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Chen MH, Deng ES, Yamada JM, Choudhury S, Scotellaro J, Kelley L, Isselbacher E, Lindsay ME, Walsh CA, Doan RN. Contributions of Germline and Somatic Mosaic Genetics to Thoracic Aortic Aneurysms in Nonsyndromic Individuals. J Am Heart Assoc 2024:e033232. [PMID: 38958128 DOI: 10.1161/jaha.123.033232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/20/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Thoracic aortic aneurysm (TAA) is associated with significant morbidity and mortality. Although individuals with family histories of TAA often undergo clinical molecular genetic testing, adults with nonsyndromic TAA are not typically evaluated for genetic causes. We sought to understand the genetic contribution of both germline and somatic mosaic variants in a cohort of adult individuals with nonsyndromic TAA at a single center. METHODS AND RESULTS One hundred eighty-one consecutive patients <60 years who presented with nonsyndromic TAA at the Massachusetts General Hospital underwent deep (>500×) targeted sequencing across 114 candidate genes associated with TAA and its related functional pathways. Samples from 354 age- and sex-matched individuals without TAA were also sequenced, with a 2:1 matching. We found significant enrichments for germline (odds ratio [OR], 2.44, P=4.6×10-6 [95% CI, 1.67-3.58]) and also somatic mosaic variants (OR, 4.71, P=0.026 [95% CI, 1.20-18.43]) between individuals with and without TAA. Likely genetic causes were present in 24% with nonsyndromic TAA, of which 21% arose from germline variants and 3% from somatic mosaic alleles. The 3 most frequently mutated genes in our cohort were FLNA (encoding Filamin A), NOTCH3 (encoding Notch receptor 3), and FBN1 (encoding Fibrillin-1). There was increased frequency of both missense and loss of function variants in TAA individuals. CONCLUSIONS Likely contributory dominant acting genetic variants were found in almost one quarter of nonsyndromic adults with TAA. Our findings suggest a more extensive genetic architecture to TAA than expected and that genetic testing may improve the care and clinical management of adults with nonsyndromic TAA.
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Affiliation(s)
- Ming Hui Chen
- Department of Cardiology Boston Children's Hospital Boston MA USA
- Division of Genetics and Genomics, Department of Pediatrics Boston Children's Hospital Boston MA USA
- Department of Pediatrics Harvard Medical School Boston MA USA
| | - Ellen S Deng
- Division of Genetics and Genomics, Department of Pediatrics Boston Children's Hospital Boston MA USA
| | - Jessica M Yamada
- Division of Genetics and Genomics, Department of Pediatrics Boston Children's Hospital Boston MA USA
| | - Sangita Choudhury
- Division of Genetics and Genomics, Department of Pediatrics Boston Children's Hospital Boston MA USA
- Department of Pediatrics Harvard Medical School Boston MA USA
| | - Julia Scotellaro
- Division of Genetics and Genomics, Department of Pediatrics Boston Children's Hospital Boston MA USA
| | - Lily Kelley
- Division of Genetics and Genomics, Department of Pediatrics Boston Children's Hospital Boston MA USA
| | - Eric Isselbacher
- Division of Cardiology, Massachusetts General Hospital Department of Medicine Harvard Medical School Boston MA USA
| | - Mark E Lindsay
- Division of Cardiology, Massachusetts General Hospital Department of Medicine Harvard Medical School Boston MA USA
| | - Christopher A Walsh
- Division of Genetics and Genomics, Department of Pediatrics Boston Children's Hospital Boston MA USA
- Department of Pediatrics Harvard Medical School Boston MA USA
- Department of Neurology Harvard Medical School Boston MA USA
- Department of Pediatrics Howard Hughes Medical Institute, Boston Children's Hospital Boston MA USA
| | - Ryan N Doan
- Division of Genetics and Genomics, Department of Pediatrics Boston Children's Hospital Boston MA USA
- Department of Pediatrics Harvard Medical School Boston MA USA
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2
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Sama C, Fongwen NT, Chobufo MD, Ajibade A, Roberts M, Greathouse M, Ngonge AL, Adekolu A, Hamirani YS. Frequency of Cardiac Valvulopathies in Patients With Marfan Syndrome: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e54141. [PMID: 38487153 PMCID: PMC10940034 DOI: 10.7759/cureus.54141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2023] [Indexed: 03/17/2024] Open
Abstract
Marfan syndrome (MFS) is a progressive connective tissue disease with a broad range of clinical manifestations. We sought to establish the spectrum of structural valvular abnormalities as cardiovascular involvement has been identified as the most life-threatening aspect of the syndrome. This was a systematic review with a meta-analysis of studies indexed in Medline from the inception of the database to November 7, 2022. Using the random-effects model, separate Forest and Galbraith plots were generated for each valvular abnormality assessed. Heterogeneity was assessed using the I2 statistics whilst funnel plots and Egger's test were used to assess for publication bias. From a total of 35 studies, a random-effects meta-analysis approximated the pooled summary estimates for the prevalence of cardiac valve abnormalities as mitral valve prolapse 65% (95% CI: 57%-73%); mitral valve regurgitation 40% (95% CI: 29%-51%); aortic valve regurgitation 40% (95% CI: 28%-53%); tricuspid valve prolapse 35% (95% CI: 15%-55%); and tricuspid valve regurgitation 43% (95% CI: 8%-78%). Only one study reported on the involvement of the pulmonary valve (pulmonary valve prolapse was estimated at 5.3% (95% CI: 1.9%-11.1%) in a cohort of 114 patients with MFS). We believe this study provides a description of the structural valvular disease spectrum and may help inform providers and patients in understanding the clinical history of MFS in the current treatment era with its increased life expectancy.
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Affiliation(s)
- Carlson Sama
- Internal Medicine, West Virginia University School of Medicine, Morgantown, USA
| | - Noah T Fongwen
- Public Health Sciences, Africa Centre for Disease Control and Prevention (Africa CDC), Addis Ababa, ETH
| | | | - Ademola Ajibade
- Internal Medicine, West Virginia University School of Medicine, Morgantown, USA
| | - Melissa Roberts
- Cardiology, West Virginia University School of Medicine, Morgantown, USA
| | - Mark Greathouse
- Cardiology, West Virginia University School of Medicine, Morgantown, USA
| | | | - Ayowumi Adekolu
- Internal Medicine, West Virginia University School of Medicine, Morgantown, USA
| | - Yasmin S Hamirani
- Cardiology, West Virginia University School of Medicine, Morgantown, USA
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3
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Cui RZ, Hodge DO, Mohney BG. Incidence and de novo mutation rate of Marfan syndrome and risk of ectopia lentis. J AAPOS 2023; 27:273.e1-273.e4. [PMID: 37716433 PMCID: PMC11000121 DOI: 10.1016/j.jaapos.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 07/06/2023] [Accepted: 07/19/2023] [Indexed: 09/18/2023]
Abstract
PURPOSE To investigate the population-based incidence and de novo mutation rate of Marfan syndrome and risk of ectopia lentis. METHODS Patients newly diagnosed with Marfan syndrome in Olmsted County, Minnesota, from January 1, 1976, through December 31, 2005, were identified through medical records review. Outcome measures were Marfan incidence, de novo mutation rate, risk of ectopia lentis. RESULTS Marfan syndrome was identified in 17 patients during the 30-year period, yielding an incidence of 0.52 per 100,000 people/year (95% CI, 0.27-0.77). Mean age at diagnosis was 24.4 years (range, 1.7 year to 51.3 years). Nine patients (53%) were female. Of the 17, 5 (29%) were new mutations, with a calculated mutation rate of 3.8 ± 1.7 × 10-5. Four (24%) were diagnosed with ectopia lentis, including 3 at the time of their Marfan diagnosis. Of the 14 patients at risk for developing ectopia lentis after being diagnosed with Marfan syndrome, 1 (7%) developed it during a mean follow-up of 9 years (range, 0-6.4). Twelve (71%) were diagnosed with dilated ascending aorta during a mean follow-up of 13.2 years (range, 6.7 months to 28.9 years). CONCLUSIONS Incidence and de novo mutation rate of Marfan syndrome in this population-based cohort was higher than prior reports. Ectopia lentis, whose prevalence in North America has not been reported previously, occurred in approximately one-fourth of study patients and more commonly around the time of initial Marfan diagnosis.
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Affiliation(s)
- Ricky Z Cui
- Department of Ophthalmology, Duke Eye Center, Durham, North Carolina
| | - David O Hodge
- Division of Biostatistics, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
| | - Brian G Mohney
- Department of Ophthalmology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota.
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4
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Stark VC, Olfe J, Pesch J, Tahir E, Weinrich JM, Wiegand P, Kozlik‐Feldmann R, Kodolitsch Y, Mir TS. Tricuspid valve prolapse as an early predictor for severe phenotype in children with Marfan syndrome. Acta Paediatr 2022; 111:1261-1266. [PMID: 35194851 DOI: 10.1111/apa.16307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/10/2022] [Accepted: 02/21/2022] [Indexed: 11/30/2022]
Abstract
AIM In Marfan syndrome, various cardiovascular pathologies, such as aortic dilatation and mitral valve pathologies, already occur in childhood and determine course of the disease. This study aimed to establish additional cardiovascular risk markers for severe Marfan phenotypes. We investigated tricuspid valve prolapse (TVP) and its predictive value for outcome of paediatric Marfan disease. METHODS In this retrospective, observational cohort study, we identified 130 paediatric Marfan patients (10.7 ± 4.8 years) with FBN1 variants. We divided patients into two groups based on TVP presence and performed a cross-sectional analysis to investigate the association of TVP with other cardiovascular, ocular and systemic pathologies, at first and last visit. A longitudinal analysis was performed with follow-up data. RESULTS At baseline, patients with TVP had higher incidence of aortic root dilatation (p = 0.013), mitral valve prolapse (p = 0.0001) and systemic manifestations (p = 0.025) than patients without TVP. At follow-up, previous presence of TVP predicted higher probability of aortic root dilatation (p = 0.002), mitral valve prolapse (p = 0.0001) and systemic manifestations (p = 0.002). CONCLUSION This shows that TVP is linked to both cardiac and extracardiac Marfan manifestations and TVP is an important marker for a disease severity in these children. Therefore, TVP should be assessed routinely using echocardiography in paediatric Marfan patients.
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Affiliation(s)
- Veronika C. Stark
- Paediatric Cardiology University Heart and Vascular Center University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Jakob Olfe
- Paediatric Cardiology University Heart and Vascular Center University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Jannis Pesch
- Paediatric Cardiology University Heart and Vascular Center University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Enver Tahir
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Julius M. Weinrich
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Peter Wiegand
- Paediatric Cardiology University Heart and Vascular Center University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Rainer Kozlik‐Feldmann
- Paediatric Cardiology University Heart and Vascular Center University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Yskert Kodolitsch
- Department of Cardiology University Heart and Vascular Center University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Thomas S. Mir
- Paediatric Cardiology University Heart and Vascular Center University Medical Center Hamburg‐Eppendorf Hamburg Germany
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Abstract
The inherited connective tissue disorders (Marfan syndrome, Loeys-Dietz syndrome [LDS], and Ehlers-Danlos syndrome [EDS]) involve connective tissue of various organ systems. These pathologies share many common features, nonetheless compared to Marfan syndrome, LDS' cardiovascular manifestations tend to be more severe. In contrast, no association is reported between LDS and the presence of ectopia lentis. The EDS are currently classified into thirteen subtypes. There is substantial symptoms overlap between the EDS subtypes, and they are associated with an increased incidence of cardiovascular abnormalities, such as mitral valve prolapse and aortic dissection.
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Morningstar JE, Nieman A, Wang C, Beck T, Harvey A, Norris RA. Mitral Valve Prolapse and Its Motley Crew-Syndromic Prevalence, Pathophysiology, and Progression of a Common Heart Condition. J Am Heart Assoc 2021; 10:e020919. [PMID: 34155898 PMCID: PMC8403286 DOI: 10.1161/jaha.121.020919] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/21/2021] [Indexed: 01/01/2023]
Abstract
Mitral valve prolapse (MVP) is a commonly occurring heart condition defined by enlargement and superior displacement of the mitral valve leaflet(s) during systole. Although commonly seen as a standalone disorder, MVP has also been described in case reports and small studies of patients with various genetic syndromes. In this review, we analyzed the prevalence of MVP within syndromes where an association to MVP has previously been reported. We further discussed the shared biological pathways that cause MVP in these syndromes, as well as how MVP in turn causes a diverse array of cardiac and noncardiac complications. We found 105 studies that identified patients with mitral valve anomalies within 18 different genetic, developmental, and connective tissue diseases. We show that some disorders previously believed to have an increased prevalence of MVP, including osteogenesis imperfecta, fragile X syndrome, Down syndrome, and Pseudoxanthoma elasticum, have few to no studies that use up-to-date diagnostic criteria for the disease and therefore may be overestimating the prevalence of MVP within the syndrome. Additionally, we highlight that in contrast to early studies describing MVP as a benign entity, the clinical course experienced by patients can be heterogeneous and may cause significant cardiovascular morbidity and mortality. Currently only surgical correction of MVP is curative, but it is reserved for severe cases in which irreversible complications of MVP may already be established; therefore, a review of clinical guidelines to allow for earlier surgical intervention may be warranted to lower cardiovascular risk in patients with MVP.
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Affiliation(s)
- Jordan E. Morningstar
- Department of Regenerative Medicine and Cell BiologyMedical University of South CarolinaCharlestonSC
| | - Annah Nieman
- Department of Regenerative Medicine and Cell BiologyMedical University of South CarolinaCharlestonSC
| | - Christina Wang
- Department of Regenerative Medicine and Cell BiologyMedical University of South CarolinaCharlestonSC
| | - Tyler Beck
- Department of Regenerative Medicine and Cell BiologyMedical University of South CarolinaCharlestonSC
| | - Andrew Harvey
- Department of Regenerative Medicine and Cell BiologyMedical University of South CarolinaCharlestonSC
| | - Russell A. Norris
- Department of Regenerative Medicine and Cell BiologyMedical University of South CarolinaCharlestonSC
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Lidal IB, Bathen T, Johansen H, Velvin G. A scoping review presenting a wide variety of research on paediatric and adolescent patients with Marfan syndrome. Acta Paediatr 2020; 109:1758-1771. [PMID: 31977115 PMCID: PMC7496935 DOI: 10.1111/apa.15186] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 01/13/2020] [Accepted: 01/20/2020] [Indexed: 12/24/2022]
Abstract
Aim The present study aimed to map and summarise the research on children, aged 0‐18 years, with Marfan syndrome, identify research gaps and point to research agendas. Methods A scoping review was systematically performed by searching multiple databases from January 1996 to April 2019. Primary studies presenting results on at least six individuals aged 0‐18 years with Marfan syndrome, diagnosed according to the Ghent nosology, were selected. Results From 2341 de‐duplicated records, 92 papers were included, mapped and described. Their topics were diagnostics (12%), cardiovascular matters (50%), skeletal matters (22%), ocular matters (9%), other medical aspects (5%) and psychosocial perspectives (2%). Most studies were from Europe and North America and published between 1999 and 2019 in subject‐specific or paediatric journals, while a few were published in genetics journals. All studies had quantitative designs, and very few were multicentre studies. Each study had six to 608 subjects for a total of approximately 5809. Conclusion A wide range of research topics on adolescent and paediatric Marfan syndrome was found, but qualitative studies and a focus on psychosocial matters were lacking. Future investigations addressing noncardiovascular consequences and patient experiences are needed, as well as studies reaffirming or replicating existing intervention study results.
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Affiliation(s)
- Ingeborg Beate Lidal
- TRS Resource Centre for Rare Disorders Sunnaas Rehabilitation Hospital Oslo Norway
| | - Trine Bathen
- TRS Resource Centre for Rare Disorders Sunnaas Rehabilitation Hospital Oslo Norway
| | - Heidi Johansen
- TRS Resource Centre for Rare Disorders Sunnaas Rehabilitation Hospital Oslo Norway
| | - Gry Velvin
- TRS Resource Centre for Rare Disorders Sunnaas Rehabilitation Hospital Oslo Norway
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8
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Vanem TT, Böker T, Sandvik GF, Kirkhus E, Smith H, Andersen K, Drolsum L, Lundby R, Røe C, Krohg‐Sørensen K, Geiran OR, Paus B, Rand‐Hendriksen S. Marfan syndrome: Evolving organ manifestations—A 10‐year follow‐up study. Am J Med Genet A 2019; 182:397-408. [DOI: 10.1002/ajmg.a.61441] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/20/2019] [Accepted: 11/26/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Thy Thy Vanem
- Faculty of Medicine, University of OsloInstitute of Clinical Medicine Oslo Norway
- Department of Cardiothoracic SurgeryOslo University Hospital (OUH) Oslo Norway
| | - Tordis Böker
- Faculty of Medicine, University of OsloInstitute of Clinical Medicine Oslo Norway
- Department of Radiology and Nuclear MedicineOUH Oslo Norway
| | - Gunhild F. Sandvik
- Faculty of Medicine, University of OsloInstitute of Clinical Medicine Oslo Norway
- Department of OphthalmologyOUH Oslo Norway
| | - Eva Kirkhus
- Department of Radiology and Nuclear MedicineOUH Oslo Norway
| | - Hans‐Jørgen Smith
- Faculty of Medicine, University of OsloInstitute of Clinical Medicine Oslo Norway
- Department of Radiology and Nuclear MedicineOUH Oslo Norway
| | - Kai Andersen
- Department of Cardiothoracic SurgeryOslo University Hospital (OUH) Oslo Norway
| | - Liv Drolsum
- Faculty of Medicine, University of OsloInstitute of Clinical Medicine Oslo Norway
- Department of OphthalmologyOUH Oslo Norway
| | - Rigmor Lundby
- Faculty of Medicine, University of OsloInstitute of Clinical Medicine Oslo Norway
- Department of Radiology and Nuclear MedicineOUH Oslo Norway
| | - Cecilie Røe
- Faculty of Medicine, University of OsloInstitute of Clinical Medicine Oslo Norway
- Department of Physical Medicine and RehabilitationOUH Oslo Norway
| | - Kirsten Krohg‐Sørensen
- Faculty of Medicine, University of OsloInstitute of Clinical Medicine Oslo Norway
- Department of Cardiothoracic SurgeryOslo University Hospital (OUH) Oslo Norway
| | - Odd R. Geiran
- Faculty of Medicine, University of OsloInstitute of Clinical Medicine Oslo Norway
- Department of Cardiothoracic SurgeryOslo University Hospital (OUH) Oslo Norway
| | - Benedicte Paus
- Faculty of Medicine, University of OsloInstitute of Clinical Medicine Oslo Norway
- Department of Medical GeneticOUH Oslo Norway
| | - Svend Rand‐Hendriksen
- Faculty of Medicine, University of OsloInstitute of Clinical Medicine Oslo Norway
- TRS, National Resource Centre for Rare DisordersSunnaas Rehabilitation Hospital Nesoddtangen Norway
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9
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Muiño-Mosquera L, Bauters F, Dhondt K, De Wilde H, Jordaens L, De Groote K, De Wolf D, Hertegonne K, De Backer J. Sleep apnea and the impact on cardiovascular risk in patients with Marfan syndrome. Mol Genet Genomic Med 2019; 7:e805. [PMID: 31245936 PMCID: PMC6687621 DOI: 10.1002/mgg3.805] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 05/23/2019] [Indexed: 12/25/2022] Open
Abstract
Background Marfan syndrome (MFS) is an inherited connective tissue disorder characterized by ectopia lentis, aortic root dilation and dissection and specific skeletal features. Obstructive sleep apnea (OSA) in MFS has been described earlier but the prevalence and its relation with the cardiovascular risk is still controversial. This study aimed to further investigate these aspects. Methods In this prospective longitudinal study, we performed an attended polysomnography in 40 MFS patients (60% women, 37 ± 12.8 years) and evaluated several cardiovascular parameters through echocardiography, resting electrocardiogram, 24 hr‐Holter monitoring and serum NT‐ProBNP measurements. Results We found that OSA was present in 42.5% of the patients and that higher body mass index was the most important factor associated with the presence of OSA. We observed that overweight was present in 27.5% of the patients in the whole cohort and in 55.6% if >40 years. Furthermore, when evaluating the impact of OSA on the cardiovascular system, we observed that patients with OSA tended to have higher systolic blood pressure, larger distal aortic diameters and a higher prevalence of ventricular arrhythmia. These differences were, however, not significant after adjusting for confounders. Conclusions Our study shows a high prevalence of OSA and a high prevalence of overweight in MFS patients. We found some trends between OSA and cardiovascular features but we could not establish a solid association. Our study, however might be underpowered, and a multicenter collaborative study could be very useful to answer some important open questions.
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Affiliation(s)
- Laura Muiño-Mosquera
- Centre for Medical Genetics, Ghent University Hospital, Ghent, Belgium.,Department of Pediatrics, Division of Pediatric Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Fré Bauters
- Department of Pneumology, Ghent University Hospital, Ghent, Belgium
| | - Karlien Dhondt
- Department of Pneumology, Ghent University Hospital, Ghent, Belgium.,Department of Psychiatry, Division of Child and Adolescent Psychiatry, Pediatric Sleep Centre, Ghent University Hospital, Ghent, Belgium
| | - Hans De Wilde
- Department of Pediatrics, Division of Pediatric Cardiology, Ghent University Hospital, Ghent, Belgium.,Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Luc Jordaens
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Katya De Groote
- Department of Pediatrics, Division of Pediatric Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Daniel De Wolf
- Department of Pediatrics, Division of Pediatric Cardiology, Ghent University Hospital, Ghent, Belgium
| | | | - Julie De Backer
- Centre for Medical Genetics, Ghent University Hospital, Ghent, Belgium.,Department of Cardiology, Ghent University Hospital, Ghent, Belgium
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10
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The Potential Beneficial Effects of Resveratrol on Cardiovascular Complications in Marfan Syndrome Patients⁻Insights from Rodent-Based Animal Studies. Int J Mol Sci 2019; 20:ijms20051122. [PMID: 30841577 PMCID: PMC6429290 DOI: 10.3390/ijms20051122] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 02/26/2019] [Accepted: 03/01/2019] [Indexed: 12/12/2022] Open
Abstract
Marfan syndrome (MFS) patients are at risk for cardiovascular disease. In particular, for aortic aneurysm formation, which ultimately can result in a life-threatening aortic dissection or rupture. Over the years, research into a sufficient pharmacological treatment option against aortopathy has expanded, mostly due to the development of rodent disease models for aneurysm formation and dissections. Unfortunately, no optimal treatment strategy has yet been identified for MFS. The biologically-potent polyphenol resveratrol (RES), that occurs in nuts, plants, and the skin of grapes, was shown to have a positive effect on aortic repair in various rodent aneurysm models. RES demonstrated to affect aortic integrity and aortic dilatation. The beneficial processes relevant for MFS included the improvement of endothelial dysfunction, extracellular matrix degradation, and smooth muscle cell death. For the wide range of beneficial effects on these mechanisms, evidence was found for the following involved pathways; alleviating oxidative stress (change in eNOS/iNOS balance and decrease in NOX4), reducing protease activity to preserve the extracellular matrix (decrease in MMP2), and improving smooth muscle cell survival affecting aortic aging (changing the miR21/miR29 balance). Besides aortic features, MFS patients may also suffer from manifestations concerning the heart, such as mitral valve prolapse and left ventricular impairment, where evidence from rodent models shows that RES may aid in promoting cardiomyocyte survival directly (SIRT1 activation) or by reducing oxidative stress (increasing superoxide dismutase) and increasing autophagy (AMPK activation). This overview discusses recent RES studies in animal models of aortic aneurysm formation and heart failure, where different advantageous effects have been reported that may collectively improve the aortic and cardiac pathology in patients with MFS. Therefore, a clinical study with RES in MFS patients seems justified, to validate RES effectiveness, and to judge its suitability as potential new treatment strategy.
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11
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Stark VC, Huemmer M, Olfe J, Mueller GC, Kozlik-Feldmann R, Mir TS. The Pulmonary Artery in Pediatric Patients with Marfan Syndrome: An Underestimated Aspect of the Disease. Pediatr Cardiol 2018; 39:1194-1199. [PMID: 29696429 DOI: 10.1007/s00246-018-1880-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 04/04/2018] [Indexed: 01/16/2023]
Abstract
Aortic root dilatation and its complications are known to be the most important and life limiting features in patients with Marfan syndrome (MFS). Since monitoring of patients, preventive medical and surgical treatments are available nowadays, other MFS pathologies are becoming more relevant for the outcome of the disease. Main pulmonary artery (MPA) dilatation is a cardiac finding, which has not been fully investigated in children. Due to the similarities in tissue composition of the aortic and pulmonary root, MPA dilatation may cause complications and require treatment. In addition, it may be a predictor for severe connective tissue involvement. We retrospectively examined 135 pediatric patients with MFS. 8.1% showed MPA dilatation. MPA dilatation was associated with earlier occurrence of aortic dilatation, mitral valve prolapse, and systemic manifestations of MFS compared with patients without MPA dilatation (p < 0.05). The presence of MPA dilatation was also associated with a higher incidence of ectopia lentis (p < 0.05). Medical treatment was started earlier in MPA dilatation patients than in those without (p < 0.05). We conclude that MPA dilatation is a sign of more severe vascular and connective tissue involvement. Regular examination of the pulmonary artery is essential in MFS to avoid complications. As medical treatment of life threatening MFS events has improved, other features of MFS need to be investigated to improve quality of life.
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Affiliation(s)
- Veronika C Stark
- Pediatric Cardiology, University Heart Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Michael Huemmer
- Pediatric Cardiology, University Heart Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Jakob Olfe
- Pediatric Cardiology, University Heart Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Goetz C Mueller
- Pediatric Cardiology, University Heart Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Rainer Kozlik-Feldmann
- Pediatric Cardiology, University Heart Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Thomas S Mir
- Pediatric Cardiology, University Heart Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
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12
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Meester JAN, Verstraeten A, Schepers D, Alaerts M, Van Laer L, Loeys BL. Differences in manifestations of Marfan syndrome, Ehlers-Danlos syndrome, and Loeys-Dietz syndrome. Ann Cardiothorac Surg 2017; 6:582-594. [PMID: 29270370 DOI: 10.21037/acs.2017.11.03] [Citation(s) in RCA: 154] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Many different heritable connective tissue disorders (HCTD) have been described over the past decades. These syndromes often affect the connective tissue of various organ systems, including heart, blood vessels, skin, joints, bone, eyes, and lungs. The discovery of these HCTD was followed by the identification of mutations in a wide range of genes encoding structural proteins, modifying enzymes, or components of the TGFβ-signaling pathway. Three typical examples of HCTD are Marfan syndrome (MFS), Ehlers-Danlos syndrome (EDS), and Loeys-Dietz syndrome (LDS). These syndromes show some degree of phenotypical overlap of cardiovascular, skeletal, and cutaneous features. MFS is typically characterized by cardiovascular, ocular, and skeletal manifestations and is caused by heterozygous mutations in FBN1, coding for the extracellular matrix (ECM) protein fibrillin-1. The most common cardiovascular phenotype involves aortic aneurysm and dissection at the sinuses of Valsalva. LDS is caused by mutations in TGBR1/2, SMAD2/3, or TGFB2/3, all coding for components of the TGFβ-signaling pathway. LDS can be distinguished from MFS by the unique presence of hypertelorism, bifid uvula or cleft palate, and widespread aortic and arterial aneurysm and tortuosity. Compared to MFS, LDS cardiovascular manifestations tend to be more severe. In contrast, no association is reported between LDS and the presence of ectopia lentis, a key distinguishing feature of MFS. Overlapping features between MFS and LDS include scoliosis, pes planus, anterior chest deformity, spontaneous pneumothorax, and dural ectasia. EDS refers to a group of clinically and genetically heterogeneous connective tissue disorders and all subtypes are characterized by variable abnormalities of skin, ligaments and joints, blood vessels, and internal organs. Typical presenting features include joint hypermobility, skin hyperextensibility, and tissue fragility. Up to one quarter of the EDS patients show aortic aneurysmal disease. The latest EDS nosology distinguishes 13 subtypes. Many phenotypic features show overlap between the different subtypes, which makes the clinical diagnosis rather difficult and highlights the importance of molecular diagnostic confirmation.
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Affiliation(s)
- Josephina A N Meester
- Center of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Aline Verstraeten
- Center of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Dorien Schepers
- Center of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Maaike Alaerts
- Center of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Lut Van Laer
- Center of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Bart L Loeys
- Center of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium.,Department of Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
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Bradley TJ, Bowdin SC, Morel CFJ, Pyeritz RE. The Expanding Clinical Spectrum of Extracardiovascular and Cardiovascular Manifestations of Heritable Thoracic Aortic Aneurysm and Dissection. Can J Cardiol 2015; 32:86-99. [PMID: 26724513 DOI: 10.1016/j.cjca.2015.11.007] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 11/09/2015] [Accepted: 11/09/2015] [Indexed: 01/09/2023] Open
Abstract
More than 30 heritable conditions are associated with thoracic aortic aneurysm and dissection (TAAD). Heritable syndromic conditions, such as Marfan syndrome, Loeys-Dietz syndrome, and vascular Ehlers-Danlos syndrome, have somewhat overlapping systemic features, but careful clinical assessment usually enables a diagnosis that can be validated with genetic testing. Nonsyndromic FTAAD can also occur and in 20%-25% of these probands mutations exist in genes that encode elements of the extracellular matrix, signalling pathways (especially involving transforming growth factor-β), and vascular smooth muscle cytoskeletal and contractile processes. Affected individuals with either a syndromic presentation or isolated TAAD can have mutations in the same gene. In this review we focus on the genes currently known to have causal mutations for syndromic and isolated FTAAD and outline the range of associated extracardiovascular and cardiovascular manifestations with each.
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Affiliation(s)
- Timothy J Bradley
- Division of Cardiology, Department of Paediatrics, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
| | - Sarah C Bowdin
- Division of Cardiology, Department of Paediatrics, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Division of Clinical and Metabolic Genetics, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Chantal F J Morel
- Fred A. Litwin Family Center in Genetic Medicine, Department of Medicine, University Health Network and Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Reed E Pyeritz
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Gu X, He Y, Li Z, Han J, Chen J, Nixon JVI. Echocardiographic versus histologic findings in Marfan syndrome. Tex Heart Inst J 2015; 42:30-4. [PMID: 25873795 DOI: 10.14503/thij-13-3848] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This retrospective study attempted to establish the prevalence of multiple-valve involvement in Marfan syndrome and to compare echocardiographic with histopathologic findings in Marfan patients undergoing valvular or aortic surgery. We reviewed echocardiograms of 73 Marfan patients who underwent cardiovascular surgery from January 2004 through October 2009. Tissue histology was available for comparison in 29 patients. Among the 73 patients, 66 underwent aortic valve replacement or the Bentall procedure. Histologic findings were available in 29 patients, all of whom had myxomatous degeneration. Of 63 patients with moderate or severe aortic regurgitation as determined by echocardiography, 4 had thickened aortic valves. The echocardiographic findings in 18 patients with mitral involvement included mitral prolapse in 15. Of 11 patients with moderate or severe mitral regurgitation as determined by echocardiography, 4 underwent mitral valve repair and 7 mitral valve replacement. Histologic findings among mitral valve replacement patients showed thickened valve tissue and myxomatous degeneration. Tricuspid involvement was seen echocardiographically in 8 patients, all of whom had tricuspid prolapse. Two patients had severe tricuspid regurgitation, and both underwent repair. Both mitral and tricuspid involvement were seen echocardiographically in 7 patients. Among the 73 patients undergoing cardiac surgery for Marfan syndrome, 66 had moderate or severe aortic regurgitation, although their valves manifested few histologic changes. Eighteen patients had mitral involvement (moderate or severe mitral regurgitation, prolapse, or both), and 8 had tricuspid involvement. Mitral valves were most frequently found to have histologic changes, but the tricuspid valve was invariably involved.
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Multimodality Imaging of Diseases of the Thoracic Aorta in Adults: From the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2015; 28:119-82. [DOI: 10.1016/j.echo.2014.11.015] [Citation(s) in RCA: 409] [Impact Index Per Article: 45.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Sheikhzadeh S, De Backer J, Gorgan NR, Rybczynski M, Hillebrand M, Schüler H, Bernhardt AM, Koschyk D, Bannas P, Keyser B, Mortensen K, Radke RM, Mir TS, Kölbel T, Robinson PN, Schmidtke J, Berger J, Blankenberg S, von Kodolitsch Y. The main pulmonary artery in adults: a controlled multicenter study with assessment of echocardiographic reference values, and the frequency of dilatation and aneurysm in Marfan syndrome. Orphanet J Rare Dis 2014; 9:203. [PMID: 25491897 PMCID: PMC4272795 DOI: 10.1186/s13023-014-0203-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 11/26/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Echocardiographic upper normal limits of both main pulmonary artery (MPA) diameters (MPA-d) and ratio of MPA to aortic root diameter (MPA-r) are not defined in healthy adults. Accordingly, frequency of MPA dilatation based on echocardiography remains to be assessed in adults with Marfan syndrome (MFS). METHODS We enrolled 123 normal adults (72 men, 52 women aged 42 ± 14 years) and 98 patients with MFS (42 men, 56 women aged 39 ± 14 years) in a retrospective cross-sectional observational controlled study in four tertiary care centers. We defined outcome measures including upper normal limits of MPA-d and MPA-r as 95 quantile of normal persons, MPA dilatation as diameters > upper normal limits, MPA aneurysm as diameters >4 cm, and indication for surgery as MPA diameters >6 cm. RESULTS MPA diameters revealed normal distribution without correlation to age, sex, body weight, body height, body mass index and body surface area. The upper normal limit was 2.6 cm (95% confidence interval (CI) =2.44-2.76 cm) for MPA-d, and 1.05 (95% CI = .86-1.24) for MPA-r. MPA dilatation presented in 6 normal persons (4.9%) and in 68 MFS patients (69.4%; P < .001), MPA aneurysm presented only in MFS (15 patients; 15.3%; P < .001), and no patient required surgery. Mean MPA-r were increased in MFS (P < .001), but ratios >1.05 were equally frequent in 7 normal persons (5%) and in 8 MFS patients (10.5%; P = .161). MPA-r related to aortic root diameters (P = .042), reduced left ventricular ejection fraction (P = .006), and increased pulmonary artery systolic pressures (P = .040). No clinical manifestations of MFS and no FBN1 mutation characteristics related to MPA diameters. CONCLUSIONS We established 2.6 cm for MPA-d and 1.05 for MPA-r as upper normal limits. MFS exhibits a high prevalence of MPA dilatation and aneurysm. However, patients may require MPA surgery only in scarce circumstances, most likely because formation of marked MPA aneurysm may require LV dysfunction and increased PASP.
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Affiliation(s)
- Sara Sheikhzadeh
- Centre of Cardiology and Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Julie De Backer
- Centre for Medical Genetics, University Hospital Ghent, Ghent, Belgium.
| | - Neda Rahimian Gorgan
- Centre of Cardiology and Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Meike Rybczynski
- Centre of Cardiology and Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Mathias Hillebrand
- Centre of Cardiology and Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Helke Schüler
- Centre of Cardiology and Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Alexander M Bernhardt
- Centre of Cardiology and Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Dietmar Koschyk
- Centre of Cardiology and Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Peter Bannas
- Department of Diagnostic and Interventional Radiology, University Hospital Eppendorf, Hamburg, Germany.
| | - Britta Keyser
- Institute of Human Genetics, Hannover Medical School, Hannover, Germany.
| | - Kai Mortensen
- Medizinische Klinik II / Kardiologie, Angiologie, am Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Germany.
| | - Robert M Radke
- Department für Kardiologie und Angiologie, Universitätsklinikum Münster, Münster, Germany.
| | - Thomas S Mir
- Centre of Cardiology and Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Tilo Kölbel
- Centre of Cardiology and Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Peter N Robinson
- Institute of Medical Genetics, Charité Universitätsmedizin Berlin, Berlin, Germany.
| | - Jörg Schmidtke
- Institute of Human Genetics, Hannover Medical School, Hannover, Germany.
| | - Jürgen Berger
- Department of Medical Biometry and Epidemiology, University Hospital Eppendorf, Hamburg, Germany.
| | - Stefan Blankenberg
- Centre of Cardiology and Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Yskert von Kodolitsch
- Centre of Cardiology and Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
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A patient with Marfan's syndrome presented with severe rheumatic mitral stenosis and successfully treated with percutaneous transmitral balloon commissurotomy - Report of first case. J Cardiovasc Dis Res 2014; 4:257-9. [PMID: 24653594 DOI: 10.1016/j.jcdr.2013.04.002] [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: 03/31/2013] [Accepted: 04/30/2013] [Indexed: 11/22/2022] Open
Abstract
Marfan's syndrome (MFS) is an inherited autosomal dominant disorder of connective tissue with mutation on the fibrillin-1 gene encoding for fibrillin. This frequently involves the cardiovascular system with prevalence is 1:5000-10,000. The clinical major criteria involve the skeletal and ocular apparatus and the cardiovascular and central nervous system. In Marfan's syndrome mitral valve prolapse and aortic dilation are the main cardiovascular manifestations. According to the literature database the prevalence of aortic dilatation is 76%, 62% for mitral valve prolapse, 29% for mitral valve regurgitation and 26% for aortic regurgitation, in adult patients with Marfan's syndrome. We are reporting a case who presented with severe rheumatic mitral stenosis & later on examination found to be a case of Marfan's syndrome. This patient was successfully treated with percutaneous transmitral balloon commissurotomy. In medline search, so far there is no other case of Marfan's syndrome reported to have rheumatic mitral stenosis.
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Abstract
Marfan syndrome is a multisystem connective tissue disorder, with primary involvement of the cardiovascular, ocular, and skeletal systems. This autosomal heritable disease is mainly attributable to a defect in the FBN1 gene. Clinical diagnosis of Marfan syndrome has been based on the Ghent criteria since 1996. In 2010, these criteria were updated, and the revised guidelines place more emphasis on aortic root dilation, ectopia lentis, and FBN1 mutation testing in the diagnostic assessment of Marfan syndrome. Among its many different clinical manifestations, cardiovascular involvement deserves special consideration, owing to its impact on prognosis. Recent molecular, surgical, and clinical research has yielded profound new insights into the pathological mechanisms that ultimately lead to tissue degradation and weakening of the aortic wall, which has led to exciting new treatment strategies. Furthermore, with the increasing life expectancy of patients with Marfan syndrome, there has been a subtle shift in the spectrum of medical problems. Consequently, this article focuses on recent advances to highlight their potential impact on future concepts of patient care from a clinical, surgical, and anesthetic perspective.
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Kühne K, Keyser B, Groene EF, Sheikhzadeh S, Detter C, Lorenzen V, Hillebrand M, Bernhardt AM, Hoffmann B, Mir TS, Robinson PN, Berger J, Reichenspurner H, von Kodolitsch Y, Rybczynski M. FBN1 gene mutation characteristics and clinical features for the prediction of mitral valve disease progression. Int J Cardiol 2013. [DOI: 10.1016/j.ijcard.2012.10.044] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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20
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Dormand H, Mohiaddin RH. Cardiovascular magnetic resonance in Marfan syndrome. J Cardiovasc Magn Reson 2013; 15:33. [PMID: 23587220 PMCID: PMC3651373 DOI: 10.1186/1532-429x-15-33] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 03/15/2013] [Indexed: 12/20/2022] Open
Abstract
This review provides an overview of Marfan syndrome with an emphasis on cardiovascular complications and cardiovascular imaging. Both pre- and post-operative imaging is addressed with an explanation of surgical management. All relevant imaging modalities are discussed with a particular focus on cardiovascular MR.
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Affiliation(s)
- Helen Dormand
- Manchester Heart Centre, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
| | - Raad H Mohiaddin
- Royal Brompton Hospital and National Heart & Lung Institute, Imperial College, Sydney Street, London SW3 6NP, UK
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Grimaldi A, De Gennaro L, Chiara Vermi A, Pappalardo F, Daniele Brunetti N, Di Biase M, La Canna G, Alfieri O. Cardiac valve involvement in systemic diseases: a review. Clin Cardiol 2013; 36:117-24. [PMID: 23408535 DOI: 10.1002/clc.22099] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2012] [Revised: 01/13/2013] [Indexed: 11/06/2022] Open
Abstract
Increasing age and new trends of mixed populations have newly aroused interest in valvular heart disease in the developed countries still in need of new clinical insights. In the clinical setting of systemic diseases, the proper assessment of cardiovascular abnormalities may be challenging, and the characterization of valvular involvement might help to recognize the underlying disease and cardiac sequelae. Prompt identification of valvular lesions may, therefore, also be useful for differential diagnosis. This article reviews the cardiac involvement in systemic diseases from etiology and background definition to echocardiographic assessment and clinical interpretation.
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Affiliation(s)
- Antonio Grimaldi
- Cardiovascular and Thoracic Department, San Raffaele Scientific Institute and Università Vita-Salute, Milan, Italy.
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Lundby R, Rand-Hendriksen S, Hald JK, Pripp AH, Smith HJ. The pulmonary artery in patients with Marfan syndrome: a cross-sectional study. Genet Med 2012; 14:922-7. [DOI: 10.1038/gim.2012.82] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Nistri S, Porciani MC, Attanasio M, Abbate R, Gensini GF, Pepe G. Association of Marfan syndrome and bicuspid aortic valve: frequency and outcome. Int J Cardiol 2012; 155:324-5. [PMID: 22225761 DOI: 10.1016/j.ijcard.2011.12.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Accepted: 12/04/2011] [Indexed: 10/14/2022]
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Dilatation of the great arteries in an infant with marfan syndrome and ventricular septal defect. Case Rep Med 2011; 2011:172109. [PMID: 21776272 PMCID: PMC3137971 DOI: 10.1155/2011/172109] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Accepted: 05/18/2011] [Indexed: 02/05/2023] Open
Abstract
We describe an infant presenting with contractures of the fingers, a large ventricular septal defect (VSD), and severe pulmonary artery dilatation. He had clinical and echocardiographic features of both neonatal or infantile Marfan syndrome (MFS) and congenital contractural arachnodactyly. After surgical VSD closure, the aortic root developed progressive dilatation while the size of pulmonary artery returned to normal limits. Eventually the diagnosis of MFS was confirmed by DNA analysis.
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Faivre L, Collod-Beroud G, Adès L, Arbustini E, Child A, Callewaert BL, Loeys B, Binquet C, Gautier E, Mayer K, Arslan-Kirchner M, Grasso M, Beroud C, Hamroun D, Bonithon-Kopp C, Plauchu H, Robinson PN, De Backer J, Coucke P, Francke U, Bouchot O, Wolf JE, Stheneur C, Hanna N, Detaint D, De Paepe A, Boileau C, Jondeau G. The new Ghent criteria for Marfan syndrome: what do they change? Clin Genet 2011; 81:433-42. [DOI: 10.1111/j.1399-0004.2011.01703.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Sohn GH, Jang SY, Moon JR, Yang JH, Sung K, Ki CS, Oh JK, Choe YH, Kim DK. The usefulness of multidetector computed tomographic angiography for the diagnosis of Marfan syndrome by Ghent criteria. Int J Cardiovasc Imaging 2011; 27:679-88. [DOI: 10.1007/s10554-011-9867-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Accepted: 04/02/2011] [Indexed: 10/18/2022]
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Rybczynski M, Treede H, Sheikhzadeh S, Groene EF, Bernhardt AM, Hillebrand M, Mir TS, Kühne K, Koschyk D, Robinson PN, Berger J, Reichenspurner H, Meinertz T, von Kodolitsch Y. Predictors of outcome of mitral valve prolapse in patients with the Marfan syndrome. Am J Cardiol 2011; 107:268-74. [PMID: 21211604 DOI: 10.1016/j.amjcard.2010.08.070] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2010] [Revised: 08/31/2010] [Accepted: 08/31/2010] [Indexed: 11/26/2022]
Abstract
Mitral valve prolapse has a prevalence of 2% to 3% in the general population, with adverse outcomes such as mitral valve regurgitation (MVR), heart failure, and endocarditis. Predictors of outcomes are used in idiopathic mitral valve prolapse for the timing of surgery, but such predictors are unknown in Marfan syndrome. Therefore, a population-based cohort study of 112 patients (49 male, 63 female; mean age 34 ± 15 years) with classic Marfan syndrome and mitral valve prolapse with moderate or less MVR at baseline was conducted. During 4.6 ± 3.6 years of follow-up, progression of MVR was observed in 41 patients and valve-related events, which comprised mitral valve endocarditis (7 events), heart failure (5 events), and mitral valve surgery (25 events), were observed in 31 patients. Multivariate Cox proportional-hazards regression analysis identified a flail mitral leaflet (hazard ratio [HR] 3.262, 95% confidence interval [CI] 1.406 to 7.566, p = 0.006) and increased indexed end-systolic left ventricular diameters (HR 1.113, 95% CI 1.043 to 1.188, p = 0.001) as independent predictors of progression of MVR. Similarly, mitral valve-related events were independently predicted by a flail mitral leaflet (HR 5.343, 95% CI 2.229 to 12.808, p <0.001), and mild (HR 14.336, 95% CI 1.873 to 109.755, p = 0.01) or moderate (HR 16.849, 95% CI 2.205 to 128.76, p = 0.006) degree of MVR. Conversely, aortic dilatation, dural ectasia, and sporadic mode of inheritance were not associated with outcome. In conclusion, the same clinical determinants that predict outcomes in idiopathic mitral valve prolapse also predict outcomes in mitral valve prolapse associated with Marfan syndrome.
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Rybczynski M, Mir TS, Sheikhzadeh S, Bernhardt AM, Schad C, Treede H, Veldhoen S, Groene EF, Kühne K, Koschyk D, Robinson PN, Berger J, Reichenspurner H, Meinertz T, von Kodolitsch Y. Frequency and age-related course of mitral valve dysfunction in the Marfan syndrome. Am J Cardiol 2010; 106:1048-53. [PMID: 20854973 DOI: 10.1016/j.amjcard.2010.05.038] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2010] [Revised: 05/18/2010] [Accepted: 05/18/2010] [Indexed: 10/19/2022]
Abstract
Mitral valve (MV) prolapse (MVP) has a high prevalence of 2% to 3% in the general population and thus constitutes the most common cause of severe nonischemic MV regurgitation (MVR). MVP is also common in persons with the Marfan syndrome. However, to date, a large-scale population-based cohort study using modern echocardiographic techniques has not been performed, and the frequency of MVP and the relation of MV dysfunction and age have not been investigated. Therefore, we conducted a population-based cohort study of 204 patients (108 males and 96 females, aged 31.2 ± 16.4 years) with classic Marfan syndrome. We performed echocardiographic follow-up of 174 patients for a mean of 4.4 ± 4.3 years. On the initial or subsequent echocardiographic scan, MVP was present in 82 patients (40%), severe MVR in 25 (12%), and MV endocarditis in 5 patients (2.5%). At 30 years of age, the Weibull cumulative distribution was 42.6% (95% confidence interval [CI] 36% to 50%) for MVP, 56.5% (95% CI 49.3% to 64%) for MVR of any degree, 6.7% (95% CI 3.9% to 11.3%) for severe MVR, and 0.92% (95% CI 0.21% to 3.91%) for MV endocarditis. The cumulative hazard for severe MVR and MV endocarditis was estimated to increase with age. MVP was associated with dural ectasia (p = 0.01), ectopia lentis (p = 0.02), and skeletal involvement (p <0.001). Severe MVR was related to tricuspid valve prolapse (p = 0.002) and to the sporadic form of the Marfan syndrome (p = 0.006). In conclusion, MVP was comparatively frequent in patients with the Marfan syndrome and carries an increased risk of progression to severe MVR and endocarditis, especially in older adults.
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Espínola-Zavaleta N, Iqbal FM, Nanda NC, Enríquez-Rodríguez E, Amezcua-Guerra LM, Bojalil-Parra R, Reyes PA, Soto ME. Echocardiographic Study of a Mestizo-Mexican Population with Marfan Syndrome. Echocardiography 2010; 27:923-30. [DOI: 10.1111/j.1540-8175.2010.01208.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Rand-Hendriksen S, Lundby R, Tjeldhorn L, Andersen K, Offstad J, Semb SO, Smith HJ, Paus B, Geiran O. Prevalence data on all Ghent features in a cross-sectional study of 87 adults with proven Marfan syndrome. Eur J Hum Genet 2009; 17:1222-30. [PMID: 19293838 DOI: 10.1038/ejhg.2009.30] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
The prevalence of each single feature in the Ghent criteria in patients with Marfan syndrome (MFS) is not known. To elucidate this, a cross-sectional study of 105 adults with presumed MFS was carried out. All patients were examined by the same group of investigators with standardized and complete assessment of all features in the Ghent criteria. Eighty-seven (83%) fulfilled the criteria in 56 different variants. The most prevalent major criterion in Ghent-positive persons was dural ectasia (91%), followed by major genetic criterion (89%) and ectopic lenses (62 %). In 14 persons (16%), the diagnosis was dependent on the dural findings. In all, 79% fulfilled both major dural and major genetic (positive family history and/or FBN1 mutation) criteria, suggesting that most patients with MFS might be identified by investigating these criteria. A history or finding of ascending aortic disease was present in 46 patients (53%). This low prevalence might partly reflect a high number of diagnosed patients encompassing the whole spectrum of the syndrome. The study confirms the need to examine for the complete set of features in the Ghent criteria to identify all patients with MFS. The majority of persons with MFS might be identified by the combined assessment of dura mater and family history, supplemented with DNA analysis in family-negative cases. The low prevalence of ascending aortic disease might indicate better future prospects in an adult population than those traditionally considered.
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Affiliation(s)
- Svend Rand-Hendriksen
- TRS National Resource Centre for Rare Disorders, Sunnaas Rehabilitation Hospital, Nesoddtangen, Norway.
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Rybczynski M, Bernhardt AMJ, Rehder U, Fuisting B, Meiss L, Voss U, Habermann C, Detter C, Robinson PN, Arslan-Kirchner M, Schmidtke J, Mir TS, Berger J, Meinertz T, von Kodolitsch Y. The spectrum of syndromes and manifestations in individuals screened for suspected Marfan syndrome. Am J Med Genet A 2009; 146A:3157-66. [PMID: 19012347 DOI: 10.1002/ajmg.a.32595] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The diagnosis of Marfan syndrome (MFS) is based on evaluating a large number of clinical criteria. We have observed that many persons presenting in specialized centers for "Marfan-like" features do not have MFS, but exhibit a large spectrum of other syndromes. The spectrum of these syndromes and the distribution of "Marfan-like" features remain to be characterized. Thus, we prospectively evaluated 279 consecutive patients with suspected MFS (144 men and 135 women at a mean age of 34+/-13 years) for presence of 27 clinical criteria considered characteristic of MFS. The most frequent reasons to refer individuals for suspected MFS were skeletal features (31%), a family history of MFS, or aortic complications (29%), aortic dissection or aneurysm (19%), and eye manifestations (9%). Using established criteria, we confirmed MFS in 138 individuals (group 1) and diagnosed other connective tissue diseases, both with vascular involvement in 30 (group 2) and without vascular involvement in 39 (group 3), and excluded any distinct disease in 72 individuals (group 4). Clinical manifestations of MFS were present in all four patient groups and there was no single clinical criterion that exhibited positive and negative likelihood ratios that were per se sufficient to confirm or rule out MFS. We conclude that "Marfan-like" features are not exclusively indicative of MFS but also of numerous, alternative inherited diseases with many of them carrying a hitherto poorly defined cardiovascular risk. These alternative diseases require future study to characterize their responses to therapy and long-term prognosis.
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Affiliation(s)
- Meike Rybczynski
- Centre of Cardiology and Cardiovascular Surgery, The University Hospital Eppendorf, Hamburg, Germany
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Taub CC, Stoler JM, Perez-Sanz T, Chu J, Isselbacher EM, Picard MH, Weyman AE. Mitral valve prolapse in Marfan syndrome: an old topic revisited. Echocardiography 2008; 26:357-64. [PMID: 19054044 DOI: 10.1111/j.1540-8175.2008.00825.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The echocardiographic features of mitral valve prolapse (MVP) in Marfan syndrome have been well described, and the incidence of MVP in Marfan syndrome is reported to be 40-80%. However, most of the original research was performed in the late 1980s and early 1990s, when the diagnostic criteria for MVP were less specific. Our goal was to investigate the characteristics of MVP associated with Marfan syndrome using currently accepted diagnostic criteria for MVP. METHODS Between January 1990 and March 2004, 90 patients with definitive diagnosis of Marfan syndrome (based on standardized criteria with or without genetic testing) were referred to Massachusetts General Hospital for transthoracic echocardiography. Patients' gender, age, weight, height, and body surface area at initial examination were recorded. Mitral valve thickness and motion, the degree of mitral regurgitation and aortic regurgitation, and aortic dimensions were quantified blinded to patients' clinical information. RESULTS There were 25 patients (28%) with MVP, among whom 80% had symmetrical bileaflet MVP. Patients with MVP had thicker mitral leaflets (5.0 +/- 1.0 mm vs. 1.8 +/- 0.5 mm, P < 0.001), more mitral regurgitation (using a scale of 1-4, 2.2 +/- 1.0 vs. 0.90 +/- 0.60, P < 0.0001), larger LVEDD, and larger dimensions of sinus of Valsalva, sinotubular junction, aortic arch, and descending aorta indexed to square root body surface area, when compared with those without MVP. When echocardiographic features of patients younger than 18 years of age and those of patients older than 18 were compared, adult Marfan patients had larger LA dimension (indexed to square root body surface area), larger sinotubular junction (indexed to square root body surface area), and more mitral regurgitation and aortic regurgitation. CONCLUSIONS The prevalence of MVP in Marfan syndrome is lower than previously reported. The large majority of patients with MVP have bileaflet involvement, and those with MVP have significantly larger aortic root diameters, suggesting a diffuse disease process.
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Affiliation(s)
- Cynthia C Taub
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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Callewaert B, Malfait F, Loeys B, De Paepe A. Ehlers-Danlos syndromes and Marfan syndrome. Best Pract Res Clin Rheumatol 2008; 22:165-89. [PMID: 18328988 DOI: 10.1016/j.berh.2007.12.005] [Citation(s) in RCA: 184] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Ehlers-Danlos syndromes (EDS) and Marfan syndrome (MFS) are multisystemic disorders that primarily affect the soft connective tissues. Both disorders have benefited from recent advances in clinical and molecular characterization, allowing improvements in clinical diagnosis and management. EDS are a heterogeneous group of conditions characterized by skin hyperextensibility, atrophic scarring, joint hypermobility and generalized tissue fragility. The current classification proposes six subtypes based on clinical, biochemical and molecular characteristics. However, examples of unclassified variants and 'overlap phenotypes' are becoming more common. Mutations in genes encoding fibrillar collagens or collagen-modifying enzymes have been identified in most forms of EDS, including the classic and vascular subtypes (collagen type V and III, respectively), and the rare arthrochalasis, kyphoscoliosis and dermatosparaxis variants (type I collagen defects). To date, the genetic background of the hypermobility type of EDS remains unclear, although some new insights have been gained recently. MFS is an autosomal-dominant disorder that affects the cardiovascular, ocular and skeletal system with aortic root dilation/dissection, ectopia lentis and bone overgrowth, respectively. Advances in therapeutic, mainly surgical, techniques have improved median survival significantly, yet severe morbidity and a substantial risk for premature mortality remain associated. The disorder is caused by mutations in the FBN1 gene, encoding the microfibrillar protein fibrillin-1. Recently, new insights in the pathogenesis changed the prevailing concept of this type 1 fibrillinopathy as a structural disorder of the connective tissue into a developmental abnormality manifesting perturbed cytokine signalling. These findings have opened new and unexpected targets for aetiologically directed drug treatments.
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Affiliation(s)
- Bert Callewaert
- Ghent University Hospital, Centre for Medical Genetics, De Pintelaan 185, B-9000 Ghent, Belgium
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Guntheroth WG. A critical review of the American College of Cardiology/American Heart Association practice guidelines on bicuspid aortic valve with dilated ascending aorta. Am J Cardiol 2008; 102:107-10. [PMID: 18572046 DOI: 10.1016/j.amjcard.2008.02.106] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2007] [Revised: 02/20/2008] [Accepted: 02/20/2008] [Indexed: 11/29/2022]
Abstract
The 2006 practice guidelines from the American College of Cardiology and the American Heart Association recommend prophylactic aortic replacement for even an asymptomatic patient with a bicuspid aortic valve (BAV) when the aortic dimensions exceed arbitrary ranges based on Marfan syndrome, without comparing risk estimates of aortic dissection with operative risks. In the International Registry of Acute Aortic Dissection, which includes >1,000 autopsied subjects, the average age is 63 years; BAVs are found in only 3%, compared with histories of hypertension in 72%. The risk for valve-sparing aortic replacement is 4% and that for late mortality is 10%, on the basis of 5 publications. The aortic dimensions are from guidelines for Marfan syndrome, with a proved genetic weakness of connective tissue, whereas no culprit genes have been demonstrated in BAV. Although cystic medial necrosis is seen in dilated aortas associated with Marfan syndrome and BAV, it is also seen in dilated aortas with other causes. There is no convincing proof that cystic medial necrosis causes dissection or is simply an effect of dilatation. BAV is not associated with dilatation of the pulmonary arteries, in contrast to Marfan syndrome. Hemodynamic explanations for dilatation of the ascending aorta have been largely ignored because of a belief that it requires severe aortic stenosis or regurgitation. In conclusion, vascular dilatation without a genetic weakness is caused by coarse periodic vibrations from even trivial valve disorders, demonstrated experimentally. There is a natural history of progressive deterioration of the BAV, including the valve left in a valve-sparing aortic replacement, that makes the operation ill advised, as opposed to valve replacement with aortic reinforcement.
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Abstract
Marfan syndrome (MFS) is the most common inherited disorder of connective tissue that affects multiple organ systems. This autosomal-dominant condition has an incidence of 2-3 per 10,000 individuals. Although genetic testing is available, the diagnosis is still primarily made using the Ghent criteria. Early identification and appropriate management is critical for patients with MFS who are prone to the life-threatening cardiovascular complications of aortic dissection and rupture. Advances in the understanding of the cause of MFS, early recognition of the disorder, and subsequent institution of medical and surgical therapy has resulted in dramatic improvement in the prognosis of this patient population over the past few decades. Beta-blockers have been demonstrated to slow aortic growth and thus delay the time to aortic surgery. Operative intervention has markedly changed the prognosis of patients with MFS and can be safely performed on an elective basis. Identification of presymptomatic patients is critical to reduce the frequency of catastrophic aortic events.
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Affiliation(s)
- Naser M Ammash
- Division of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Johnson PT, Chen JK, Loeys BL, Dietz HC, Fishman EK. Loeys-Dietz syndrome: MDCT angiography findings. AJR Am J Roentgenol 2007; 189:W29-35. [PMID: 17579132 DOI: 10.2214/ajr.06.1316] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Loeys-Dietz syndrome is a newly described phenotype caused by heterozygous mutations in the genes encoding type I or II transforming growth factor-beta (TGF-beta) receptor. Characterized by a unique constellation of clinical and pathologic findings, Loeys-Dietz syndrome manifests with aggressive vascular pathology. Aneurysms may form at a young age and have a propensity for arterial dissection. In addition, aneurysms rupture at diameters smaller than those used to dictate surgical intervention for other syndromes and disorders. This article presents the spectrum of arterial pathology that may be identified on MDCT angiography in patients with Loeys-Dietz syndrome. CONCLUSION For patients with Loeys-Dietz syndrome, early diagnosis and rapid intervention are instrumental in averting catastrophic events. Serial imaging assessment by radiologists is an important component in the management of these patients.
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Affiliation(s)
- Pamela T Johnson
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, 601 N Caroline St., Rm. 3251, Baltimore, MD 21287, USA.
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