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Zeigler SM, Sloan B, Jones JA. Pathophysiology and Pathogenesis of Marfan Syndrome. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1348:185-206. [PMID: 34807420 DOI: 10.1007/978-3-030-80614-9_8] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Marfan syndrome (MFS) is a systemic connective tissue disorder that is inherited in an autosomal dominant pattern with variable penetrance. While clinically this disease manifests in many different ways, the most life-threatening manifestations are related to cardiovascular complications including mitral valve prolapse, aortic insufficiency, dilatation of the aortic root, and aortic dissection. In the past 30 years, research efforts have not only identified the genetic locus responsible but have begun to elucidate the molecular pathogenesis underlying this disorder, allowing for the development of seemingly rational therapeutic strategies for treating affected individuals. In spite of these advancements, the cardiovascular complications still remain as the most life-threatening clinical manifestations. The present chapter will focus on the pathophysiology and clinical treatment of Marfan syndrome, providing an updated overview of the recent advancements in molecular genetics research and clinical trials, with an emphasis on how this information can focus future efforts toward finding betters ways to detect, diagnose, and treat this devastating condition.
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Affiliation(s)
- Sanford M Zeigler
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Brandon Sloan
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Jeffrey A Jones
- Division of Cardiothoracic Surgery, Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA.
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Siegel AU, Castro A, Sechrist J. Subclavian artery aneurysmal rupture and left internal mammary artery extravasation secondary to advanced Marfan syndrome. Am J Emerg Med 2020; 45:684.e1-684.e3. [PMID: 33388184 DOI: 10.1016/j.ajem.2020.12.045] [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: 12/07/2020] [Revised: 12/12/2020] [Accepted: 12/14/2020] [Indexed: 10/22/2022] Open
Abstract
This case highlights the unusual life-threatening findings found in a patient with Marfan syndrome (MFS) in the emergency department setting. MFS is a rare autosomal dominant disease that affects 1 in 3000-5000 individuals and has a highly variable range of clinical severity. This case is a 63-year-old male with COPD, scoliosis, aortic and mitral valve replacements on warfarin, and MFS who presented with acute onset hemoptysis, tachypnea, and oxygen saturation of 77% on 4 l nasal cannula. Emergent chest computed tomography angiography (CTA) revealed both a contained rupture of a left subclavian artery aneurysm and active extravasation from his left internal mammary artery (LIMA) into his left chest. The patient was on warfarin and reversed with IV vitamin K and prothrombin complex concentrate. Vascular surgery emergently took the patient to the operating room for embolization of his LIMA and stenting of the contained ruptured left subclavian artery aneurysm. The patient was discharged home one month after admission. This case report illustrates the potential severe sequelae of MFS and the importance of rapid recognition by emergency physicians. An expanded understanding of the pathophysiology of MFS has resulted in great advancement in medical therapies and lifestyle modification and thus has significantly prolonged life expectancy in these patients. Increased awareness and familiarity will facilitate continued high-quality management and treatment by emergency physicians.
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Affiliation(s)
- Alex U Siegel
- UPMC Presbyterian Hospital, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
| | - Alexandra Castro
- UPMC Presbyterian Hospital, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Jacob Sechrist
- UPMC Presbyterian Hospital, 200 Lothrop Street, Pittsburgh, PA 15213, USA
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Di Marino M, Cesareo M, Aloe G, Nucci C, Giannini C, Martucci A, Aiello F, Pisano C, Ruvolo G, Mancino R. Retinal and Choroidal Vasculature in Patients with Marfan Syndrome. Transl Vis Sci Technol 2020; 9:5. [PMID: 32879762 PMCID: PMC7442862 DOI: 10.1167/tvst.9.9.5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 06/25/2020] [Indexed: 12/14/2022] Open
Abstract
Purpose To assess the retinal and choroidal vasculature in patients with genetically confirmed Marfan syndrome (MfS). Methods This prospective, case-control, observational study included 48 eyes of 24 patients with a genetic diagnosis of MfS and compared them with 52 eyes of 26 healthy controls. Best-corrected visual acuity, choroidal and retinal thickness measured by spectral domain-optical coherence tomography, retinal and choroidal vasculature characterized by optical coherence tomography angiography, were collected. A genetic counseling was carried out. A transthoracic echocardiogram was performed to evaluate the dimension of the aortic root, the ascending aorta and the left ventricle function and dimensions. Results A significant decrease in the superficial and deep retinal capillary plexi vessel density (VD) was evident, such as a decrease in the choriocapillaris plexus VD. In patients with MfS, a negative correlation between left ventricular diameter and the VD of the superficial and deep plexi was observed. Patients with MfS with greater posterior wall and interventricular septum dimensions had lower VD in both plexi (P < 0.05). Moreover, there was a negative correlation between the dimension of the ascending aorta and foveal choriocapillary VD. In patients with MfS, increasing diameter of the ascending aorta was associated with a lower foveal choriocapillary VD (P < 0.05). Conclusions The severity of MfS correlates with the impairment of the retinal and choroidal vasculature. Translational Relevance Optical coherence tomography angiography may be a reproducible and noninvasive tool to study retinal blood flow in patients with MfS, with potential diagnostic and prognostic value.
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Affiliation(s)
- Matteo Di Marino
- Ophthalmology Unit, Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Massimo Cesareo
- Ophthalmology Unit, Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Gianluca Aloe
- Ophthalmology Unit, Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Carlo Nucci
- Ophthalmology Unit, Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Clarissa Giannini
- Ophthalmology Unit, Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Alessio Martucci
- Ophthalmology Unit, Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Francesco Aiello
- Ophthalmology Unit, Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Calogera Pisano
- Department of Cardiac Surgery, Tor Vergata University Hospital of Rome, Rome, Italy
| | - Giovanni Ruvolo
- Department of Cardiac Surgery, Tor Vergata University Hospital of Rome, Rome, Italy
| | - Raffaele Mancino
- Ophthalmology Unit, Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy
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El Ouali Z, Id El Haj N, Boubia S, Ridai M. [Recurrent spontaneous pneumothorax revealing Marfan's syndrome]. Rev Mal Respir 2019; 37:86-90. [PMID: 31883816 DOI: 10.1016/j.rmr.2019.11.649] [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: 04/09/2019] [Accepted: 11/26/2019] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Because of its rarity and lack of specific symptoms, the diagnosis of Marfan's syndrome can be delayed. Though cardiovascular, skeletal and ophthalmological manifestations are the most frequent features, the respiratory system can also be involved. OBSERVATION We report the case of a 35-year-old patient who presented with a large, right sided, encysted pyopneumothorax. The history revealed two episodes of spontaneous pneumothorax, cataract surgery ten years before his admission, and a similar case in the family. Clinical examination showed skeletal abnormalities of the wrist and thumb as well as deformity of the hindfoot with a flat foot. He had no characteristic thoracic deformity. Ophthalmologically, the right eye had a subluxed lens and the left eye had a totally subluxed cataract. CONCLUSION The development of the third episode of pneumothorax led to the diagnosis of Marfan's syndrome thanks to the patient's combination of symptoms. To avoid diagnostic delay, criteria were established in 1996 and revised in 2010 to ensure an early diagnosis of this condition.
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Affiliation(s)
- Z El Ouali
- Service de chirurgie thoracique, CHU d'Ibn Rochd, Casablanca, Maroc.
| | - N Id El Haj
- Service de chirurgie thoracique, CHU d'Ibn Rochd, Casablanca, Maroc
| | - S Boubia
- Service de chirurgie thoracique, CHU d'Ibn Rochd, Casablanca, Maroc
| | - M Ridai
- Service de chirurgie thoracique, CHU d'Ibn Rochd, Casablanca, Maroc
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Lung Function Changes are More Common in Marfan Patients Who Need Major Thoracic Surgery. Lung 2019; 197:465-472. [PMID: 31089858 PMCID: PMC6647216 DOI: 10.1007/s00408-019-00236-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 05/02/2019] [Indexed: 11/24/2022]
Abstract
Introduction Marfan syndrome is a genetic disorder affecting the connective tissue. Changes in lung tissue might influence respiratory function; however, a detailed respiratory functional assessment according to the need for major thoracic surgery is missing. Methods Comprehensive pulmonary examinations were performed in 55 Marfan patients including respiratory symptoms, lung function (LF) testing using European Coal and Steel Community (ECSC) reference values, TLCO and quality of life measurements. Groups included patients who did not need surgery (Mf, n = 32) and those who underwent major thoracic surgery (Mfop, n = 23). Results Respiratory symptoms affected 20% of patients. Scoliosis was significantly more frequent in the Mfop group. LF demonstrated in all Marfan patients a tendency towards airway obstruction (FEV1/FVC = 0.77 ± 0.10), more prominent in Mfop patients (0.74 ± 0.08 vs. Mf: 0.80 ± 0.11; p = 0.03). Correction of LF values using a standing height modification by arm span (Hcorrected) revealed additional changes in FVC and FEV1. TLCO and quality of life did not differ between groups. Conclusions Marfan syndrome is associated with airway obstruction, especially in patients who have undergone major thoracic surgery, indicative of more severe connective tissue malfunction. The use of arm span for height correction is suitable to evaluate LF changes in this special patient group including patients with significant scoliosis.
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Thoracoscopic Treatment of Pneumothorax in Marfan Syndrome: Hemostatic Patch to Support Lung Resection Recovery. Case Rep Surg 2018; 2018:7597215. [PMID: 30254783 PMCID: PMC6142756 DOI: 10.1155/2018/7597215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 07/31/2018] [Indexed: 11/18/2022] Open
Abstract
Introduction In selected patients, the absorbable fibrin patch TachoSil® is superior to standard surgical treatment in reducing air leakage after pulmonary lobectomy. Pulmonary involvement is not considered a main feature of Marfan syndrome (MFS); however, spontaneous pneumothorax (SP) with a high rate of recurrence is frequently reported. We describe the use of TachoSil® in the supportive treatment of recurrent pneumothorax in a girl with MFS. Case Report A 12-year-old girl with a previous diagnosis of MFS and recurrent history of left spontaneous pneumothorax was submitted to thoracoscopic atypical lung resection. Two patches (9.5 × 4.8 cm) were cut from the adhesive/foam complex (TachoSil®) and were pressed against the sutured area as supportive treatment. The patient recovered with no further SP recurrences. Conclusions The use of the TachoSil® surgical patch may be useful in pneumothorax supportive treatment, particularly in pediatric MFS by ameliorating the mechanical strength of the lung.
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Wang YJ, Negron-Rubio E, Keshavamurthy JH, Bates WB. Primary spontaneous pneumothorax in conjunction with Marfan syndrome. BMJ Case Rep 2018; 2018:bcr-2017-222354. [PMID: 29487097 DOI: 10.1136/bcr-2017-222354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 25-year-old man with a history of Marfan syndrome, asthma and smoking presented with worsening dyspnoea and right-sided chest pain worsened with deep breathing after a fall 2 days prior. Diagnostic imaging revealed a spontaneous right-sided pneumothorax due to ruptured subpleural bullae in the apex of the right lung. Smaller subpleural bullae were also noted in the apex of the left lung. A chest tube was placed to reduce the right pneumothorax successfully.
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Affiliation(s)
- Yannan J Wang
- Department of Radiology, Augusta University Medical College of Georgia, Augusta, Georgia, USA
| | - Elsio Negron-Rubio
- Department of Radiology, Augusta University Medical College of Georgia, Augusta, Georgia, USA
| | - Jayanth H Keshavamurthy
- Department of Diagnostic Radiology, Augusta University Medical College of Georgia, Augusta, Georgia, USA
| | - William B Bates
- Department of Radiology, Augusta University Medical College of Georgia, Augusta, Georgia, USA
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Fraser S, Child A, Hunt I. Pectus updates and special considerations in Marfan syndrome. Pediatr Rep 2017; 9:7277. [PMID: 29383220 PMCID: PMC5768089 DOI: 10.4081/pr.2017.7227] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 10/02/2017] [Accepted: 10/20/2017] [Indexed: 11/23/2022] Open
Abstract
Congenital chest wall or pectus deformities including pectus excavatum (funnel chest) and pectus carinatum (pigeon chest) affect a significant proportion of the general population and up to 70% of patients with Marfan syndrome. Patients often experience significant morbidity and psychological distress, which can worsen with age. Here we discuss new techniques for both operative and non-operative treatment of pectus deformity, the importance of a welltimed intervention and special considerations in patients with Marfan syndrome.
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Importance of Early Detection and Cardiovascular Surgical Intervention in Marfan Syndrome. Adv Emerg Nurs J 2017; 39:217-223. [PMID: 28759513 DOI: 10.1097/tme.0000000000000153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Marfan syndrome is an autosomal dominant connective tissue disorder that affects multiple systems, including the skeletal, ligamentous, oculofacial, pulmonary, abdominal, neurological, and cardiovascular systems. Cardiovascular complications, which involve the aorta and aortic valve, contribute most significantly to patient morbidity and mortality. A literature review was conducted on pathophysiology of the disease and recommendations for early diagnosis and treatment. Diagnosis largely relies on clinical features and a thorough history. Echocardiogram is used for monitoring aortic abnormalities and disease progression. Aortic valve-sparing surgery is indicated in any valvular abnormality and in patients with a murmur. Aortic root replacement is indicated prophylactically in women who want to give birth with diameters greater than 40 mm, anyone with a diameter greater than 50 mm, and progressive dilatation of greater than 5 mm per year. Medical management involves antihypertensive therapy. It is imperative for all health care providers to understand the clinical features, progression, and management of Marfan syndrome to appropriately care for their patients. Ensuring regular follow-up and adherence to medical and surgical prophylaxis is essential to patient well-being.
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