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Jin Y, Li T, Wu S, Liu Z, Li Y. MFAP5 variant-induced multiple giant thoracic aortic aneurysm. Cardiol Young 2024; 34:212-217. [PMID: 38031457 DOI: 10.1017/s1047951123004122] [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] [Indexed: 12/01/2023]
Abstract
Heritable thoracic aortic aneurysms are complex conditions characterised by the dilation or rupture of the thoracic aorta, often occurring as an autosomal-dominant disorder associated with life-threatening complications. In this case report, we present a de novo variant, MFAP5 c.236_237insA (p.N79Kfs9), which is implicated in the development of inherited thoracic aortic aneurysm. The proband, a 15-year-old male, presented with recurrent cough, dull chest pain, chest distress, vomiting, and reduced activity tolerance, leading to the diagnosis of heritable thoracic aortic aneurysms. Whole-exome sequencing identified a novel heterozygous variant in MFAP5 (NM_003480, c.236_237insA, and p.N79Kfs9). MutationTester and PolyPhen-s predicted this variant to be damaging and disease-causing (probability = 1), while the SFIT score indicated protein damage (0.001). Structural analysis using the AlphaFold Protein structure database revealed that this mutation disrupted the N-linked glycosylation site, resulting in a frameshift, amino acid sequence alteration, and truncation of an essential protein site. To our knowledge, this is the first case report describing a young patient with heritable thoracic aortic aneurysm carrying the novel MFAP5 c.236_237insA (p.N79Kfs*9) variant. This variant represents the third identified mutation site associated with heritable thoracic aortic aneurysm. Given the high mortality and morbidity rates associated with thoracic aortic aneurysms, the prevention of severe and fatal complications is crucial in the clinical management of this condition. Our case highlights the importance of whole-exome sequencing and genetic screening in identifying potential pathogenic or likely pathogenic variants, particularly in early-onset patients with aortic dilation, to inform appropriate management strategies.
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Affiliation(s)
- Yuxi Jin
- Department of Pediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, West China Second University Hospital, Sichuan University, Chengdu, SC, China
| | - Tiange Li
- Department of Pediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, West China Second University Hospital, Sichuan University, Chengdu, SC, China
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, SC, China
| | - Shaoying Wu
- Department of Pediatrics, The Second People's Hospital of Liangshan Yi Autonomous Prefecture, Xichang, SC, China
| | - Zhongqiang Liu
- Department of Pediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, West China Second University Hospital, Sichuan University, Chengdu, SC, China
| | - Yifei Li
- Department of Pediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, West China Second University Hospital, Sichuan University, Chengdu, SC, China
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2
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di Gioia CRT, Ascione A, Carletti R, Giordano C. Thoracic Aorta: Anatomy and Pathology. Diagnostics (Basel) 2023; 13:2166. [PMID: 37443560 DOI: 10.3390/diagnostics13132166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 06/09/2023] [Accepted: 06/21/2023] [Indexed: 07/15/2023] Open
Abstract
The aorta is the largest elastic artery in the human body and is classically divided into two anatomical segments, the thoracic and the abdominal aorta, separated by the diaphragm. The thoracic aorta includes the aortic root, the ascending aorta, the arch, and the descending aorta. The aorta's elastic properties depend on its wall structure, composed of three distinct histologic layers: intima, media, and adventitia. The different aortic segments show different embryological and anatomical features, which account for their different physiological properties and impact the occurrence and natural history of congenital and acquired diseases that develop herein. Diseases of the thoracic aorta may present either as a chronic, often asymptomatic disorder or as acute life-threatening conditions, i.e., acute aortic syndromes, and are usually associated with states that increase wall stress and alter the structure of the aortic wall. This review aims to provide an update on the disease of the thoracic aorta, focusing on the morphological substrates and clinicopathological correlations. Information on anatomy and embryology will also be provided.
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Affiliation(s)
- Cira Rosaria Tiziana di Gioia
- Department of Radiology, Oncology and Pathology, Sapienza, University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Andrea Ascione
- Department of Radiology, Oncology and Pathology, Sapienza, University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Raffaella Carletti
- Department of Radiology, Oncology and Pathology, Sapienza, University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Carla Giordano
- Department of Radiology, Oncology and Pathology, Sapienza, University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
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3
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Nekoui M, Pirruccello JP, Di Achille P, Choi SH, Friedman SN, Nauffal V, Ng K, Batra P, Ho JE, Philippakis AA, Lubitz SA, Lindsay ME, Ellinor PT. Spatially Distinct Genetic Determinants of Aortic Dimensions Influence Risks of Aneurysm and Stenosis. J Am Coll Cardiol 2022; 80:486-497. [PMID: 35902171 DOI: 10.1016/j.jacc.2022.05.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 04/29/2022] [Accepted: 05/09/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND The left ventricular outflow tract (LVOT) and ascending aorta are spatially complex, with distinct pathologies and embryologic origins. Prior work examined the genetics of thoracic aortic diameter in a single plane. OBJECTIVES We sought to elucidate the genetic basis for the diameter of the LVOT, aortic root, and ascending aorta. METHODS Using deep learning, we analyzed 2.3 million cardiac magnetic resonance images from 43,317 UK Biobank participants. We computed the diameters of the LVOT, the aortic root, and at 6 locations of ascending aorta. For each diameter, we conducted a genome-wide association study and generated a polygenic score. Finally, we investigated associations between these scores and disease incidence. RESULTS A total of 79 loci were significantly associated with at least 1 diameter. Of these, 35 were novel, and most were associated with 1 or 2 diameters. A polygenic score of aortic diameter approximately 13 mm from the sinotubular junction most strongly predicted thoracic aortic aneurysm (n = 427,016; mean HR: 1.42 per SD; 95% CI: 1.34-1.50; P = 6.67 × 10-21). A polygenic score predicting a smaller aortic root was predictive of aortic stenosis (n = 426,502; mean HR: 1.08 per SD; 95% CI: 1.03-1.12; P = 5 × 10-6). CONCLUSIONS We detected distinct genetic loci underpinning the diameters of the LVOT, aortic root, and at several segments of ascending aorta. We spatially defined a region of aorta whose genetics may be most relevant to predicting thoracic aortic aneurysm. We further described a genetic signature that may predispose to aortic stenosis. Understanding genetic contributions to proximal aortic diameter may enable identification of individuals at risk for aortic disease and facilitate prioritization of therapeutic targets.
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Affiliation(s)
- Mahan Nekoui
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA; Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA; Cardiovascular Disease Initiative, Broad Institute, Cambridge, Massachusetts, USA. https://twitter.com/MahanNekoui
| | - James P Pirruccello
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA; Cardiovascular Disease Initiative, Broad Institute, Cambridge, Massachusetts, USA; Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA. https://twitter.com/jpirruccello
| | - Paolo Di Achille
- Data Sciences Platform, Broad Institute, Cambridge, Massachusetts, USA
| | - Seung Hoan Choi
- Cardiovascular Disease Initiative, Broad Institute, Cambridge, Massachusetts, USA
| | - Samuel N Friedman
- Data Sciences Platform, Broad Institute, Cambridge, Massachusetts, USA
| | - Victor Nauffal
- Cardiovascular Disease Initiative, Broad Institute, Cambridge, Massachusetts, USA; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kenney Ng
- IBM Research, Cambridge, Massachusetts, USA
| | - Puneet Batra
- Data Sciences Platform, Broad Institute, Cambridge, Massachusetts, USA
| | - Jennifer E Ho
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Anthony A Philippakis
- Data Sciences Platform, Broad Institute, Cambridge, Massachusetts, USA; GV, Mountain View, California, USA
| | - Steven A Lubitz
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA; Cardiovascular Disease Initiative, Broad Institute, Cambridge, Massachusetts, USA; Demoulas Center for Cardiac Arrhythmias, Boston, Massachusetts, USA
| | - Mark E Lindsay
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA; Cardiovascular Disease Initiative, Broad Institute, Cambridge, Massachusetts, USA; Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA; Thoracic Aortic Center, Massachusetts General Hospital, Boston, Massachusetts, USA. https://twitter.com/MarkELindsay
| | - Patrick T Ellinor
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA; Cardiovascular Disease Initiative, Broad Institute, Cambridge, Massachusetts, USA; Demoulas Center for Cardiac Arrhythmias, Boston, Massachusetts, USA.
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4
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Pirruccello JP, Chaffin MD, Chou EL, Fleming SJ, Lin H, Nekoui M, Khurshid S, Friedman SF, Bick AG, Arduini A, Weng LC, Choi SH, Akkad AD, Batra P, Tucker NR, Hall AW, Roselli C, Benjamin EJ, Vellarikkal SK, Gupta RM, Stegmann CM, Juric D, Stone JR, Vasan RS, Ho JE, Hoffmann U, Lubitz SA, Philippakis AA, Lindsay ME, Ellinor PT. Deep learning enables genetic analysis of the human thoracic aorta. Nat Genet 2022; 54:40-51. [PMID: 34837083 PMCID: PMC8758523 DOI: 10.1038/s41588-021-00962-4] [Citation(s) in RCA: 79] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 09/30/2021] [Indexed: 11/16/2022]
Abstract
Enlargement or aneurysm of the aorta predisposes to dissection, an important cause of sudden death. We trained a deep learning model to evaluate the dimensions of the ascending and descending thoracic aorta in 4.6 million cardiac magnetic resonance images from the UK Biobank. We then conducted genome-wide association studies in 39,688 individuals, identifying 82 loci associated with ascending and 47 with descending thoracic aortic diameter, of which 14 loci overlapped. Transcriptome-wide analyses, rare-variant burden tests and human aortic single nucleus RNA sequencing prioritized genes including SVIL, which was strongly associated with descending aortic diameter. A polygenic score for ascending aortic diameter was associated with thoracic aortic aneurysm in 385,621 UK Biobank participants (hazard ratio = 1.43 per s.d., confidence interval 1.32-1.54, P = 3.3 × 10-20). Our results illustrate the potential for rapidly defining quantitative traits with deep learning, an approach that can be broadly applied to biomedical images.
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Affiliation(s)
- James P Pirruccello
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Disease Initiative, Broad Institute, Cambridge, MA, USA
- Precision Cardiology Laboratory, The Broad Institute & Bayer US LLC, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Mark D Chaffin
- Cardiovascular Disease Initiative, Broad Institute, Cambridge, MA, USA
- Precision Cardiology Laboratory, The Broad Institute & Bayer US LLC, Cambridge, MA, USA
| | - Elizabeth L Chou
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Stephen J Fleming
- Precision Cardiology Laboratory, The Broad Institute & Bayer US LLC, Cambridge, MA, USA
- Data Sciences Platform, Broad Institute, Cambridge, MA, USA
| | - Honghuang Lin
- Framingham Heart Study, Boston University and National Heart, Lung, and Blood Institute, Framingham, MA, USA
- Department of Medicine, Section of Computational Biomedicine, Boston University School of Medicine, Boston, MA, USA
| | - Mahan Nekoui
- Cardiovascular Disease Initiative, Broad Institute, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Shaan Khurshid
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Disease Initiative, Broad Institute, Cambridge, MA, USA
| | | | - Alexander G Bick
- Cardiovascular Disease Initiative, Broad Institute, Cambridge, MA, USA
- Department of Medicine, Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Alessandro Arduini
- Cardiovascular Disease Initiative, Broad Institute, Cambridge, MA, USA
- Precision Cardiology Laboratory, The Broad Institute & Bayer US LLC, Cambridge, MA, USA
| | - Lu-Chen Weng
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Disease Initiative, Broad Institute, Cambridge, MA, USA
| | - Seung Hoan Choi
- Cardiovascular Disease Initiative, Broad Institute, Cambridge, MA, USA
| | - Amer-Denis Akkad
- Precision Cardiology Laboratory, The Broad Institute & Bayer US LLC, Cambridge, MA, USA
| | - Puneet Batra
- Data Sciences Platform, Broad Institute, Cambridge, MA, USA
| | | | - Amelia W Hall
- Cardiovascular Disease Initiative, Broad Institute, Cambridge, MA, USA
| | - Carolina Roselli
- Cardiovascular Disease Initiative, Broad Institute, Cambridge, MA, USA
- University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Emelia J Benjamin
- Framingham Heart Study, Boston University and National Heart, Lung, and Blood Institute, Framingham, MA, USA
- Department of Medicine, Cardiology and Preventive Medicine Sections, Boston University School of Medicine, Boston, MA, USA
- Epidemiology Department, Boston University School of Public Health, Boston, MA, USA
| | | | - Rajat M Gupta
- Department of Medicine, Divisions of Cardiovascular Medicine and Genetics, Brigham and Women's Hospital, Boston, MA, USA
| | - Christian M Stegmann
- Precision Cardiology Laboratory, The Broad Institute & Bayer US LLC, Cambridge, MA, USA
| | - Dejan Juric
- Harvard Medical School, Boston, MA, USA
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA
| | - James R Stone
- Harvard Medical School, Boston, MA, USA
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Ramachandran S Vasan
- Framingham Heart Study, Boston University and National Heart, Lung, and Blood Institute, Framingham, MA, USA
- Department of Medicine, Cardiology and Preventive Medicine Sections, Boston University School of Medicine, Boston, MA, USA
- Epidemiology Department, Boston University School of Public Health, Boston, MA, USA
| | - Jennifer E Ho
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Udo Hoffmann
- Department of Radiology, Harvard Medical School, Boston, MA, USA
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Steven A Lubitz
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Disease Initiative, Broad Institute, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Anthony A Philippakis
- Data Sciences Platform, Broad Institute, Cambridge, MA, USA
- GV, Mountain View, CA, USA
| | - Mark E Lindsay
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Disease Initiative, Broad Institute, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
- Thoracic Aortic Center, Massachusetts General Hospital, Boston, MA, USA
| | - Patrick T Ellinor
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA.
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA.
- Cardiovascular Disease Initiative, Broad Institute, Cambridge, MA, USA.
- Precision Cardiology Laboratory, The Broad Institute & Bayer US LLC, Cambridge, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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5
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Virmani R, Sato Y, Sakamoto A, Romero ME, Butany J. Aneurysms of the aorta: ascending, thoracic, and abdominal and their management. Cardiovasc Pathol 2022. [DOI: 10.1016/b978-0-12-822224-9.00009-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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6
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Suslov AV, Afanasyev MA, Degtyarev PA, Chumachenko PV, Ekta MB, Sukhorukov VN, Khotina VA, Yet SF, Sobenin IA, Postnov AY. Molecular Pathogenesis and the Possible Role of Mitochondrial Heteroplasmy in Thoracic Aortic Aneurysm. Life (Basel) 2021; 11:1395. [PMID: 34947926 PMCID: PMC8709403 DOI: 10.3390/life11121395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 11/26/2021] [Accepted: 12/07/2021] [Indexed: 12/06/2022] Open
Abstract
Thoracic aortic aneurysm (TAA) is a life-threatening condition associated with high mortality, in which the aortic wall is deformed due to congenital or age-associated pathological changes. The mechanisms of TAA development remain to be studied in detail, and are the subject of active research. In this review, we describe the morphological changes of the aortic wall in TAA. We outline the genetic disorders associated with aortic enlargement and discuss the potential role of mitochondrial pathology, in particular mitochondrial DNA heteroplasmy, in the disease pathogenesis.
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Affiliation(s)
- A. V. Suslov
- National Medical Research Center of Cardiology, Moscow 121552, Russia; (A.V.S.); (M.A.A.); (P.V.C.); (I.A.S.); (A.Y.P.)
- Department of Human Anatomy, First Moscow State Medical University (Sechenov University), Moscow 119435, Russia;
| | - M. A. Afanasyev
- National Medical Research Center of Cardiology, Moscow 121552, Russia; (A.V.S.); (M.A.A.); (P.V.C.); (I.A.S.); (A.Y.P.)
| | - P. A. Degtyarev
- Department of Human Anatomy, First Moscow State Medical University (Sechenov University), Moscow 119435, Russia;
| | - P. V. Chumachenko
- National Medical Research Center of Cardiology, Moscow 121552, Russia; (A.V.S.); (M.A.A.); (P.V.C.); (I.A.S.); (A.Y.P.)
| | - M. Bagheri Ekta
- Research Institute of Human Morphology, Moscow 117418, Russia; (M.B.E.); (V.A.K.)
| | - V. N. Sukhorukov
- National Medical Research Center of Cardiology, Moscow 121552, Russia; (A.V.S.); (M.A.A.); (P.V.C.); (I.A.S.); (A.Y.P.)
- Research Institute of Human Morphology, Moscow 117418, Russia; (M.B.E.); (V.A.K.)
| | - V. A. Khotina
- Research Institute of Human Morphology, Moscow 117418, Russia; (M.B.E.); (V.A.K.)
- Institute of General Pathology and Pathophysiology, Moscow 125315, Russia
| | - S.-F. Yet
- Institute of Cellular and System Medicine, National Health Research Institutes, 35 Keyan Road, Zhunan Town 35053, Taiwan;
| | - I. A. Sobenin
- National Medical Research Center of Cardiology, Moscow 121552, Russia; (A.V.S.); (M.A.A.); (P.V.C.); (I.A.S.); (A.Y.P.)
| | - A. Yu Postnov
- National Medical Research Center of Cardiology, Moscow 121552, Russia; (A.V.S.); (M.A.A.); (P.V.C.); (I.A.S.); (A.Y.P.)
- Research Institute of Human Morphology, Moscow 117418, Russia; (M.B.E.); (V.A.K.)
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7
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Pathology of the Aorta and Aorta as Homograft. J Cardiovasc Dev Dis 2021; 8:jcdd8070076. [PMID: 34209632 PMCID: PMC8304113 DOI: 10.3390/jcdd8070076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/16/2021] [Accepted: 06/21/2021] [Indexed: 11/19/2022] Open
Abstract
The aorta is not a rigid tube, it is an “organ” with lamellar units, consisting of elastic fibers, extracellular matrix and smooth muscle cells in between as parenchyma. Several diseases may occur in the natural history of the aorta, requiring replacement of both semilunar cusps and ascending aorta. They may be congenital defects, such as bicuspid aortic valve and isthmal coarctation with aortopathy; genetically determined, such as Marfan and William syndromes; degenerative diseases, such as atherosclerosis and medial necrosis with aortic dilatation, valve incompetence and dissecting aneurysm; inflammatory diseases such as Takayasu arteritis, syphilis, giant cell and IgM4 aortitis; neoplasms; and trauma. Aortic homografts from cadavers, including both the sinus portion with semilunar cusps and the tubular portion, are surgically employed to replace a native sick ascending aorta. However, the antigenicity of allograft cells, in the lamellar units and interstitial cells in the cusps, is maintained. Thus, an immune reaction may occur, limiting durability. After proper decellularization and 6 months’ implantation in sheep, endogenous cell repopulation was shown to occur in both the valve and aortic wall, including the endothelium, without evidence of inflammation and structural deterioration/calcification in the mid-term. The allograft was transformed into an autograft.
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8
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Key P, Qiryaqoz Z, Prahlow J, Fisher-Hubbard A. Tuberous Sclerosis Complex Diagnosed After Fatal Aortic Dissection. Am J Forensic Med Pathol 2021; 42:e1-e4. [PMID: 33074837 DOI: 10.1097/paf.0000000000000625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Phillip Key
- From the Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI
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9
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Keravnou A, Bashiardes E, Barberis V, Michailidou K, Soteriou M, Tanteles GA, Cariolou MA. Identification of novel splice mutation in SMAD3 in two Cypriot families with nonsyndromic thoracic aortic aneurysm. Two case reports. Mol Genet Genomic Med 2020; 8:e1378. [PMID: 32597575 PMCID: PMC7507478 DOI: 10.1002/mgg3.1378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 05/21/2020] [Accepted: 06/01/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Thoracic aortic aneurysm and dissection (TAA/D) represents a potentially lethal disease group characterized by an increased risk of dissection or rupture. Only a small percentage (approximately 30%) of individuals with nonsyndromic familial TAA/D have a pathogenic variant in one of the genes that have been found to be associated with the disease. METHODS A targeted sequencing panel and direct sequencing approach were used to identify causative mutations in the index patients and other family members. RESULTS In this study we report two apparently unrelated Cypriot families with nonsyndromic familial TAA/D. The proband A is a female patient diagnosed with TAA/D and intracranial aneurysm and opted for an elective intervention. The proband B is a male patient who was diagnosed with TAA/D and underwent cardiac surgery. Sequencing analysis identified a novel splice site variant (c.871+1G>A) in SMAD3 which is shown to be associated with the disease. Analysis of mRNA from the patient's tissue confirmed aberrant splicing and exon 6 skipping. CONCLUSION Our findings expand the mutation spectrum of variants that have been shown to be associated with nonsyndromic familial TAA/D. This study demonstrates the importance of a comprehensive clinical and genetic evaluation aiming at early diagnosis and intervention.
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Affiliation(s)
- Anna Keravnou
- Department of Cardiovascular Genetics and The Laboratory of Forensic Genetics, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus.,Cyprus School of Molecular Medicine, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Evy Bashiardes
- Department of Cardiovascular Genetics and The Laboratory of Forensic Genetics, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus.,Cyprus School of Molecular Medicine, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Vassilis Barberis
- Department of Cardiology and Cardiovascular Surgery, American Medical Center, Nicosia, Cyprus
| | - Kyriaki Michailidou
- Cyprus School of Molecular Medicine, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus.,Biostatistics Unit, The Cyprus Institute of Neurology & Genetics, Nicosia, Cyprus
| | - Marinos Soteriou
- Department of Cardiology and Cardiovascular Surgery, American Medical Center, Nicosia, Cyprus
| | - George A Tanteles
- Clinical Genetics Clinic, The Cyprus Institute of Neurology & Genetics, Nicosia, Cyprus
| | - Marios A Cariolou
- Department of Cardiovascular Genetics and The Laboratory of Forensic Genetics, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus.,Cyprus School of Molecular Medicine, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
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10
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Keravnou A, Bashiardes E, Michailidou K, Soteriou M, Moushi A, Cariolou M. Novel variants in the ACTA2 and MYH11 genes in a Cypriot family with thoracic aortic aneurysms: a case report. BMC MEDICAL GENETICS 2018; 19:208. [PMID: 30526509 PMCID: PMC6286578 DOI: 10.1186/s12881-018-0728-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 11/27/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Thoracic aortic aneurysm (TAA) and/or thoracic aortic aneurysm and dissection (TAAD) is characterized by a considerable risk of morbidity and mortality of affected individuals. It is inherited in an autosomal dominant pattern and the 20% of patients with non-syndromic TAA have a positive family history. To date, the genetic basis of Cypriot patients with TAA has not been investigated. The purpose of this case report is to determine underlying genetic cause in this Cypriot family with TAA. CASE PRESENTATION In this report we present a patient with hyper-acute onset chest and back pain diagnosed with Type A Aortic Dissection with severe aortic valve regurgitation, who underwent emergency aortic surgery and Bentall procedure. Further investigation of the patient's family was undertaken where both parents and an additional child were also found to be affected. A targeted sequencing panel including genes with known association to TAA was used to identify causative mutations in the index patient. Massively Parallel Sequencing results identified a frameshift deletion c.363_367del GAGTC, p.Met121Ilefs*5 in the ACTA2 gene and a non-synonymous variant c.3234C > G, p.Ile1078Met in the MYH11 gene. The presence or absence of these variants in the index patient and other family members was verified by Sanger sequencing. To our knowledge, this is the first report of a Cypriot family case diagnosed with TAA presented by two novel variants one in the ACTA2 and the other in the MYH11 genes. CONCLUSIONS We describe two novel variants in a Cypriot family with TAA that are potentially pathogenic, highlighting the importance of molecular genetic evaluation in families with TAA. These results may prove useful for screening purposes in Cypriot patients with non-syndromic familial TAA facilitating early identification of atrisk family members and direct intervention.
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Affiliation(s)
- Anna Keravnou
- Department of Cardiovascular Genetics and The Laboratory of Forensic Genetics, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus. .,Cyprus School of Molecular Medicine, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus.
| | - Evy Bashiardes
- Department of Cardiovascular Genetics and The Laboratory of Forensic Genetics, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus.,Cyprus School of Molecular Medicine, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Kyriaki Michailidou
- Cyprus School of Molecular Medicine, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus.,Department of Electron Microscopy/Molecular Pathology, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | | | - Areti Moushi
- Cyprus School of Molecular Medicine, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Marios Cariolou
- Department of Cardiovascular Genetics and The Laboratory of Forensic Genetics, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus. .,Cyprus School of Molecular Medicine, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus.
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11
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Interleukin-3 is required for thoracic aneurysm and dissection in a mouse model. Clin Sci (Lond) 2018; 132:1253-1256. [DOI: 10.1042/cs20180185] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 05/16/2018] [Accepted: 05/18/2018] [Indexed: 11/17/2022]
Abstract
The pathogenesis of thoracic aortic aneurysm and dissection (TAAD) is complex and incompletely understood. The hallmarks of the disease process are aortic inflammatory cell infiltration and protease mediated elastic fiber disruption. In a study recently published in Clinical Science (2018) 132 (6), 655–668), Liu et al. explore the mechanism through which aortic vascular smooth cells and macrophages participate in TAAD using a mouse model. The authors propose that interleukin-3 (IL-3) released from aortic vascular smooth cells is central to the disease process. IL-3 stimulated matrix metalloproteinase 12 (MMP12) release from macrophages via mitogen activated protein kinase pathways. MMP12 is a protease known to be involved in both aortic aneurysm and dissection. IL-3 knockout mice had significantly reduced aortic wall MMP12, and reduced protease activity. This was associated with protection against TAAD.
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12
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Ouzounian M, LeMaire SA. How can genetic diagnosis inform the decision of when to operate? J Vis Surg 2018; 4:68. [PMID: 29780714 DOI: 10.21037/jovs.2018.03.08] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 03/07/2018] [Indexed: 12/16/2022]
Abstract
Genetic discovery for heritable thoracic aortic disease (HTAD) has been progressing at a brisk pace. Surgical management of thoracic aortic aneurysms and dissections has become more personalized, with genetic factors increasingly informing the decision of when to operate on patients. An improved understanding of genotype-phenotype correlations in patients with HTAD will ultimately lead to gene- and mutation-specific recommendations for surgical repair. Until more robust data from larger cohorts can inform our decisions, patients with HTAD should be seen by an aortic specialist for a tailored approach to elective surgical repair.
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Affiliation(s)
- Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, and the Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas, USA.,Cardiovascular Surgery Service, The Texas Heart Institute, Houston, Texas, USA
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13
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Abstract
Thoracic aortic aneurysm (TAA) has been associated with mutations affecting members of the TGF-β signaling pathway, or components and regulators of the vascular smooth muscle cell (VSMC) actomyosin cytoskeleton. Although both clinical groups present similar phenotypes, the existence of potential common mechanisms of pathogenesis remain obscure. Here we show that mutations affecting TGF-β signaling and VSMC cytoskeleton both lead to the formation of a ternary complex comprising the histone deacetylase HDAC9, the chromatin-remodeling enzyme BRG1, and the long noncoding RNA MALAT1. The HDAC9–MALAT1–BRG1 complex binds chromatin and represses contractile protein gene expression in association with gain of histone H3-lysine 27 trimethylation modifications. Disruption of Malat1 or Hdac9 restores contractile protein expression, improves aortic mural architecture, and inhibits experimental aneurysm growth. Thus, we highlight a shared epigenetic pathway responsible for VSMC dysfunction in both forms of TAA, with potential therapeutic implication for other known HDAC9-associated vascular diseases. Vascular smooth muscle cell (VSMC) dysfunction is a common feature of thoracic aortic aneurysms (TAAs). Here, Lino Cardenas and colleagues show that the formation of a HDAC9-MALAT1-BRG1 complex promotes VSMC dysfunction in TAA by epigenetically altering the expression of key components of the cytoskeleton in VSMCs.
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14
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Abstract
Genetic disorders of the aorta are rare but can lead to life-threatening thoracic aortic aneurysms. Although the genetic causes of many of these connective tissue diseases are well defined, others such as familial thoracic aortic aneurysm and bicuspid aortic valve aortopathy are not. The natural history of genetic thoracic aortic aneurysms is not well understood or predictable, and surgical guidelines for treatment remain imprecise. Future research should strive to provide in-depth and detailed genetic profiling to drive clinical management, including medical and surgical therapies.
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15
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Zhang W, Han Q, Zhou M, Ran F, Qiao T, Yi L, Liu C, Liu Z. Identification of a missense mutation of COL3A1 in a Chinese family with atypical Ehlers-Danlos syndrome using targeted next-generation sequencing. Mol Med Rep 2016; 15:936-940. [PMID: 28035354 PMCID: PMC5364830 DOI: 10.3892/mmr.2016.6082] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 11/21/2016] [Indexed: 01/13/2023] Open
Abstract
Aortopathy represents an important cause of mortality in industrialized countries, with a number of genes identified as predispose factors. It can be difficult to identify the genetic lesions underlying this disorder, particularly when the phenotype is atypical. The present study performed targeted next-generation sequencing of 428 genes associated with cardiovascular diseases in a family with aortopathy, the proband of which presented with abdominal aortic aneurysm rupture only, with tissue fragility noted in surgery. After targeted capture, sequencing and bioinformatics analysis, a missense mutation, p.A1259T, was identified in the collagen type III α1 (COL3A1) gene and co-segregated with the disease in the family. Crystal structure modeling revealed abnormal hydrogen bonds generated by the mutation, which likely affected the spatial structure of the procollagen C-propeptide. Mutations in the procollagen C-propeptide are rare and genotype-phenotype correlation may explain the atypical manifestations of affected individuals. The results of the present study suggested that targeted gene capture combined with next-generation sequencing can serve as a useful technique in the genetic diagnosis of aortopathy, particularly in the content of an atypical phenotype.
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Affiliation(s)
- Wenwen Zhang
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu 210008, P.R. China
| | - Qian Han
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu 210008, P.R. China
| | - Min Zhou
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu 210008, P.R. China
| | - Feng Ran
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu 210008, P.R. China
| | - Tong Qiao
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu 210008, P.R. China
| | - Long Yi
- Center for Translational Medicine, Nanjing University Medical School, Nanjing, Jiangsu 210093, P.R. China
| | - Changjian Liu
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu 210008, P.R. China
| | - Zhao Liu
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu 210008, P.R. China
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16
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Mallat Z, Tedgui A, Henrion D. Role of Microvascular Tone and Extracellular Matrix Contraction in the Regulation of Interstitial Fluid: Implications for Aortic Dissection. Arterioscler Thromb Vasc Biol 2016; 36:1742-7. [PMID: 27444198 DOI: 10.1161/atvbaha.116.307909] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 07/06/2016] [Indexed: 01/16/2023]
Abstract
The pathophysiology of aortic dissection is poorly understood, and its risk is resistant to medical treatment. Most studies have focused on a proposed pathogenic role of transforming growth factor-β in Marfan disease and related thoracic aortic aneurysms and aortic dissections. However, clinical testing of this concept using angiotensin II type 1 receptor antagonists to block transforming growth factor-β signaling fell short of promise. Genetic mutations that predispose to thoracic aortic aneurysms and aortic dissections affect components of the extracellular matrix and proteins involved in cellular force generation. Thus, a role for dysfunctional mechanosensing in abnormal aortic wall remodeling is emerging. However, how abnormal mechanosensing leads to aortic dissection remains a mystery. Here, we review current knowledge about the regulation of interstitial fluid dynamics and myogenic tone and propose that alteration in contractile force reduces vascular tone in the microcirculation (here, aortic vasa vasorum) and leads to elevations of blood flow, transmural pressure, and fluid flux into the surrounding aortic media. Furthermore, reduced contractile force in medial smooth muscle cells coupled with alteration of structural components of the extracellular matrix limits extracellular matrix contraction, further promoting the formation of intramural edema, a critical step in the initiation of aortic dissection. The concept is supported by several pathophysiological and clinical observations. A direct implication of this concept is that drugs that lower blood pressure and limit interstitial fluid accumulation while preserving or increasing microvascular tone would limit the risk of dissection. In contrast, drugs that substantially lower microvascular tone would be ineffective or may accelerate the disease and precipitate aortic dissection.
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MESH Headings
- Aortic Dissection/metabolism
- Aortic Dissection/pathology
- Aortic Dissection/physiopathology
- Animals
- Aorta, Thoracic/metabolism
- Aorta, Thoracic/pathology
- Aorta, Thoracic/physiopathology
- Aortic Aneurysm, Thoracic/genetics
- Aortic Aneurysm, Thoracic/metabolism
- Aortic Aneurysm, Thoracic/pathology
- Aortic Aneurysm, Thoracic/physiopathology
- Dilatation, Pathologic
- Extracellular Fluid/metabolism
- Extracellular Matrix/metabolism
- Extracellular Matrix/pathology
- Gene Expression Regulation
- Genetic Predisposition to Disease
- Humans
- Mechanotransduction, Cellular
- Microcirculation
- Microvessels/metabolism
- Microvessels/pathology
- Microvessels/physiopathology
- Models, Biological
- Models, Cardiovascular
- Pressure
- Vasoconstriction
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Affiliation(s)
- Ziad Mallat
- From the Division of Cardiovascular Medicine, Department of Medicine, University of Cambridge, Cambridge, United Kingdom (Z.M.); Institut National de la Santé et de la Recherche Médicale (Inserm) U970, Paris, France (Z.M., A.T.); and Inserm U1083, Centre National de la Recherche Scientifque (CNRS) UMR6214, Laboratoire de Biologie Neurovasculaire et Mitochondriale Intégrée, Angers, France (D.H.).
| | - Alain Tedgui
- From the Division of Cardiovascular Medicine, Department of Medicine, University of Cambridge, Cambridge, United Kingdom (Z.M.); Institut National de la Santé et de la Recherche Médicale (Inserm) U970, Paris, France (Z.M., A.T.); and Inserm U1083, Centre National de la Recherche Scientifque (CNRS) UMR6214, Laboratoire de Biologie Neurovasculaire et Mitochondriale Intégrée, Angers, France (D.H.)
| | - Daniel Henrion
- From the Division of Cardiovascular Medicine, Department of Medicine, University of Cambridge, Cambridge, United Kingdom (Z.M.); Institut National de la Santé et de la Recherche Médicale (Inserm) U970, Paris, France (Z.M., A.T.); and Inserm U1083, Centre National de la Recherche Scientifque (CNRS) UMR6214, Laboratoire de Biologie Neurovasculaire et Mitochondriale Intégrée, Angers, France (D.H.)
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17
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Ladich E, Yahagi K, Romero ME, Virmani R. Vascular diseases: aortitis, aortic aneurysms, and vascular calcification. Cardiovasc Pathol 2016; 25:432-41. [PMID: 27526100 DOI: 10.1016/j.carpath.2016.07.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 07/01/2016] [Accepted: 07/07/2016] [Indexed: 12/27/2022] Open
Abstract
Inflammatory diseases of the aorta broadly include noninfectious and infectious aortitis, periaortitis, atherosclerosis, and inflammatory atherosclerotic aneurysms. Aortitis is uncommon but is increasingly recognized as an important cause of aortic aneurysms and dissections. Abdominal (AAA) and thoracic aortic aneurysms (TAA) have different pathologies and etiologies. AAAs are the most common type of aortic aneurysm, and the vast majority of these are atherosclerotic. The causes of TAA vary depending on the site of involvement, but medial degeneration is a common pathologic substrate, regardless of etiology, and genetic influences play a prominent role in TAA expression. Standardized classification schemes for inflammatory and degenerative diseases of the aorta have only recently been added to the pathology literature. A brief overview of the new histopathologic classifications for aortic inflammatory and degenerative diseases has recently been published by the Society for Cardiovascular Pathology and the Association for European Cardiovascular Pathology as a consensus document on the surgical pathology of the aorta. Vascular calcification is a highly regulated biologic process, and the mechanisms leading to vascular calcification are under investigation. Calcification may occur in the intima (atherosclerotic) or in the media secondary to metabolic disease. Rarely, vascular calcification may be associated with genetic disorders.
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18
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Schubert JA, Landis BJ, Shikany AR, Hinton RB, Ware SM. Clinically relevant variants identified in thoracic aortic aneurysm patients by research exome sequencing. Am J Med Genet A 2016; 170A:1288-94. [PMID: 26854089 DOI: 10.1002/ajmg.a.37568] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Accepted: 01/09/2016] [Indexed: 11/09/2022]
Abstract
Thoracic aortic aneurysm (TAA) is a genetically heterogeneous disease involving subclinical and progressive dilation of the thoracic aorta, which can lead to life-threatening complications such as dissection or rupture. Genetic testing is important for risk stratification and identification of at risk family members, and clinically available genetic testing panels have been expanding rapidly. However, when past testing results are normal, there is little evidence to guide decision-making about the indications and timing to pursue additional clinical genetic testing. Results from research based genetic testing can help inform this process. Here we present 10 TAA patients who have a family history of disease and who enrolled in research-based exome testing. Nine of these ten patients had previous clinical genetic testing that did not identify the cause of disease. We sought to determine the number of rare variants in 23 known TAA associated genes identified by research-based exome testing. In total, we found 10 rare variants in six patients. Likely pathogenic variants included a TGFB2 variant in one patient and a SMAD3 variant in another. These variants have been reported previously in individuals with similar phenotypes. Variants of uncertain significance of particular interest included novel variants in MYLK and MFAP5, which were identified in a third patient. In total, clinically reportable rare variants were found in 6/10 (60%) patients, with at least 2/10 (20%) patients having likely pathogenic variants identified. These data indicate that consideration of re-testing is important in TAA patients with previous negative or inconclusive results.
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Affiliation(s)
- Jeffrey A Schubert
- Department of Molecular Genetics, Biochemistry and Microbiology, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Department of Pediatrics and Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Benjamin J Landis
- Department of Pediatrics and Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Amy R Shikany
- Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Robert B Hinton
- Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Stephanie M Ware
- Department of Molecular Genetics, Biochemistry and Microbiology, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Department of Pediatrics and Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana
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19
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Ladich E, Butany J, Virmani R. Aneurysms of the Aorta. Cardiovasc Pathol 2016. [DOI: 10.1016/b978-0-12-420219-1.00005-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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20
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Balistreri CR. Genetic contribution in sporadic thoracic aortic aneurysm? Emerging evidence of genetic variants related to TLR-4-mediated signaling pathway as risk determinants. Vascul Pharmacol 2015; 74:1-10. [PMID: 26409318 DOI: 10.1016/j.vph.2015.09.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 08/26/2015] [Accepted: 09/23/2015] [Indexed: 01/16/2023]
Affiliation(s)
- Carmela Rita Balistreri
- Department of Pathobiology and Medical Biotechnologies, University of Palermo, Corso Tukory 211, Palermo 90134, Italy.
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