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Martín CE, Evangelista A, Teixidó G, Villar S, Serrano-Fiz S, Ospina V, Mingo S, Moñivas V, Martínez D, Villarreal J, Forteza A. Aortic events in pregnant patients with Marfan syndrome. Lessons from a multicenter study. ACTA ACUST UNITED AC 2021; 75:552-558. [PMID: 34481752 DOI: 10.1016/j.rec.2021.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 06/07/2021] [Indexed: 01/15/2023]
Abstract
INTRODUCTION AND OBJECTIVES Pregnancy in women with Marfan syndrome (MS) is associated with an increased risk of aortic events. The clinical evidence on pregnant patients with MS is limited and there is no specific consensus on their optimal management. We report our multicenter experience. METHODS From January 2004 to January 2020, 632 patients with MS underwent periodic monitoring in Marfan units. During this period, we identified all pregnant women with MS and analyzed the incidence of aortic events during pregnancy and puerperium. RESULTS There were 133 pregnancies in 89 women with MS (8 women with prior aortic surgery). There were no maternal deaths, but 5 women had aortic events during the third trimester and puerperium (type A dissections in 2, type B dissection in 1, and significant [≥ 3mm] aortic growth in 2). The aortic event rate was 3.7%. Pregestational aortic diameter≥ 40mm showed a nonsignificant association with aortic events (P=.058). Fetal mortality was 3% and 37.6% of births were cesarean deliveries. CONCLUSIONS Women with MS have an increased risk of aortic events during pregnancy, especially in the third trimester and postpartum period. Patients with MS and aortic diameters ≥40mm should be assessed in experienced centers for prophylactic aortic surgery before pregnancy. It is important to provide early diagnosis, prepregnancy study of the aorta, beta-blocker administration, and close monitoring during pregnancy, especially during the last trimester and postpartum.
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Affiliation(s)
- Carlos E Martín
- Servicio de Cirugía Cardiaca, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain.
| | - Arturo Evangelista
- Servicio de Cardiología, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Gisella Teixidó
- Servicio de Cardiología, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Susana Villar
- Servicio de Cirugía Cardiaca, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Santiago Serrano-Fiz
- Servicio de Cirugía Cardiaca, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Víctor Ospina
- Servicio de Cirugía Cardiaca, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Susana Mingo
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Vanessa Moñivas
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Daniel Martínez
- Servicio de Cirugía Cardiaca, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Juan Villarreal
- Servicio de Cirugía Cardiaca, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Alberto Forteza
- Servicio de Cirugía Cardiaca, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
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Martín CE, Evangelista A, Teixidó G, Villar S, Serrano-Fiz S, Ospina V, Mingo S, Moñivas V, Martínez D, Villarreal J, Forteza A. Eventos aórticos en el embarazo de pacientes con síndrome de Marfan. Lecciones de un estudio multicéntrico. Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2021.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Groth KA, Nielsen BB, Sheyanth IN, Gravholt CH, Andersen NH, Stochholm K. Maternal health and pregnancy outcome in diagnosed and undiagnosed Marfan syndrome: A registry-based study. Am J Med Genet A 2021; 185:1414-1420. [PMID: 33590700 DOI: 10.1002/ajmg.a.62122] [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: 11/13/2020] [Revised: 01/15/2021] [Accepted: 01/30/2021] [Indexed: 11/09/2022]
Abstract
In Marfan syndrome (MFS), pregnancy is considered as high risk due to the deficiency of fibrillin in the connective tissue and increased risk of aortic dissection. The objective was to demonstrate the consequences on maternal health, in women with diagnosed and undiagnosed MFS at the time of pregnancy and childbirth. By using national health care registries, we identified all pregnancy related outcomes, from women with MFS (n = 183) and an age-matched background population (n = 18,300). We found 91 pregnancies during follow-up. Significantly fewer women with MFS gave birth, compared to the background population. No women with known MFS had a pregnancy related aortic dissection but complications related to the cervix were increased (HR:19.8 [95% CI:2.2-177.5]). Fifty women with MFS were undiagnosed at the time of their first pregnancy and/or childbirth. Among these, there were more birth canal related complications HR:27.2 (95% CI: 2.3-315.0), preeclampsia (HR:2.25 [95% CI: 1.11-4.60]), fetal deaths (HR:12.3 [95% CI: 1.51-99.8]), and all delivery-related dissections came from this subgroup. In conclusion, undiagnosed women with MFS experienced more pregnancy and childbirth related complications including fetal death, birth canal issues, preeclampsia, and aortic disease, which emphasizes the need for an early MFS diagnosis and special care during pregnancy and childbirth.
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Affiliation(s)
- Kristian A Groth
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Birgitte B Nielsen
- Department of Obstetrics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Inger N Sheyanth
- Department of Clinical Genetics, Aalborg University Hospital, Aalborg, Denmark
| | - Claus H Gravholt
- Department of Internal Medicine and Endocrinology, Aarhus University Hospital, Aarhus, Denmark.,Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Niels H Andersen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Kirstine Stochholm
- Department of Internal Medicine and Endocrinology, Aarhus University Hospital, Aarhus, Denmark
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Patberg E, Duffy J, Hameed AB. Rupture of a Type B Aortic Dissection in a Postpartum Patient with Marfan Syndrome. AJP Rep 2019; 9:e256-e261. [PMID: 31435486 PMCID: PMC6702027 DOI: 10.1055/s-0039-1692712] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 05/14/2019] [Indexed: 02/06/2023] Open
Abstract
Background Pregnant women with Marfan syndrome (MFS) are known to be at increased risk of aortic dissection; however, cases of aortic rupture are extremely rare. There is lack of consensus on the exact site and size of aortic diameter measurement that increases this risk, and whether this applies to both Type A and Type B dissections. Case A 23-year-old G2P1001 with known Marfan syndrome who underwent an uncomplicated antepartum and intrapartum course. She experienced persistent backache 10 days postpartum that led to the diagnosis of Stanford Type B dissection. The patient was hospitalized for close observation. Dissection progressed to aortic rupture within 24 hours that required emergent thoracic endovascular aortic repair. She had an uncomplicated postoperative course. Conclusion Our report demonstrates rupture of a known aortic dissection within a very short time in the postpartum period. The case highlights the importance of patient education and close surveillance especially in the postpartum period. It also brings home the value of imaging of the whole aorta rather than focusing on the ascending alone. Multidisciplinary care and timely diagnosis and intervention likely led to the favorable outcome in our case.
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Affiliation(s)
- Elizabeth Patberg
- Department of Obstetrics and Gynecology, Irvine Medical Center, University of California, Orange, California
| | - Jennifer Duffy
- Department of Obstetrics and Gynecology, Irvine Medical Center, University of California, Orange, California
| | - Afshan B Hameed
- Department of Obstetrics and Gynecology, Irvine Medical Center, University of California, Orange, California
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Minsart AF, Mongeon FP, Laberge AM, Morin F, Dore A, Leduc L. Obstetric and cardiac outcomes in women with Marfan syndrome and an aortic root diameter ≤ 45mm. Eur J Obstet Gynecol Reprod Biol 2018; 230:68-72. [DOI: 10.1016/j.ejogrb.2018.09.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 08/10/2018] [Accepted: 09/10/2018] [Indexed: 01/16/2023]
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Williams D, Lindley KJ, Russo M, Habashi J, Dietz HC, Braverman AC. Pregnancy after Aortic Root Replacement in Marfan's Syndrome: A Case Series and Review of the Literature. AJP Rep 2018; 8:e234-e240. [PMID: 30473905 PMCID: PMC6193806 DOI: 10.1055/s-0038-1675347] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 08/30/2018] [Indexed: 11/03/2022] Open
Abstract
Objectives We sought to characterize pregnancy-related aortic complications in women with Marfan's syndrome who had prior aortic root replacement. Study Design This is a retrospective case series study and literature review of women with Marfan's syndrome with pregnancy after aortic root replacement. We surveyed women with Marfan's syndrome who had successful pregnancy after aortic root replacement using the Marfan Foundation Website and from two large tertiary care Marfan's clinics. Clinical data, counseling information, and details of pregnancy-related aortic complications were compiled. A literature review was performed assessing aortic outcomes in women with Marfan's syndrome with pregnancy after aortic surgery. Results Fourteen women with 20 pregnancies were identified. Two women had three pregnancies following root replacement for aortic dissection. There were no aortic dissections during the 20 pregnancies. In contrast, aortic dissection was frequently reported in the literature. Conclusions Women with Marfan's syndrome who become pregnant following aortic root replacement remain at risk for distal aortic dissection related to pregnancy. The exact risk is difficult to quantify but is not zero and women should be counseled accordingly.
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Affiliation(s)
- Dominique Williams
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Kathryn J Lindley
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Melissa Russo
- Department of Obstetrics and Gynecology, Warren Alpert Medical School at Brown University, Providence, Rhode Island
| | - Jennifer Habashi
- Johns Hopkins University School of Medicine, Howard Hughes Medical Institute, Baltimore, Maryland
| | - Harry C Dietz
- Johns Hopkins University School of Medicine, Howard Hughes Medical Institute, Baltimore, Maryland
| | - Alan C Braverman
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
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Goland S, Elkayam U. Pregnancy and Marfan syndrome. Ann Cardiothorac Surg 2017; 6:642-653. [PMID: 29270376 PMCID: PMC5721114 DOI: 10.21037/acs.2017.10.07] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 10/16/2017] [Indexed: 01/15/2023]
Abstract
Pregnancy in women with Marfan syndrome (MFS) presents challenges to the clinician and the patient due to the increased incidence of maternal complications and involvement of the fetus, and deserves special consideration. The leading cause of morbidity and mortality in MFS is aortic dissection. This article presents an extensive review of available clinical information and provides recommendations for the management of patients with MFS during pregnancy.
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Affiliation(s)
- Sorel Goland
- Heart Institute, Kaplan Medical Center, Rehovot, affiliated to Hebrew University, Jerusalem, Israel
| | - Uri Elkayam
- Department of Medicine, Division of Cardiovascular Disease, and Department of Obstetrics and Gynaecology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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8
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Nienaber CA, Clough RE. Management of Acute Aortic Syndromes. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Elkayam U, Goland S, Pieper PG, Silversides CK. High-Risk Cardiac Disease in Pregnancy. J Am Coll Cardiol 2016; 68:502-516. [DOI: 10.1016/j.jacc.2016.05.050] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Accepted: 05/03/2016] [Indexed: 02/09/2023]
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Lindley KJ, Conner SN, Cahill AG, Madden T. Contraception and Pregnancy Planning in Women With Congenital Heart Disease. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2015; 17:50. [DOI: 10.1007/s11936-015-0413-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Muiño Mosquera L, De Backer J. Managing aortic aneurysms and dissections during pregnancy. Expert Rev Cardiovasc Ther 2015; 13:703-14. [DOI: 10.1586/14779072.2015.1042862] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Yip J, Sawatzky JA. Cardiovascular Management of Marfan Syndrome: Implications for Nurse Practitioners. J Nurse Pract 2014. [DOI: 10.1016/j.nurpra.2014.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Management of the pregnant woman with Marfan syndrome complicated by ascending aorta dilation. Arch Gynecol Obstet 2014; 290:797-802. [DOI: 10.1007/s00404-014-3307-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 05/28/2014] [Indexed: 10/25/2022]
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van Hagen IM, Roos-Hesselink JW. Aorta pathology and pregnancy. Best Pract Res Clin Obstet Gynaecol 2014; 28:537-50. [DOI: 10.1016/j.bpobgyn.2014.03.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Revised: 03/07/2014] [Accepted: 03/18/2014] [Indexed: 01/15/2023]
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Abstract
Marfan syndrome (MFS), a relatively common autosomal dominant hereditary disorder of connective tissue with prominent manifestations in the skeletal, ocular, and cardiovascular systems, is caused by mutations in the glycoprotein gene fibrillin-1 (FBN1). Aortic root dilation and mitral valve prolapse are the main presentations among the cardiovascular malformations of MFS. The revised Ghent diagnostics nosology of Marfan syndrome is established in accordance with a combination of major and minor clinical manifestations in various organ systems and the family history. The pathogenesis of Marfan syndrome has not been fully elucidated. However, fibrillin-1 gene mutations are believed to exert a dominant negative effect. The treatment includes prophylactic β-blockers and angiotensin II-receptor blockers in order to slow down the dilation of the ascending aorta and prophylactic aortic surgery. Importantly, β-blocker therapy may reduce TGF-β activation, which has been recognized as a contributory factor in MFS. The identification of a mutation allows for early diagnosis, prognosis, genetic counseling, preventive management of carriers and reassurance for unaffected relatives. The importance of knowing in advance the location of the putative family mutation is highlighted by its straightforward application to prenatal and postnatal screening. The present article aims to provide an overview of this rare hereditary disorder. The revised Ghent diagnostics nosology is used for MFS detection. β-Blockers and angiotensin II-receptor blockers are used in the prophylaxis of MFS. MFS mutation identification involve in genetic counseling family members and relatives.
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Affiliation(s)
- Ashok Kumar
- Department of Genetics Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014, India
| | - Sarita Agarwal
- Department of Genetics Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014, India
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Curry RA, Gelson E, Swan L, Dob D, Babu-Narayan SV, Gatzoulis MA, Steer PJ, Johnson MR. Marfan syndrome and pregnancy: maternal and neonatal outcomes. BJOG 2014; 121:610-7. [PMID: 24418012 PMCID: PMC4162995 DOI: 10.1111/1471-0528.12515] [Citation(s) in RCA: 103] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2013] [Indexed: 11/30/2022]
Abstract
Objective To report outcomes in a recent series of pregnancies in women with Marfan syndrome (MFS). Design Retrospective case note review. Setting Tertiary referral unit (Chelsea and Westminster and Royal Brompton Hospitals). Sample Twenty-nine pregnancies in 21 women with MFS between 1995 and 2010. Methods Multidisciplinary review of case records. Main outcome measures Maternal and neonatal mortality and morbidity of patients with MFS and healthy controls. Results There were no maternal deaths. Significant cardiac complications occurred in five pregnancies (17%): one woman experienced a type–A aortic dissection; two women required cardiac surgery within 6 months of delivery; and a further two women developed impaired left ventricular function during the pregnancy. Women with MFS were also more likely to have obstetric complications (OR 3.29, 95% CI 1.30–8.34), the most frequent of which was postpartum haemorrhage (OR 8.46, 95% CI 2.52–28.38). There were no perinatal deaths, although babies born to mothers with MFS were delivered significantly earlier than those born to the control group (median 39 versus 40 weeks of gestation, Mann–Whitney U–test, P = 0.04). These babies were also significantly more likely to be small for gestational age (24% in the MFS group versus 6% in the controls; OR 4.95, 95% CI 1.58–15.55). Conclusions Pregnancy in women with MFS continues to be associated with significant rates of maternal, fetal, and neonatal complications. Effective pre-pregnancy counselling and meticulous surveillance during pregnancy, delivery, and the puerperium by an experienced multidisciplinary team are warranted for women with MFS.
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Affiliation(s)
- R A Curry
- Department of Maternal and Fetal Medicine, Institute for Women's Health, University College London, London, UK; Academic Department of Obstetrics and Gynaecology, Faculty of Medicine, Imperial College London, Chelsea and Westminster NHS Foundation Trust, London, UK
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Surgical treatment and thoracic endovascular aortic repair in type A aortic dissection in a pregnant patient with Marfan syndrome. Ann Vasc Surg 2013; 28:1317.e7-10. [PMID: 24365078 DOI: 10.1016/j.avsg.2013.10.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 10/22/2013] [Accepted: 10/24/2013] [Indexed: 11/21/2022]
Abstract
We report an acute aortic dissection type Stanford A extending down to both iliac arteries affecting a 32-year-old woman suspected to have Marfan syndrome during week 37 of pregnancy. In a multidisciplinary approach, and emergency Cesarean section was performed followed by an abdominal hysterectomy and a valve-sparing aortic root replacement using a reimplantation technique. The aorta was replaced up to the hemi arch. Because of the high suspicion of visceral ischemia as confirmed ex juvantibus, an endovascular stent graft was implanted. Molecular testing revealed a frameshift mutation and confirmed the diagnosis of Marfan syndrome. Both the patient and her healthy child underwent an uneventful recovery.
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Abstract
Marfan syndrome is a systemic, heritable connective tissue disorder that affects many different organ systems and is best managed by using a multidisciplinary approach. The guidance in this report is designed to assist the pediatrician in recognizing the features of Marfan syndrome as well as caring for the individual with this disorder.
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Kumar A, Agarwal S. WITHDRAWN: Marfan syndrome: An eyesight of syndrome. Gene 2013:S0378-1119(13)00998-0. [PMID: 23954223 DOI: 10.1016/j.gene.2013.07.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 06/10/2013] [Accepted: 07/25/2013] [Indexed: 11/28/2022]
Abstract
This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.
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Affiliation(s)
- Ashok Kumar
- Department of Genetics Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014, India.
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Preimplantation genetic diagnosis in marfan syndrome. Case Rep Obstet Gynecol 2013; 2013:542961. [PMID: 23781359 PMCID: PMC3678443 DOI: 10.1155/2013/542961] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 05/14/2013] [Indexed: 12/02/2022] Open
Abstract
Marfan syndrome (MFS) is a systemic hereditable disorder of the connective tissue with mainly cardiovascular manifestations, such as aortic dilatation and dissection. We describe a case of a 32-year-old Caucasian woman, clinically asymptomatic with MFS who presented for genetic consultation to prevent the transmission of disease to her offspring. She underwent controlled ovarian stimulation (COH), in vitro fertilization (IVF) combined with preimplantation genetic diagnosis (PGD), and a singleton pregnancy with positive fetal heart rate was revealed. At 34 weeks' gestation she delivered vaginally a healthy premature male infant weighting 2440 gr. The patient remained asymptomatic during pregnancy, delivery, and 3 months postpartum. It is has to be mentioned that the availability of PGD is essential to prevent the transmission of disease to the next generation.
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Acute aortic dissection in pregnancy in a woman with undiagnosed marfan syndrome. Case Rep Obstet Gynecol 2012; 2012:490169. [PMID: 23304584 PMCID: PMC3532913 DOI: 10.1155/2012/490169] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Accepted: 11/26/2012] [Indexed: 12/02/2022] Open
Abstract
We report a case of acute aortic dissection in a lady of 28 weeks of gestation with undiagnosed Marfan syndrome. The patient had been seen in our antenatal clinics. Her history documented in her pregnancy record was negative for genetic/congenital abnormalities. There was no family history documented. Subsequently, at 28 weeks of gestation, the patient presented with sudden onset chest, jaw, and back pain. Further history revealed that her father had died at the age of 27 of an aortic dissection. Echocardiography showed aortic root dissection with occlusion of aortic branches. She subsequently underwent an emergency lower segment caesarean section followed by surgical repair of type A dissection. A simultaneous type B dissection was managed conservatively. On later examination, our patient fulfilled the diagnostic criteria for phenotypic expression of Marfan syndrome. Genetic testing also confirmed that she has a mutation of the fibrillin (FBN 1) gene associated with the disease.
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Hatton R, Colman JM, Sermer M, Grewal J, Silversides CK. Cardiac risks and management of complications in pregnant women with congenital heart disease. Future Cardiol 2012; 8:315-27. [PMID: 22413989 DOI: 10.2217/fca.12.18] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
There are a growing number of women with congenital heart disease reaching adulthood and contemplating and/or undergoing pregnancy. However, pregnancy imposes hemodynamic stress on the heart and this can result in maternal, fetal and neonatal complications. Most women with congenital heart disease do well during pregnancy, but some women with high-risk cardiac lesions will not tolerate the hemodynamic changes of pregnancy. Physicians must be aware of the potential risks for the mother both during and after pregnancy, the risks to the fetus and neonate, and the risks and benefits of medications and procedures used during pregnancy. For women with complex cardiac conditions, management during pregnancy benefits from multidisciplinary care involving cardiologists with expertise in pregnancy, obstetricians with expertise in maternal fetal medicine, neonatologists and obstetric anesthetists, among others. This review will focus on the cardiac risks faced by women with congenital heart disease; particularly those at high risk, and on management strategies to mitigate risk and address cardiac complications.
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Affiliation(s)
- Rachael Hatton
- Mount Sinai Hospital, OPG Building, 700 University Ave, Room 3147, Toronto, ON, M5G 1Z5, Canada
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Abstract
Advances in the surgical palliation and correction of congenital heart lesions have improved survival and increased the number of patients living into adulthood. Although pregnancy outcomes will be favorable for most patients with congenital heart disease, the cardiovascular challenges associated with pregnancy and delivery are best managed with a multidisciplinary approach during the puerperium. This review addresses the prevalence, physiology, risk assessment, peripartum complications, and anesthetic management of the pregnant patient with underlying congenital heart disease.
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Affiliation(s)
- Amy J Ortman
- University of Kansas Medical Center, Kansas City, KS 66160-7415, USA.
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Type A aortic dissection during late pregnancy in a patient with Marfan syndrome. Can J Anaesth 2011; 58:1024-8. [DOI: 10.1007/s12630-011-9569-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2011] [Accepted: 07/27/2011] [Indexed: 10/17/2022] Open
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Cook JR, Nistala H, Ramirez F. Drug-based therapies for vascular disease in Marfan syndrome: from mouse models to human patients. ACTA ACUST UNITED AC 2011; 77:366-73. [PMID: 20687182 DOI: 10.1002/msj.20200] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Marfan syndrome is a congenital disorder of the connective tissue with a long history of clinical and basic science breakthroughs that have forged our understanding of vascular-disease pathogenesis. The biomedical importance of Marfan syndrome was recently underscored by the discovery that the underlying genetic lesion impairs both tissue integrity and transforming growth factor-beta regulation of cell behavior. This discovery has led to the successful implementation of the first pharmacological intervention in a connective-tissue disorder otherwise incurable by either gene-based or stem cell-based therapeutic strategies. More generally, information gathered from the study of Marfan syndrome pathogenesis has the potential to improve the clinical management of common acquired disorders of connective-tissue degeneration.
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Affiliation(s)
- Jason R Cook
- Mount Sinai School of Medicine, New York, NY, USA
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Affiliation(s)
- Satoru Wakasa
- Department of Cardiovascular and Thoracic Surgery, Graduate School of Medicine, Hokkaido University
| | - Yoshiro Matsui
- Department of Cardiovascular and Thoracic Surgery, Graduate School of Medicine, Hokkaido University
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Abstract
Marfan's syndrome is an autosomal dominant condition with an estimated prevalence of one in 10,000 to 20,000 individuals. This rare hereditary connective tissue disorder affects many parts of the body. The diagnosis of Marfan's syndrome is established in accordance with a review of the diagnostic criteria, known as the Ghent nosology, through a comprehensive assessment largely based on a combination of major and minor clinical manifestations in various organ systems and the family history. Aortic root dilation and mitral valve prolapse are the main presentations among the cardiovascular malformations of Marfan's syndrome. The pathogenesis of Marfan's syndrome has not been fully elucidated. However, fibrillin-1 gene mutations are believed to exert a dominant negative effect. Therefore, Marfan's syndrome is termed a fibrillinopathy, along with other connective tissue disorders with subtle differences in clinical manifestations. The treatment may include prophylactic β-blockers and angiotensin II-receptor blockers in order to slow down the dilation of the ascending aorta, and prophylactic aortic surgery. Importantly, β-blocker therapy may reduce TGF-β activation, which has been recognized as a contributory factor in Marfan's syndrome. The present article aims to provide an overview of this rare hereditary disorder.
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Affiliation(s)
- Shi-Min Yuan
- Postdoctoral Researcher, Department of Cardiothoracic Surgery, Jinling Hospital, School of Clinical Medicine, Nanjing University, Nanjing 210002, Jiangsu Province, People's Republic of China.
| | - Hua Jing
- Professor and Head, Department of Cardiothoracic Surgery, Jinling Hospital, School of Clinical Medicine, Nanjing University, Nanjing 210002, Jiangsu Province, People's Republic of China.
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Vitarelli A, Capotosto L. Role of echocardiography in the assessment and management of adult congenital heart disease in pregnancy. Int J Cardiovasc Imaging 2010; 27:843-57. [PMID: 21082254 DOI: 10.1007/s10554-010-9750-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Accepted: 11/08/2010] [Indexed: 01/10/2023]
Abstract
Congenital heart disease represent a large proportion of heart disease in pregnancy. With the exception of patients with Eisenmenger's syndrome, pulmonary vascular obstructive disease, and Marfan's syndrome with aortopathy, maternal death during pregnancy is rare in women with CHD but morbidity occurs such as heart failure, arrhythmias, and stroke. Echocardiography represents a milestone in diagnosis, understanding of pathophysiology, assessment of disease severity and patient monitoring in pregnant women with unoperated and post-operative congenital heart disease.
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Affiliation(s)
- Antonio Vitarelli
- Echocardiology Unit, Cardiac Department, Sapienza University, Via Lima 35, 00198, Rome, Italy.
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