Tonet
- Unit of Cardiology, University Hospital of Ferrara, Ferrara, Italy
| | - Giulia Passarini
- Unit of Cardiology, University Hospital of Ferrara, Ferrara, Italy
| | - Matteo Serenelli
- Unit of Cardiology, University Hospital of Ferrara, Ferrara, Italy
| | - Gianluca Campo
- Unit of Cardiology, University Hospital of Ferrara, Ferrara, Italy -
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McClure RS, Lindsay TF, Keir M, Bayne JP, Berry RF, Chu MWA, Chung JCY, Dagenais F, Ducas RA, Duncan A, Horne G, Klass D, Mongeon FP, Richer J, Rommens KL. The Aortic Team Model and Collaborative Decision Pathways for the Management of Complex Aortic Disease: Clinical Practice Update From the Canadian Cardiovascular Society/Canadian Society of Cardiac Surgeons/Canadian Society for Vascular Surgery/Canadian Association for Interventional Radiology. Can J Cardiol 2023; 39:1484-1498. [PMID: 37949520 DOI: 10.1016/j.cjca.2023.07.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/30/2023] [Accepted: 07/31/2023] [Indexed: 11/12/2023] Open
Abstract
Disease of the aortic arch, descending thoracic, or thoracoabdominal aorta necessitates dedicated expertise across medical, endovascular, and surgical specialties. Cardiologists, cardiac surgeons, vascular surgeons, interventional radiologists, and others have expertise and skills that aid in the management of patients with complex aortic disease. No specialty is uniformly expert in all aspects of required care. Because of this dispersion of expertise across specialties, an aortic team model approach to decision-making and treatment is advocated. A nonhierarchical partnership across specialties within an interdisciplinary aortic clinic ensures that all treatment options are considered and promotes shared decision-making between the patient and all aortic experts. Furthermore, regionalization of care for aortic disease of increased complexity assures that the breadth of treatment options is available and that favourable volume-outcome ratios for high-risk procedures are maintained. An awareness of best practice care pathways for patient referrals for preventative management, acute care scenarios, chronic care scenarios, and pregnancy might facilitate a more organized management schema for aortic disease across Canada and improve lifelong surveillance initiatives.
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Affiliation(s)
- R Scott McClure
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada.
| | - Thomas F Lindsay
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Keir
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jason P Bayne
- Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Robert F Berry
- QEII Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Michael W A Chu
- London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Jennifer C-Y Chung
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Francois Dagenais
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Quebec City, Quebec, Canada
| | - Robin A Ducas
- St Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Audra Duncan
- London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Gabrielle Horne
- QEII Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Darren Klass
- Vancouver Coastal Health, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Julie Richer
- University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Kenton L Rommens
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
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Zaradzki M, Mohr F, Lont S, Soethoff J, Remes A, Arif R, Müller OJ, Karck M, Hecker M, Wagner AH. Short-term rapamycin treatment increases life span and attenuates aortic aneurysm in a murine model of Marfan-Syndrome. Biochem Pharmacol 2022; 205:115280. [PMID: 36198355 DOI: 10.1016/j.bcp.2022.115280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/27/2022] [Accepted: 09/27/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Marfan syndrome (MFS) is a genetic disorder leading to medial aortic degeneration and life-limiting dissections. To date, there is no causal prevention or therapy. Rapamycin is a potent and selective inhibitor of the mechanistic target of rapamycin (mTOR) protein kinase, regulating cell growth and metabolism. The mgR/mgR mice represent an accepted MFS model for studying aortic pathologies to understand the underlying molecular pathomechanisms. This study investigated whether rapamycin inhibits the development of thoracic aortic aneurysms and dissections in mgR/mgR mice. METHODS Isolated primary aortic smooth muscle cells (mAoSMCs) from mgR/mgR mice were used for in vitro studies. Two mg kg/BW rapamycin was injected intraperitoneally daily for two weeks, beginning at 7-8 weeks of age. Mice were sacrificed 30 days post-treatment. Histopathological and immunofluorescence analyses were performed using adequate tissue specimens and techniques. Animal survival was evaluated accompanied by periodic echocardiographic examinations of the aorta. RESULTS The protein level of the phosphorylated ribosomal protein S6 (p-RPS6), a downstream target of mTOR, was significantly increased in the aortic tissue of mgR/mgR mice. In mAoSMCs isolated from these animals, expression of mTOR, p-RPS6, tumour necrosis factor α, matrix metalloproteinase-2 and -9 was significantly suppressed by rapamycin, demonstrating its anti-inflammatory capacity. Short-term rapamycin treatment of Marfan mice was associated with delayed aneurysm formation, medial aortic elastolysis and improved survival. CONCLUSIONS Short-term rapamycin-mediated mTOR inhibition significantly reduces aortic aneurysm formation and thus increases survival in mgR/mgR mice. Our results may offer the first causal treatment option to prevent aortic complications in MFS patients.
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Affiliation(s)
- M Zaradzki
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - F Mohr
- Department of Cardiovascular Physiology, Heidelberg University, Heidelberg, Germany
| | - S Lont
- Department of Cardiovascular Physiology, Heidelberg University, Heidelberg, Germany
| | - J Soethoff
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - A Remes
- Department of Internal Medicine III, University of Kiel and University Hospital Schleswig-Holstein, Kiel; German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Germany
| | - R Arif
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - O J Müller
- Department of Internal Medicine III, University of Kiel and University Hospital Schleswig-Holstein, Kiel; German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Germany
| | - M Karck
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - M Hecker
- Department of Cardiovascular Physiology, Heidelberg University, Heidelberg, Germany
| | - A H Wagner
- Department of Cardiovascular Physiology, Heidelberg University, Heidelberg, Germany.
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杨 书, 罗 芳. [Latest advances in the diagnosis and treatment of Marfan syndrome]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2022; 24:826-831. [PMID: 35894201 PMCID: PMC9336618 DOI: 10.7499/j.issn.1008-8830.2203099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 06/01/2022] [Indexed: 06/15/2023]
Abstract
Marfan syndrome (MFS) is a multisystem connective tissue disease with autosomal dominant inheritance. It is mainly caused by FBN1 gene mutation and often has different clinical manifestations. Neonatal MFS is especially rare with severe conditions and a poor prognosis. At present, there is still no radical treatment method for MFS, but early identification, early diagnosis, and early treatment can effectively prolong the life span of patients. This article reviews the latest advances in the diagnosis and treatment of MFS.
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