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Ponińska JK, Pelczar-Płachta W, Pollak A, Jończyk-Potoczna K, Truszkowska G, Michałowska I, Szafran E, Bilińska ZT, Bobkowski W, Płoski R. Double Heterozygous Pathogenic Variants in the LOX and PKD1 Genes in a 5-Year-Old Patient with Thoracic Aortic Aneurysm and Polycystic Kidney Disease. Genes (Basel) 2023; 14:1983. [PMID: 38002926 PMCID: PMC10671125 DOI: 10.3390/genes14111983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 10/16/2023] [Accepted: 10/20/2023] [Indexed: 11/26/2023] Open
Abstract
Familial thoracic aortic aneurysms and dissections may occur as an isolated hereditary trait or as part of connective tissue disorders with Mendelian inheritance, but severe cardiovascular disease in pediatric patients is extremely rare. There is growing knowledge on pathogenic variants causing the disease; however, much of the phenotypic variability and gene-gene interactions remain to be discovered. We present a case report of a 5.5-year-old girl with an aortic aneurysm and concomitant polycystic kidney disease. Whole exome sequencing was performed, followed by family screening by amplicon deep sequencing and diagnostic imaging studies. In the proband, two pathogenic variants were identified: p.Tyr257Ter in the LOX gene inherited from her mother, and p.Thr2977Ile in the PKD1 gene inherited from her father. All adult carriers of either of these variants showed symptoms of aortic disease. We conclude that the coexistence of two independent genetic variants in the proband may be the reason for an early onset of disease.
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Affiliation(s)
- Joanna Kinga Ponińska
- Department of Medical Biology, National Institute of Cardiology, 04-628 Warszawa, Poland;
| | - Weronika Pelczar-Płachta
- Department of Pediatric Cardiology, Poznan University of Medical Sciences, 61-701 Poznań, Poland
| | - Agnieszka Pollak
- Department of Medical Genetics, Centre of Biostructure, Medical University of Warsaw, 02-106 Warszawa, Poland
| | | | - Grażyna Truszkowska
- Department of Medical Biology, National Institute of Cardiology, 04-628 Warszawa, Poland;
| | - Ilona Michałowska
- Department of Radiology, National Institute of Cardiology, 04-628 Warszawa, Poland
| | - Emilia Szafran
- Department of Pediatric Cardiology, Poznan University of Medical Sciences, 61-701 Poznań, Poland
| | - Zofia T. Bilińska
- Unit for Screening Studies in Inherited Cardiovascular Diseases, National Institute of Cardiology, 04-628 Warszawa, Poland;
| | - Waldemar Bobkowski
- Department of Pediatric Cardiology, Poznan University of Medical Sciences, 61-701 Poznań, Poland
| | - Rafał Płoski
- Department of Medical Genetics, Centre of Biostructure, Medical University of Warsaw, 02-106 Warszawa, Poland
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Bhimani SA, Rahmy A, Kim S, Jin JB, Zahka K, Komarlu R, Svensson LG, Pande A, Karamlou T. Optimizing Evaluation in Pediatric and Young Adult Marfan Syndrome: Novel Longitudinal Metrics to Track Growth of Aortic Structures. J Thorac Cardiovasc Surg 2022; 164:724-740.e6. [DOI: 10.1016/j.jtcvs.2021.12.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 11/03/2021] [Accepted: 12/02/2021] [Indexed: 10/18/2022]
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Comparability of different Z-score equations for aortic root dimensions in children with Marfan syndrome. Cardiol Young 2021; 31:1962-1968. [PMID: 33843540 DOI: 10.1017/s1047951121001311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Aortic root dilation is a major complication of Marfan syndrome and is one of the most important criteria in establishing the diagnosis. Currently, different echocardiographic nomograms are used to calculate aortic root Z-scores. The aim of the present study was to assess the potential differences in aortic root measurements when aortic root Z-scores were obtained in a cohort of paediatric Marfan patients using several published nomograms. METHODS In a cohort of 100 children with Marfan syndrome, Z-scores for aortic root dimensions were calculated according to the nomograms of Pettersen et al, Gautier et al, Colan et al, and Lopez et al. Bland-Altman plots were used to estimate mean differences in Z-scores and to establish limits of agreement. RESULTS The mean Z-score of the sinus of Valsalva for Lopez et al was significantly higher compared to Gautier et al (p < 0.01) and Pettersen et al (p = 0.03). The nomogram of Lopez et al resulted in substantially higher Z-scores in patients with a large sinus of Valsalva diameter. Thirty-five percentage of the studied patients would have a Z-score ≥ 2 using Lopez et al compared to 20% for Pettersen et al, 21% for Gautier et al, and 33% for Colan et al. CONCLUSION The currently available nomograms for calculating Z-scores of aortic dilation in children with Marfan syndrome lead to clinically relevant differences in Z-scores, especially in children with a relative large aortic root diameter. This could have impact on both the diagnosis and treatment of patients with Marfan syndrome.
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Al-Mousily MF, Lopez L, Muniz JC, Sasaki N, Seltzer I, Gruber J, Welch E. Aortic size in children: Systolic measurements are different from diastolic measurements. Ann Pediatr Cardiol 2021; 14:165-169. [PMID: 34103855 PMCID: PMC8174627 DOI: 10.4103/apc.apc_157_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 11/30/2020] [Accepted: 12/06/2020] [Indexed: 11/16/2022] Open
Abstract
Background: Current guidelines recommended aortic measurements during diastole in adults and during systole in children. Recent studies in adults have demonstrated noteworthy differences in aortic measurements during systole and diastole in the same subjects. In the present study, we aimed to characterize systolic and diastolic differences in aortic measurements in healthy children. Materials and Methods : This retrospective study included 272 children who had a complete echocardiogram and no heart disease. Aortic measurements at the annulus (ANN), aortic root (AOR), sinotubular junction (STJ), and ascending aorta (AAO) were performed. Systolic and diastolic values were compared by calculating the mean systolic to diastolic (SD) percent difference for each segment; if the SD difference was >5%, it was considered clinically important. Similar measurements were conducted by another observer in 18% of the subjects. Results: Systolic measurements were larger than diastolic measurements with mean SD percent differences >5% (P < 0.001) for the AOR (7.3% ± 5.5%), STJ (10.24% ± 7.1%), and AAO (9.8% ± 7.4%). There was no clinically significant SD difference for the ANN. There was an excellent intraclass correlation coefficient between observers (0.982–0.995). Conclusions: Systolic measurements for the AOR, STJ, and AAO were larger than diastolic measurements. Normal reference values are utilized to design treatment for patients with abnormal aortic sizes, and the timing in the cardiovascular cycle used to decide the reference values should be equivalent to the timing used to make measurements in clinical practice. This is particularly imperative as patients transition their care from a pediatric to an adult cardiologist.
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Affiliation(s)
- Mohammad F Al-Mousily
- Department of Cardiology, Nicklaus Children's Hospital, Miami, FL, USA.,Department of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Leo Lopez
- Department of Cardiology, Nicklaus Children's Hospital, Miami, FL, USA.,Department of Pediatric Cardiology, Stanford, Palo Alto, CA, USA
| | - Juan Carlos Muniz
- Department of Cardiology, Nicklaus Children's Hospital, Miami, FL, USA
| | - Nao Sasaki
- Department of Cardiology, Nicklaus Children's Hospital, Miami, FL, USA
| | - Irwin Seltzer
- Department of Cardiology, Nicklaus Children's Hospital, Miami, FL, USA
| | - Joshua Gruber
- Department of Cardiology, Nicklaus Children's Hospital, Miami, FL, USA
| | - Elizabeth Welch
- Department of Cardiology, Nicklaus Children's Hospital, Miami, FL, USA
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5
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Wozniak-Mielczarek L, Sabiniewicz R, Nowak R, Gilis-Malinowska N, Osowicka M, Mielczarek M. New Screening Tool for Aortic Root Dilation in Children with Marfan Syndrome and Marfan-Like Disorders. Pediatr Cardiol 2020; 41:632-641. [PMID: 32006082 PMCID: PMC7170831 DOI: 10.1007/s00246-020-02307-0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 01/22/2020] [Indexed: 11/28/2022]
Abstract
One of the roles of a pediatric cardiologist who suspects or diagnoses a genetically determined connective tissue disease (e.g., Marfan, Ehlers-Danlos, and Loeys-Dietz syndromes) is to assess whether the aortic root is dilated. The aortic root diameter is affected by the patient's age, sex, and body surface area. Therefore, the aortic root diameter needs to be determined and expressed as a z-score. Calculation of the z-score is time-consuming and problematic if used infrequently. This study aimed to introduce a simple screening method for identifying aortic root dilation in children. The study population consisted of 190 children who were diagnosed with Marfan syndrome or Marfan-like disorders. The aortic root ratio (ARr) was formulated. The value of the ARr was compared in each patient with the results in z-scores, which were obtained using on-line calculators based on the most widespread nomograms. The optimal cut-off value of the ARr was ≥ 18.7. At this cut-off point, the sensitivity of the ARr ranged from 88.3% to 100% and the specificity ranged from 94% to 97.8%. All of the patients in whom the ARr failed to identify aortic root dilation were also divergently classified by different nomograms. At the ARr cut-off point of ≥ 18.0, a sensitivity of 100% was achieved for all nomograms with minimal reduction in specificity. The ARr allows for rapid and precise screening for aortic root dilation in children. Unlike classic analysis, the ARr does not require nomograms or on-line calculations.
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Affiliation(s)
- Lidia Wozniak-Mielczarek
- Department of Pediatric Cardiology and Congenital Heart Diseases, Medical University of Gdansk, 7 Debinki Street, 80-211, Gdansk, Poland.
| | - Robert Sabiniewicz
- Department of Pediatric Cardiology and Congenital Heart Diseases, Medical University of Gdansk, 7 Debinki Street, 80-211, Gdansk, Poland
| | - Radosław Nowak
- 2nd Department of Cardiology, Medical University of Gdansk, Gdansk, Poland
| | | | - Michalina Osowicka
- Department of Pediatric Cardiology and Congenital Heart Diseases, Medical University of Gdansk, 7 Debinki Street, 80-211, Gdansk, Poland
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Xing J, Min L, Zhang H, Li P, Li W, Lv F, Wang Y, Zhang Z, Li H, Guo Q, Wang S, Zhao Y, Wang J, Shi X, Wang A, Zhu S, Ji M, Wu Y, Zhang S. A nomogram for endoscopic screening in a high esophageal squamous cell cancer risk area: results from a population-based study. Cancer Manag Res 2019; 11:431-442. [PMID: 30655695 PMCID: PMC6322513 DOI: 10.2147/cmar.s167311] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Endoscopy is the main approach used for esophageal squamous cell carcinoma (ESCC) screening, especially in high-risk areas. However, little consensus has been achieved in recent ESCC screening programs, and endoscopists have selected patients only by age and family history. Patients and methods To generate a proper strategy for selecting an eligible population for endoscopic screening based on demographic factors, lifestyle, and eating habits, a total of 7,830 residents in an area with a high risk of ESCC were recruited for this study. All participants underwent endoscopic examinations that were conducted by experienced endoscopists. Risk factors for ESCC and other lesions were selected by univariate and multivariate logistic regressions. A nomogram for the prediction of ESCC and premalignant lesions was constructed, which included information on age, sex, occupation, labor intensity, income, and mining exposure. Receiver operating characteristic (ROC) curve analysis was performed to present the predictive accuracy of the nomograms. Results The area under the curve (95% CI) was 0.749 (0.711–0.788) for this nomogram. By applying this nomogram, we could exclude 60% (4704/7830) of patients before endoscopy screening and detect all ESCC cases as well as most esophageal lesions in the remaining population. Conclusion In conclusion, we provided a ready-to-use preclinical tool with the potential to select eligible people with high risk of ESCC for endoscopy screening.
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Affiliation(s)
- Jie Xing
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing 100050, People's Republic of China,
| | - Li Min
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing 100050, People's Republic of China,
| | - Hao Zhang
- Department of Gastroenterology, Jizhong Energy Fengfeng Group Hospital, Handan, Hebei 056200, People's Republic of China
| | - Peng Li
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing 100050, People's Republic of China,
| | - Wei Li
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing 100050, People's Republic of China,
| | - Fujin Lv
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing 100050, People's Republic of China,
| | - Yongjun Wang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing 100050, People's Republic of China,
| | - Zheng Zhang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing 100050, People's Republic of China,
| | - Hengcun Li
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing 100050, People's Republic of China,
| | - Qingdong Guo
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing 100050, People's Republic of China,
| | - Siyi Wang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing 100050, People's Republic of China,
| | - Yu Zhao
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing 100050, People's Republic of China,
| | - Junmin Wang
- Department of Gastroenterology, Handan Central Hospital, Handan, Hebei 056001, People's Republic of China
| | - Xiaoyan Shi
- Department of Pathology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, People's Republic of China
| | - Anxin Wang
- Department of Epidemiology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100029, People's Republic of China
| | - Shengtao Zhu
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing 100050, People's Republic of China,
| | - Ming Ji
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing 100050, People's Republic of China,
| | - Yongdong Wu
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing 100050, People's Republic of China,
| | - Shutian Zhang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing 100050, People's Republic of China,
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7
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Hoskoppal A, Menon S, Trachtenberg F, Burns KM, De Backer J, Gelb BD, Gleason M, James J, Lai WW, Liou A, Mahony L, Olson AK, Pyeritz RE, Sharkey AM, Stylianou M, Wechsler SB, Young L, Levine JC, Tierney ESS, Lacro RV, Bradley TJ. Predictors of Rapid Aortic Root Dilation and Referral for Aortic Surgery in Marfan Syndrome. Pediatr Cardiol 2018; 39:1453-1461. [PMID: 29948025 PMCID: PMC6150800 DOI: 10.1007/s00246-018-1916-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 05/31/2018] [Indexed: 01/15/2023]
Abstract
Few data exist regarding predictors of rapid aortic root dilation and referral for aortic surgery in Marfan syndrome (MFS). To identify independent predictors of the rate of aortic root (AoR) dilation and referral for aortic surgery, we investigated the data from the Pediatric Heart Network randomized trial of atenolol versus losartan in young patients with MFS. Data were analyzed from the echocardiograms at 0, 12, 24, and 36 months read in the core laboratory of 608 trial subjects, aged 6 months to 25 years, who met original Ghent criteria and had an AoR z-score (AoRz) > 3. Repeated measures linear and logistic regressions were used to determine multivariable predictors of AoR dilation. Receiver operator characteristic curves were used to determine cut-points in AoR dilation predicting referral for aortic surgery. Multivariable analysis showed rapid AoR dilation as defined by change in AoRz/year > 90th percentile was associated with older age, higher sinotubular junction z-score, and atenolol use (R2 = 0.01) or by change in AoR diameter (AoRd)/year > 90th percentile with higher sinotubular junction z-score and non-white race (R2 = 0.02). Referral for aortic root surgery was associated with higher AoRd, higher ascending aorta z-score, and higher sinotubular junction diameter:ascending aorta diameter ratio (R2 = 0.17). Change in AoRz of 0.72 SD units/year had 42% sensitivity and 92% specificity and change in AoRd of 0.34 cm/year had 38% sensitivity and 95% specificity for predicting referral for aortic surgery. In this cohort of young patients with MFS, no new robust predictors of rapid AoR dilation or referral for aortic root surgery were identified. Further investigation may determine whether generalized proximal aortic dilation and effacement of the sinotubular junction will allow for better risk stratification. Rate of AoR dilation cut-points had high specificity, but low sensitivity for predicting referral for aortic surgery, limiting their clinical use. Clinical Trial Number ClinicalTrials.gov number, NCT00429364.
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Affiliation(s)
| | | | | | - Kristin M Burns
- National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | | | - Bruce D Gelb
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Marie Gleason
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeanne James
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | | | - Aimee Liou
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Lynn Mahony
- Southwestern Medical Center, University of Texas, Dallas, TX, USA
| | | | - Reed E Pyeritz
- The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Mario Stylianou
- National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | | | - Luciana Young
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Jami C Levine
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Ronald V Lacro
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Timothy J Bradley
- The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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8
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Affiliation(s)
- John M. Simpson
- From the Department of Congenital Heart Disease, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Trust, London, UK (J.M.S.); Division of Imaging Sciences and Biomedical Engineering, King’s College London, United Kingdom (H.C.); and Department of Paediatric Cardiology, Great Ormond Street Hospital, London, United Kingdom (H.C.)
| | - Henry Chubb
- From the Department of Congenital Heart Disease, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Trust, London, UK (J.M.S.); Division of Imaging Sciences and Biomedical Engineering, King’s College London, United Kingdom (H.C.); and Department of Paediatric Cardiology, Great Ormond Street Hospital, London, United Kingdom (H.C.)
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9
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Xing J, Min L, Zhu S, Zhang H, Zhao Y, Li H, Zhang Z, Li P, Zhang S. Factors associated with gastric adenocarcinoma and dysplasia in patients with chronic gastritis: a population-based study. Chin J Cancer Res 2017; 29:341-350. [PMID: 28947866 PMCID: PMC5592822 DOI: 10.21147/j.issn.1000-9604.2017.04.07] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE Gastric cancer (GC) is one of the leading causes of death in China and other Asian countries. Recently, gastric endoscopy has become the main approach for GC screening, but the identification of high-risk individuals remains a challenge in GC screening programs. METHODS There were 7,302 patients with chronic gastritis involved in this study. Endoscopic examinations were performed, and their demographic characteristics and lifestyle data were collected. Each possible associated factor of GC/premalignant and precursor lesions was evaluated by univariate and multivariate logistic regressions. Nomograms were used for visualization of those models, and receiver operating characteristic (ROC) curve analysis was used to present the predictive accuracy. RESULTS We detected 8 (0.11%) gastric adenocarcinomas, 17 (0.23%) dysplasia cases, 14 (0.19%) hyperplasia cases, 52 (0.71%) intestinal metaplasia cases, 217 (2.97%) inflammatory lesions, 141 (1.93%) gastric ulcers, 10 (0.14%) atrophic gastritis cases, 1,365 (18.69%) erosive gastritis cases, and 5,957 (81.58%) superficial gastritis cases in 7,302 patients. The age (P<0.001), gender (P=0.086), labor intensity (P=0.018) and leek food intake (P=0.143) were identified as independent predictive factors of GC/premalignant lesions possibility. The corresponding nomogram exhibited an area under the curve (AUC) [95% confidence interval (95% CI)] of 0.82 (0.74-0.89) for the modeling group and 0.80 (0.75-0.85) for the validation group. The age (P=0.002), gender (P=0.024), smoking (P=0.002) and leek food intake (P=0.039) were independent predictive factors of precursor lesions possibility. The corresponding nomogram exhibited an AUC (95% CI) of 0.62 (0.60-0.65) for the modeling group and 0.61 (0.59-0.63) for the validation group. CONCLUSIONS We identified several potential associated factors and provided a preclinical nomogram with the potential to predict the possibility of GC/premalignant and precursor lesions.
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Affiliation(s)
- Jie Xing
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing 100050, China
| | - Li Min
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing 100050, China
| | - Shengtao Zhu
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing 100050, China
| | - Hao Zhang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing 100050, China
| | - Yu Zhao
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing 100050, China
| | - Hengcun Li
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing 100050, China
| | - Zheng Zhang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing 100050, China
| | - Peng Li
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing 100050, China
| | - Shutian Zhang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing 100050, China
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10
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Mariucci E, Donti A, Guidarini M, Oppido G, Angeli E, Lovato L, Wischmeijer A, Finlay M, Gargiulo GD, Picchio FM, Bonvicini M. Diagnostic Accuracy of Aortic Root Cross-sectional Area/Height Ratio in Children and Young Adults with Marfan and Loeys-Dietz Syndrome. CONGENIT HEART DIS 2015; 11:276-82. [PMID: 26555028 DOI: 10.1111/chd.12315] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/22/2015] [Indexed: 01/06/2023]
Abstract
BACKGROUND Accurate quantification of aortic dilatation is critical in children with syndromes associated with thoracic aortic aneurysm, yet classification of normality is difficult. Current methods of normalization use body surface area to account for growth, despite a nonlinear relationship of body surface area to aortic root dimensions. In contrast, height has a linear relationship with aortic root dimensions in normal children, is simple to measure and requires no secondary calculation. We evaluated the diagnostic accuracy of an height-based aortic root-indexing method, aortic root cross-sectional area/height ratio (AHr), in children with Marfan and Loeys-Dietz syndromes. METHODS A cohort of 54 children with Marfan or Loeys-Dietz syndromes, aged 3 months to 17 years, were evaluated with a transthoracic echocardiogram. AHr was measured in diastole at sinuses of Valsalva (SoV) and proximal ascending aorta (pAA) in a group of normal subjects matched for age and body surface area and normal values were provided. AHr values were recorded for patients and compared with z-scores results obtained with Gautier's and Campens's nomograms. RESULTS AHr values in the group of normal subjects were 2.6 ± 0.6 at SoV and 2 ± 0.5 at pAA. Categorization of z-scores and AHr showed good correspondence between AHr and Gautier's method (P = .341 at SoV and .185 at pAA) and AHr and Campens method (P =.465 at SoV and 0.110 at pAA). CONCLUSIONS There was a good correspondence of AHr results with two different z-scores. AHr is a simple to use and valid option to quantify aortic root dilatation in pediatric patients.
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Affiliation(s)
| | | | | | | | | | | | - Anita Wischmeijer
- Department of Medical Genetics, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Malcolm Finlay
- Queen Mary, University of London & Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
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Campens L, Demulier L, De Groote K, Vandekerckhove K, De Wolf D, Roman MJ, Devereux RB, De Paepe A, De Backer J. Reference values for echocardiographic assessment of the diameter of the aortic root and ascending aorta spanning all age categories. Am J Cardiol 2014; 114:914-20. [PMID: 25092193 DOI: 10.1016/j.amjcard.2014.06.024] [Citation(s) in RCA: 134] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 06/12/2014] [Accepted: 06/12/2014] [Indexed: 11/17/2022]
Abstract
Thoracic aortic dilatation requires accurate and timely detection to prevent progression to thoracic aortic aneurysm and aortic dissection. The detection of thoracic aortic dilatation necessitates the availability of cut-off values for normal aortic diameters. Tools to evaluate aortic dimension above the root are scarce and inconsistent regarding age groups. The aim of this study was to provide reference values for aortic root and ascending aortic diameters on the basis of transthoracic echocardiographic measurements in a large cohort of children and adults. Diameters at the level of the sinuses of Valsalva (SoV) and ascending aorta (AA) were assessed with transthoracic echocardiography in 849 subjects (453 females, age range 1 to 85 years, mean 40.1 ± 21.3 years) and measured according to published guidelines. Linear regression analysis was applied to create nomograms, as well as equations for upper limits of normal and z-scores. SoV and AA diameters were strongly correlated with age, body surface area (BSA), and weight (r = 0.67 to 0.79, p <0.001 for all). Male subjects had significantly larger aortic dimensions at all levels in adulthood, even after BSA correction (p ≤0.004 for all age intervals). Gender-, age-, and BSA-specific upper limits of normal and z-score equations were developed from a multivariate regression model, which strongly predicts SoV and AA diameters (adjusted R(2) for SoV = 0.84 and 0.67 and for AA = 0.82 and 0.74, for male and female subjects, respectively). In conclusion, this study provides widely applicable reference values for thoracic aortic dilatation screening purposes. Age, BSA, and gender must be taken into account when assessing an individual patient.
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Affiliation(s)
- Laurence Campens
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium.
| | - Laurent Demulier
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Katya De Groote
- Department of Pediatric Cardiology, Ghent University Hospital, Ghent, Belgium
| | | | - Daniël De Wolf
- Department of Pediatric Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Mary J Roman
- Division of Cardiology, Weill Cornell Medical College, New York, New York
| | - Richard B Devereux
- Division of Cardiology, Weill Cornell Medical College, New York, New York
| | - Anne De Paepe
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium
| | - Julie De Backer
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium; Department of Cardiology, Ghent University Hospital, Ghent, Belgium
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12
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Franken R, Heesterbeek TJ, de Waard V, Zwinderman AH, Pals G, Mulder BJM, Groenink M. Diagnosis and genetics of Marfan syndrome. Expert Opin Orphan Drugs 2014. [DOI: 10.1517/21678707.2014.950223] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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13
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Paterick TE, Humphries JA, Ammar KA, Jan MF, Loberg R, Bush M, Khandheria BK, Tajik AJ. Aortopathies: etiologies, genetics, differential diagnosis, prognosis and management. Am J Med 2013; 126:670-8. [PMID: 23800581 DOI: 10.1016/j.amjmed.2013.01.029] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Revised: 01/29/2013] [Accepted: 01/30/2013] [Indexed: 01/15/2023]
Abstract
Aortic root and ascending aortic dilatation are indicators associated with risk of aortic dissection, which varies according to underlying etiologic associations, indexed aortic root size, and rate of progression. Typical aortic involvement is most commonly seen in syndromic cases for which there is increasing evidence that aortic aneurysm represents a spectrum of familial inheritance associated with variable genetic penetrance and phenotypic expression. Aortic root and ascending aortic dimensions should be measured routinely with echocardiography. Pharmacologic therapy may reduce the rate of progression. Timing of surgical intervention is guided by indexed aortic size and rate of change of aortic root and ascending aorta dimensions. Lifelong surveillance is recommended.
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Affiliation(s)
- Timothy E Paterick
- Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke's Medical Centers, University of Wisconsin School of Medicine and Public Health, Milwaukee, WI, USA.
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14
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Franken R, den Hartog AW, Singh M, Pals G, Zwinderman AH, Groenink M, Mulder BJ. Marfan syndrome: Progress report. PROGRESS IN PEDIATRIC CARDIOLOGY 2012. [DOI: 10.1016/j.ppedcard.2012.05.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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15
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Ozdemir O, Olgunturk R, Kula S, Tunaoglu FS. Echocardiographic findings in children with Marfan syndrome. Cardiovasc J Afr 2010; 22:245-8. [PMID: 21161115 PMCID: PMC3721876 DOI: 10.5830/cvja-2010-085] [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: 02/10/2010] [Accepted: 09/07/2010] [Indexed: 11/15/2022] Open
Abstract
Background The typical cardiac manifestations of Marfan syndrome are aortic regurgitation with progressive dilatation of the aortic root, which may cause dissection and rupture of the ascending aorta, mitral valve prolapse and mitral valve regurgitation. In this study, we aimed to show echocardiographic findings in 11 patients with Marfan syndrome. Methods Diagnosis of Marfan syndrome was based on the Ghent criteria. All patients had a full echocardiographic evaluation. During the evaluation, we investigated the presence of mitral valve prolapse, mitral valve regurgitation, tricuspid valve prolapse, dilatation of the aortic root, and aortic regurgitation. Results Eleven patients were diagnosed as Marfan syndrome (seven male, four female, age 4–14 years). All had mitral valve prolapse (nine with mitral valve regurgitation). Among these 11 patients, seven had accompanying tricuspid valve prolapse, six had dilatation of the aortic root and two had aortic regurgitation. Conclusion Eleven patients in our clinic were diagnosed as Marfan syndrome since they had distinct characteristics of marfanoid phenotype. Echocardiographic evaluation of these patients showed marked heart valve involvement. In Marfan syndrome, it is known that the aortic valve is affected following mitral valve involvement. In our experience, aortic root dilatation is less common. However, particular attention should be given to following up aortic root status with non-invasive echocardiography to institute measures to prevent complications.
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Affiliation(s)
- O Ozdemir
- Kecioren Training and Research Hospital, Ankara, Turkey.
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16
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Recommendations for quantification methods during the performance of a pediatric echocardiogram: a report from the Pediatric Measurements Writing Group of the American Society of Echocardiography Pediatric and Congenital Heart Disease Council. J Am Soc Echocardiogr 2010; 23:465-95; quiz 576-7. [PMID: 20451803 DOI: 10.1016/j.echo.2010.03.019] [Citation(s) in RCA: 1084] [Impact Index Per Article: 77.4] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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17
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Gautier M, Detaint D, Fermanian C, Aegerter P, Delorme G, Arnoult F, Milleron O, Raoux F, Stheneur C, Boileau C, Vahanian A, Jondeau G. Nomograms for aortic root diameters in children using two-dimensional echocardiography. Am J Cardiol 2010; 105:888-94. [PMID: 20211339 DOI: 10.1016/j.amjcard.2009.11.040] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2009] [Revised: 11/06/2009] [Accepted: 11/06/2009] [Indexed: 11/25/2022]
Abstract
The evaluation of aortic root dilation is of major importance for the diagnosis and follow-up of patients with diverse diseases, including the Marfan syndrome. However, we noted that the available nomograms suggested a lower aortic root dilation rate in adults (75%) than in children (90%), when the opposite would have been expected. To establish new nomograms, we selected a population of 353 normal children. We took transthoracic echocardiographic measurements of the aortic root diameters at the level of the aortic annulus, sinuses of Valsalva, sinotubular junction, and ascending aorta according to the American Society of Echocardiography recommendations. All diameters correlated well with the height, weight, body surface area, and age (r = 0.75 to 0.84, p <0.0001). Covariance analysis adjusting for body surface area showed slightly larger diameters at the level of the sinuses of Valsalva in male children than in female children (+1 mm, p = 0.0002). Equations and derived nomograms were developed, giving the upper limit of normal (allowing simple recognition of aortic dilation) and the Z score (allowing fine quantification of dilation and differentiation of normal growth from pathologic dilation) for all 4 aortic root diameters (ie, aortic annulus, sinuses of Valsalva, sinotubular junction, and proximal ascending aorta) according to body surface area and gender. We applied the nomograms to 282 children with confirmed Marfan syndrome, of whom 65.2% presented with dilation of the sinuses of Valsalva. In conclusion, we propose equations to calculate the upper limit of normal and Z-score for aortic root diameters measured by 2-dimensional echocardiography, which should be useful tools for the diagnosis and follow-up of aortic root aneurysms in children.
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Johnson RK, Premraj S, Patel SS, Walker N, Wahle A, Sonka M, Scholz TD. Automated analysis of four-dimensional magnetic resonance images of the human aorta. Int J Cardiovasc Imaging 2010; 26:571-8. [PMID: 20146003 DOI: 10.1007/s10554-010-9592-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Accepted: 01/07/2010] [Indexed: 11/30/2022]
Abstract
The purpose of the study was to demonstrate the accuracy and clinical utility of an automated method of image analysis of 4D (3D + time) magnetic resonance (MR) imaging of the human aorta. Serial MR images of the entire thoracic aorta were acquired on 32 healthy individuals. Graph theory based segmentation was applied to the images and cross sectional area (CSA) was determined for the entire length of thoracic aorta. Mean CSA was compared between the 3 years. CSA values at the level of sinuses of Valsalva and sino-tubular junction were used to calculate average diameters for comparison to Roman-Devereux norms. A robust automated segmentation method was developed that accurately reproduced CSA measurements for the entire length of thoracic aorta in serially acquired scans with a 1% error compared to expert tracing. Calculated aortic root diameters based on CSA correlated with Roman-Devereux norms. Mean CSA for the aortic root agreed well with previously published manually derived values. Automated analysis of 4D MR images of the thoracic aorta provides accurate and reproducible results for CSA in healthy human subjects. The ability to simultaneously analyze the entire length of thoracic aorta throughout the cardiac cycle opens the door to the calculation of novel indices of aortic biophysical properties. These novel indices may lead to earlier detection of patients at risk for adverse events.
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Affiliation(s)
- Ryan K Johnson
- Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
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19
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Ucar SK, Paterson WF, Donaldson MDC, Young D. Ethinyl estradiol treatment for growth limitation in girls with Marfan's syndrome--experience from a single center. Endocr Res 2009; 34:109-20. [PMID: 19878071 DOI: 10.3109/07435800903207283] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Tall stature, a major characteristic of Marfan's syndrome, may be of concern to the family, particularly if the patient is a girl. Experience with treatment options-sex steroid or somatostatin analogue-for height reduction in girls is limited. We have evaluated our experience of estrogen treatment in girls with Marfan's syndrome attending the pediatric endocrine clinic in Glasgow between 1989 and 2005. DESIGN AND METHODS Retrospective case note analysis combined with ascertainment of final/near final height, comparing outcome in treated and untreated girls. Cardiovascular health was assessed by examining aortic root diameter and blood pressure. RESULTS The study cohort comprised four treated and five untreated girls, of whom three were sisters. Treatment was started in the four girls at chronological age 10.0 (2.1) years, mean (SD) height 155.0 (9.8) cm, and Tanner breast stage B1 in three and B2 in one. Ethinyl estradiol was administered in stepwise incremental regimens, starting at 10 microg/day and reaching 100 microg/day after 10 weeks in two girls and starting at 2 microg/day and reaching a maximum of 30-50 microg/day over a 2- to 3-year period in two girls. Mean +/- SD (range) final/near final height of the four treated girls was 174.3 (2.6) (170.6-176.6) cm compared with 183.0 (6.9) (171.5-190.3) cm in the five untreated girls. No deaths occurred in the treated group while one untreated girl died from presumed arrhythmia aged 18 years. Aortic root diameter increased with age, by mean (SD) 5.0 (2.1) and 5.8 (4.5) mm in treated and untreated groups, respectively, but with no between-group differences after treatment. CONCLUSIONS The estrogen doses used in this study are lower than in previous reports. The results, although unsuitable for statistical analysis due to small numbers, are encouraging with no adverse events being recorded. Future research should be multicenter in design.
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Affiliation(s)
- Sema Kalkan Ucar
- Department of Paediatric Endocrinology and Metabolism, Ege University Medical Faculty, Izmir, Turkey.
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20
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Abstract
Prolonged survival of patients with Marfan syndrome after aortic root replacement has led to an increased number of patients with aortic complications beyond the root. Elective replacement of the aortic root removes the most important predilection site for aneurysms, but the distal aorta remains at risk. Predictors for aortic growth and adverse events in the distal aorta include aortic diameter, aortic distensiblity, previous aortic root replacement, hypertension and aortic regurgitation. After aortic dissection, the initial false lumen diameter is an independent predictor for late aneurysm formation. Although there are a few reports of short-term success after endovascular stent grafting of the descending thoracic aorta, stent grafting in patients with Marfan syndrome is not recommended unless intervention is clearly indicated and the risk of conventional open surgical repair is deemed prohibitive. Optimal long-term outcome demands lifelong radiographic follow-up and medical treatment with beta-blocker therapy. After aortic dissection rigorous antihypertensive medication is of utmost importance. Losartan, an angiotensin II type I receptor antagonist, might offer the first potential for primary prevention of clinical manifestations in Marfan syndrome, but the results of clinical trials have to be awaited. (Neth Heart J 2008;16:382-6.).
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Affiliation(s)
- B J M Mulder
- Department of Cardiology, Academic Medical Center Amsterdam, the Netherlands
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21
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Predictors for aneurismal formation. Int J Cardiovasc Imaging 2008; 24:641-3. [PMID: 18415703 PMCID: PMC2493604 DOI: 10.1007/s10554-008-9310-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2008] [Accepted: 03/25/2008] [Indexed: 11/03/2022]
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22
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Abstract
In recent years, there have been many advances in the treatment of cardiac disease in children with Marfan's syndrome. Early diagnosis, meticulous echocardiographic follow-up and multidisciplinary assessment are essential. Medical treatment with beta-blockers is probably helpful in most children with aortic root dilatation. Research on TGFbeta signalling and the potential treatment role of TGFbeta antagonists may lead to exciting new treatments, but the results of clinical trials are awaited. In managing the cardiovascular complications of Marfan's syndrome, the paediatrician has to walk a difficult path. On the one hand, restrictive lifestyle advice and drugs may need to be prescribed, often in the context of a family history of major surgery or even sudden death. On the other hand, it is essential to encourage the often asymptomatic child to develop and mature as normally as possible.
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Affiliation(s)
- Alan Graham Stuart
- Congenital Heart Centre, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol, UK.
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Abstract
Today, the availability of competing techniques for coarctation repair, including numerous surgical approaches as well as interventional ones, raises important questions about indications, risks and criteria for procedural success. Surgical treatment of coarctation is an extremely well tolerated procedure with excellent long-term efficacy due to an 88 to 96% 5 years freedom from re-intervention in patients operated on within the first months of life. If compared with surgery, balloon angioplasty features a higher risk for aneurysm formation, aortic rupture and a lower degree of success, with potentially important residual pressure gradient in up to 20.7% of patients. Stents are believed to overcome the problems of simple dilation, but concerns remain about the materials and the potential of re-expandibility in view of the growth of the treated aorta. Moreover, serious complications, including death, have been reported by stent implantation as well, similar to aneurysms or dissections (4.3%), balloon rupture with stent migration or cerebral vascular injury (9%). There is no evidence to date for the superiority of any interventional approach to surgical treatment of primary coarctation. The favorable long-term surgical results outweigh the proposed short-term benefits of angioplasty and stenting, which should be restricted to well selected cases.
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Affiliation(s)
- Tom R Karl
- Pediatric Heart Center, University of California, San Francisco, California 94143, USA.
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24
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Erentug V, Polat A, Bozbuga NU, Polat E, Erdogan HB, Kirali K, Guler M, Akinci E, Yakut C. Cardiovascular Reoperations in Marfan Syndrome. J Card Surg 2006; 21:455-7. [PMID: 16948755 DOI: 10.1111/j.1540-8191.2006.00276.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIM OF THE STUDY The purpose of this study is to analyze the outcome results of reoperations in Marfan syndrome patients. METHODS Between 1985 and December 2004, 49 patients with Marfan syndrome were operated for aortic aneurysms. Of these 49 patients, 9 (18,4%) required > or =1 reoperations after a mean duration of 32.2 +/- 26.6 months. The mean duration of follow-up was 52.0 +/- 46.8 months, a total of 39 patient/years. Survival free of reoperation was calculated by Cox regression analysis. RESULTS Surgical indication for operation was a chronic aneurysmal dilatation of the ascending or abdominal aorta in seven patients (77.8%) and aortic dissection in two (22.2%) at the initial operation. In the reoperations, repair of thoracoabdominal aortic aneurysm with separated graft interposition in six patients (66.7%), replacement of ascending aorta in one (11.1%), replacement of ascending and hemiarchus aorta in one (11.1%), and mitral valve replacement in three patients (33.3%) were performed. The hospital mortality was 11.1% with one patient. Among the survivors, one expired in the follow-up five months after the second operation (12.5%). With the Cox regression analysis, survival without reoperation for 13, 24, and 123 months are 95.56 +/- 3.04%, 90.66 +/- 4.40%, and 60.32 +/- 12.63%, respectively. Mean survival for reoperated patients is 99 +/- 14 months (95% confidence interval 72-127 months). CONCLUSIONS Reoperations can be done with low morbidity and mortality. Patients should be kept under close follow-up using imaging techniques infinitely.
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Affiliation(s)
- Vedat Erentug
- Cardiovascular Surgeon, Koşuyolu Heart and Research Hospital, Istanbul, Turkey.
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Volach V, Elami A, Gilon D, Pollak A, Ginosar Y, Ezra Y. Pregnancy in Marfan Syndrome after Aortic Root Replacement: A Case Report and Review of the Literature. CONGENIT HEART DIS 2006; 1:184-8. [DOI: 10.1111/j.1747-0803.2006.00032.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Das BB, Taylor AL, Yetman AT. Left ventricular diastolic dysfunction in children and young adults with Marfan syndrome. Pediatr Cardiol 2006; 27:256-8. [PMID: 16463128 DOI: 10.1007/s00246-005-1139-5] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Adults with Marfan syndrome (MFS) demonstrate abnormal aortic elastic properties manifest by decreased aortic distensibility and increased aortic stiffness. Left ventricular (LV) diastolic dysfunction has been reported in adults with MFS. The objective of this study was to assess the frequency of LV diastolic dysfunction in a group of children and young adults with MFS and to determine whether diastolic dysfunction is associated with hemodynamic alterations of the aorta. Review of echocardiographic findings in 40 patients with MFS was performed to assess LV size, systolic function, isovolumic relaxation time (IVRT), mitral inflow velocities, deceleration time (DT) of mitral E wave, and aortic root dimension. No patient had significant valvar disease or was on any cardiac medication at the time of study. A group of 40 age and sex-matched healthy subjects undergoing echocardiography served as controls. Significant differences in LV diastolic function were found between MFS patients and controls. MFS patients had prolonged DT and IVRT and decreased mitral E/A ratio, suggesting impaired LV relaxation. No relationship between aortic root dimension and diastolic performance was identified. Left ventricular diastolic dysfunction may be an early marker of myocardial involvement in young MFS patients occurring independently of aortic root dilatation.
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Affiliation(s)
- B B Das
- Section of Pediatric Cardiology, University of Louisville, Louisville, KY 40202, USA
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Meijboom LJ, Timmermans J, Zwinderman AH, Engelfriet PM, Mulder BJM. Aortic root growth in men and women with the Marfan's syndrome. Am J Cardiol 2005; 96:1441-4. [PMID: 16275195 DOI: 10.1016/j.amjcard.2005.06.094] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2005] [Revised: 06/28/2005] [Accepted: 06/28/2005] [Indexed: 11/26/2022]
Abstract
The leading cause of premature death in patients with Marfan's syndrome (MS) is type A aortic dissection or rupture due to progressive aortic root dilation. The aim of this study was to analyze aortic root growth in 113 men and 108 women with MS. All patients were prospectively followed with serial echocardiograms of the native aortic root. At baseline, women had on average a 5-mm smaller aortic root diameter adjusted for age than men. Average aortic root growth was 0.42 mm/year (SE 0.05) in men and 0.38 mm/year (SE 0.04) in women. On the basis of aortic root growth rates, the men and women could be divided into 2 normally distributed subgroups: fast and slow growers. Approximately 1 in 7 men (1.5 mm/year, SE 0.5) and approximately 1 in 9 women (1.8 mm/year, SE 0.3) had fast-growing aortic root diameters. Significantly more type A dissections (25% vs 4%, p <0.001) were observed in fast growers than in slow growers; this was found in men and women. Type A dissections were observed in 4 men and 9 women. By reducing the cut-off value by 5 mm for elective aortic root replacement in women, type A dissections could have been prevented in 3 women. In conclusion, guidelines should take gender differences into account, and therefore, the investigators propose reducing the threshold for elective aortic root replacement in women with MS by 5 mm.
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Affiliation(s)
- Lilian J Meijboom
- Department of Cardiology, Academic Medical Centre, Amsterdam, The Netherlands
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28
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Meijboom LJ, Vos FE, Timmermans J, Boers GH, Zwinderman AH, Mulder BJM. Pregnancy and aortic root growth in the Marfan syndrome: a prospective study. Eur Heart J 2005; 26:914-20. [PMID: 15681576 DOI: 10.1093/eurheartj/ehi103] [Citation(s) in RCA: 186] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
AIMS In women with Marfan syndrome pregnancy presents an increased risk of dilatation, dissection, and rupture of the aorta. The aim of this study was to investigate the influence of pregnancy on growth of the aortic root. METHODS AND RESULTS Between 1993 and 2004 127 women with Marfan syndrome were prospectively followed; 61 women had one or more children; in 23 women, 33 pregnancies could be followed prospectively for aortic dimensions. Only one woman had suffered an aortic complication, a type A dissection (limited to the ascending aorta), before pregnancy. Out of 66 childless women a comparison group of 22 women was selected and individually matched. Mean initial aortic root diameter just before pregnancy was 37+/-5 mm (range 25-45). Before, during, and after pregnancy the overall individual aortic root diameter change (in 31 pregnancies) was not significant (P=0.77). Only the woman with a previous type A dissection developed an aortic complication (type B dissection) during her second pregnancy. No cardiac complications occurred in the other 22 women during their pregnancies. During a median follow-up of 6.4 years, no significant difference in growth of the aortic root was observed between the pregnancy group and the matched childless group (0.28 vs. 0.19 mm/year, P=0.08, respectively). CONCLUSION Pregnancy in women with Marfan syndrome seems to be relatively safe up to an aortic root diameter of 45 mm, at least as far as our observed diameter range of 25-45 mm is concerned.
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Affiliation(s)
- Lilian J Meijboom
- Department of Cardiology, Rm B2-240, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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Gurvitz M, Chang RK, Drant S, Allada V. Frequency of aortic root dilation in children with a bicuspid aortic valve. Am J Cardiol 2004; 94:1337-40. [PMID: 15541263 DOI: 10.1016/j.amjcard.2004.07.130] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2004] [Revised: 07/15/2004] [Accepted: 07/15/2004] [Indexed: 11/30/2022]
Abstract
Bicuspid aortic valve (BAV) is associated with aortic root dilation and dissection in adults, but the age and conditions when dilation begins are unknown. Using echocardiographic data, we compared the aortic root dimensions and valve hemodynamics of 76 children with BAV with valves derived from 41 normal children. The children with BAV had significantly larger aortic roots (p <0.001) regardless of the presence of aortic stenosis or regurgitation.
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30
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Immer FF, Bansi AG, Immer-Bansi AS, McDougall J, Zehr KJ, Schaff HV, Carrel TP. Aortic dissection in pregnancy: analysis of risk factors and outcome. Ann Thorac Surg 2003; 76:309-14. [PMID: 12842575 DOI: 10.1016/s0003-4975(03)00169-3] [Citation(s) in RCA: 303] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Aortic dissection during pregnancy is a life-threatening event. Recent studies have revealed similar histologic changes in the wall of the ascending aorta in patients with bicuspid aortic valve disease (BAVD). Based on a review of the literature, including the experience from two institutions, we looked at the patient's characteristics in patients with thoracic aortic dissection during pregnancy. We found that aortic root enlargement (> 4cm) or an increase of aortic root size during pregnancy in patients with BAVD, and Marfan syndrome is associated with a considerable risk for the occurrence of Type A dissection.
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Affiliation(s)
- Franz F Immer
- Department of Cardiovascular Surgery, Berne, Switzerland.
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Mulder BJM. Project report: adult congenital heart disease. Neth Heart J 2002; 10:480-483. [PMID: 25696051 PMCID: PMC2499803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023] Open
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Nollen GJ, Groenink M, van der Wall EE, Mulder BJM. Current insights in diagnosis and management of the cardiovascular complications of Marfan's syndrome. Cardiol Young 2002; 12:320-7. [PMID: 12206553 DOI: 10.1017/s1047951100012907] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Marfan's syndrome is an inherited disorder of connective tissue, caused by mutations in the fibrillin-1 gene located on chromosome 15. Diagnosis is still based on a combination of major and minor clinical features. Prognosis is mainly determined by the cardiovascular complications. Advances in surgical and medical treatment for these complications have dramatically improved the prognosis of the syndrome.
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Affiliation(s)
- Gijs J Nollen
- Department of Cardiology, Academic Medical Center Amsterdam, The Netherlands
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Hager A, Kaemmerer H, Rapp-Bernhardt U, Blücher S, Rapp K, Bernhardt TM, Galanski M, Hess J. Diameters of the thoracic aorta throughout life as measured with helical computed tomography. J Thorac Cardiovasc Surg 2002; 123:1060-6. [PMID: 12063451 DOI: 10.1067/mtc.2002.122310] [Citation(s) in RCA: 174] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The use of helical computed tomography is well established in the evaluation of the thoracic aorta. Nevertheless, normal diameters and their changes during adult life according to this method are not available. We planned to set up normal diameters for the thoracic aorta of adults obtained by helical computed tomography. METHODS Seventy adults, 17 to 89 years old, without any signs of cardiovascular disease were investigated with helical computed tomography. Aortic diameters were measured at seven predefined thoracic levels. RESULTS Aortic diameters (mean +/- SD) were 2.98 +/- 0.46 cm at the aortic valve sinus, 3.09 +/- 0.41 cm at the ascending aorta, 2.94 +/- 0.42 cm proximal to the innominate artery, 2.77 +/- 0.37 cm at the proximal transverse arch, 2.61 +/- 0.41 cm at the distal transverse arch, 2.47 +/- 0.40 cm at the isthmus, and 2.43 +/- 0.35 cm at the diaphragm. Men had slightly longer diameters than did women. All diameters increased with age. There was no influence of weight, height, or body surface area. After normalization to the diameter at diaphragmatic level, no statistically significantly influential factor could be detected. CONCLUSIONS This study delineates normal intrathoracic aortic diameters for helical computed tomography, including relationships with sex and age. Pathologic dimensions of the aorta should preferably be provided as percentiles or z scores.
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Affiliation(s)
- Alfred Hager
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technische Universität München, München, Germany.
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Wenstrup RJ, Meyer RA, Lyle JS, Hoechstetter L, Rose PS, Levy HP, Francomano CA. Prevalence of aortic root dilation in the Ehlers-Danlos syndrome. Genet Med 2002; 4:112-7. [PMID: 12180144 DOI: 10.1097/00125817-200205000-00003] [Citation(s) in RCA: 103] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE To determine the prevalence of proximal aortic abnormalities in patients with Ehlers-Danlos syndrome (EDS). METHODS In a prospective cohort study, aortic measurements by two-dimensional echocardiography were performed on consecutive EDS patients. RESULTS Twenty-eight percent (20 of 71) had aortic root dilation (ARD) (> +2 SD above population based norms). Fourteen of 42 individuals with the classical form of EDS (types I/II) and 6 of 29 individuals with the hypermobile form (type III) had ARD, with no gender differences. CONCLUSION ARD is a common finding in EDS. Longitudinal studies are indicated to determine progression of ARD and its clinical significance.
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Affiliation(s)
- Richard J Wenstrup
- Division of Human Genetics, Children's Hospital Research Foundation, Cincinnati, OH 45229-3039, USA
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Meijboom LJ, Groenink M, van der Wall EE, Romkes H, Stoker J, Mulder BJ. Aortic root asymmetry in marfan patients; evaluation by magnetic resonance imaging and comparison with standard echocardiography. INTERNATIONAL JOURNAL OF CARDIAC IMAGING 2000; 16:161-8. [PMID: 11144769 DOI: 10.1023/a:1006429603062] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Patients with Marfan syndrome may develop aortic root dissection despite only mild aortic root dilation as shown by standard echocardiography, which may be due to aortic root asymmetry. Purpose of the present study was to investigate aortic root asymmetry by magnetic resonance (MR) imaging in patients with Marfan syndrome and to compare these measurements with standardly performed echocardiography. METHODS Eighty-seven Marfan patients (mean age 31 +/- 8 years) underwent MR imaging. From this population, 15 patients (mean age 29 +/- 3 years) were selected in whom both echocardiography and MR imaging had been performed within 3 months. With echocardiography, the aortic root was measured according to the recommendations of the American Society of Echocardiography. With MR imaging, a short axis view of the aortic root was obtained to measure distances between the noncoronary, right coronary and left coronary cusps and the aortic root area. Correlations between aortic root area and diameters were assessed, and 95% confidence intervals (95% CIs) calculated. RESULTS No difference in the standardly measured noncoronary to right coronary cusp diameter between MR imaging and echocardiography was shown (42 +/- 6 mm). Largest aortic root diameter on the MR images was the right to left coronary cusp diameter (46 +/- 7 mm, p < 0.02). For a given noncoronary to right coronary cusp diameter, 95% confidence intervals revealed a variation of -20 to +20% in the aortic root area. CONCLUSIONS The majority of Marfan patients show asymmetric dilation of the aortic root by MR imaging. This phenomenon may go unnoticed when standard echocardiography is performed. The asymmetry of the aortic root might be of clinical importance in unexpected aortic root dissection.
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Affiliation(s)
- L J Meijboom
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
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Groenink M, Lohuis TA, Tijssen JG, Naeff MS, Hennekam RC, van der Wall EE, Mulder BJ. Survival and complication free survival in Marfan's syndrome: implications of current guidelines. Heart 1999; 82:499-504. [PMID: 10490568 PMCID: PMC1760285 DOI: 10.1136/hrt.82.4.499] [Citation(s) in RCA: 123] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To evaluate survival and complication free survival in patients with Marfan's syndrome and to assess the possible influence of recently revised guidelines for prophylactic aortic root replacement in these patients. METHODS 130 patients who had been attending one institution over 14 years were evaluated. Kaplan-Meier analysis was performed in 125 patients who did not present with aortic root dissection as the first sign of Marfan's syndrome, with the end points: death, aortic root dissection, and prophylactic aortic root replacement after diagnosis. In the patients developing aortic root dissection, current guidelines for prophylactic aortic root replacement were retrospectively applied to investigate the number of dissections that could theoretically have been prevented. The guidelines were: (1) aortic root diameter >/= 55 mm, (2) positive family history of aortic dissections and aortic root diameter >/= 50 mm, and (3) aortic root growth >/= 2 mm/year. Outcomes following emergency surgery (15 patients) and prophylactic surgery of the aortic root (30 patients) were compared. RESULTS Five and 10 year survival after diagnosis was 95% and 88%, and the five and 10 year complication free survival was 78% and 66%, respectively. Thirteen patients developed dissection, 30 underwent prophylactic repair, and 82 had an uncomplicated course. Eleven dissections could theoretically have been prevented by application of the current guidelines. Five year survival following emergency and prophylactic repair of the aortic root was 51%, and 97%, respectively. CONCLUSIONS Survival in the Marfan's syndrome in the past 14 years seems satisfactory; with application of current guidelines, it has probably even improved. However, because of the high fatality rate in Marfan patients developing aortic root dissection, more extensive screening for Marfan's syndrome and a search for additional risk factors are desirable.
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Affiliation(s)
- M Groenink
- Department of Cardiology, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
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Ergin MA, Spielvogel D, Apaydin A, Lansman SL, McCullough JN, Galla JD, Griepp RB. Surgical treatment of the dilated ascending aorta: when and how? Ann Thorac Surg 1999; 67:1834-9; discussion 1853-6. [PMID: 10391320 DOI: 10.1016/s0003-4975(99)00439-7] [Citation(s) in RCA: 154] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The aorta is considered pathologically dilated if the diameters of the ascending aorta and the aortic root exceed the norms for a given age and body size. A 50% increase over the normal diameter is considered aneurysmal dilatation. Such dilatation of the ascending aorta frequently leads to significant aortic valvular insufficiency, even in the presence of an otherwise normal valve. The dilated or aneurysmal ascending aorta is at risk for spontaneous rupture or dissection. The magnitude of this risk is closely related to the size of the aorta and the underlying pathology of the aortic wall. The occurrence of rupture or dissection adversely alters natural history and survival even after successful emergency surgical treatment. METHODS In recommending elective surgery for the dilated ascending aorta, the patient's age, the relative size of the aorta, the structure and function of the aortic valve, and the pathology of the aortic wall have to be considered. The indications for replacement of the ascending aorta in patients with Marfan's syndrome, acute dissection, intramural hematoma, and endocarditis with annular destruction are supported by solid clinical information. Surgical guidelines for intervening in degenerative dilatation of the ascending aorta, however, especially when its discovery is incidental to other cardiac operations, remain mostly empiric because of lack of natural history studies. The association of a bicuspid aortic valve with ascending aortic dilatation requires special attention. RESULTS There are a number of current techniques for surgical restoration of the functional and anatomical integrity of the aortic root. The choice of procedure is influenced by careful consideration of multiple factors, such as the patient's age and anticipated survival time; underlying aortic pathology; anatomical considerations related to the aortic valve leaflets, annulus, sinuses, and the sino-tubular ridge; the condition of the distal aorta; the likelihood of future distal operation; the risk of anticoagulation; and, of course, the surgeon's experience with the technique. Currently, elective root replacement with an appropriately chosen technique should not carry an operative risk much higher than that of routine aortic valve replacement. Composite replacement of the aortic valve and the ascending aorta, as originally described by Bentall, DeBono and Edwards (classic Bentall), or modified by Kouchoukos (button Bentall), remains the most versatile and widely applied method. Since 1989, the button modification of the Bentall procedure has been used in 250 patients at Mount Sinai Medical Center, with a hospital mortality of 4% and excellent long-term survival. In this group, age was the only predictor of operative risk (age > 60 years, mortality 7.3% [9/124] compared with age < 60, mortality 0.8% [1/126], p = 0.02). CONCLUSIONS This modification of the Bentall procedure has set a standard for evaluating the more recently introduced methods of aortic root repair.
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Affiliation(s)
- M A Ergin
- Department of Cardiothoracic Surgery, Mount Sinai Medical Center, New York, New York 10029, USA
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Groenink M, Rozendaal L, Naeff MS, Hennekam RC, Hart AA, van der Wall EE, Mulder BJ. Marfan syndrome in children and adolescents: predictive and prognostic value of aortic root growth for screening for aortic complications. Heart 1998; 80:163-9. [PMID: 9813564 PMCID: PMC1728770 DOI: 10.1136/hrt.80.2.163] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE To assess and measure the diagnostic and prognostic value of individual aortic root growth in children and adolescents with Marfan syndrome. DESIGN From 1983 to 1996, 250 children were screened for Marfan syndrome. Serial echocardiographic aortic root measurements of 123 children (57 Marfan, 66 control) were available for evaluation of aortic root growth. Aortic root diameters were correlated with body surface area. Based on individual growth of the aortic root a discrimination formula was derived to distinguish Marfan patients from control subjects. RESULTS Sensitivity and specificity of this method, which were dependent on the number of measurements, were 84% and 73%, respectively, for three serial measurements. The discrimination score also predicted a five year complication free survival in all patients. CONCLUSIONS In children and adolescents with Marfan syndrome, aortic root growth differs significantly from subjects in whom Marfan syndrome was definitely ruled out during screening. Measurement of individual aortic root growth may serve to establish diagnosis at an early stage and is of prognostic value for occurrence of aortic complications.
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Affiliation(s)
- M Groenink
- Department of Cardiology, Academic Medical Centre, Amsterdam, Netherlands
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