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Khodabakhshian N, Howell AJ, Lopez PP, Hui W, Mertens LL, Guerra VC. Impact of Genotype-Phenotype Interactions on Cardiovascular Function in Paediatric Loeys-Dietz Syndrome. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2024; 3:47-54. [PMID: 38774681 PMCID: PMC11103043 DOI: 10.1016/j.cjcpc.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 12/22/2023] [Indexed: 05/24/2024]
Abstract
Background The relationship between genotype and phenotypical vascular and cardiac properties in paediatric Loeys-Dietz syndrome (LDS) patients are not well characterized. This study explores the phenotypical differences in aortic properties and cardiac structural and functional parameters between paediatric LDS patients with TGFBR1 and TGFBR2 mutations. Methods We included 32 LDS patients with either TGFBR1 (n = 17) or TGFBR2 (n = 15) mutations. Echocardiographic data included aortic dimensions, distensibility, strain, and stiffness at the level of the annulus, sinuses of Valsalva, sinotubular junction, ascending aorta, and descending aorta. Parameters for left ventricular size and function were also recorded. Results Demographics were similar between the groups. Patients with TGFBR2 were more likely to have undergone aortic surgery (47% vs 12%, P = 0.057) and use angiotensin receptor blockers (93% vs 47%, P = 0.015). Aortic z scores were significantly larger in the TGFBR2 group at the level of the aortic valve annulus (P = 0.007), sinuses of Valsalva (P = 0.001), sinotubular junction (P = 0.001), and ascending aorta (P = 0.054). Patients with TGFBR2 also had significantly lower aortic distensibility and strain coupled with higher stiffness index at the level of the annulus, sinotubular junction, and ascending aorta. Parameters for the descending aorta, cardiac morphology, and cardiac function were similar between the groups. Conclusions Paediatric LDS patients with TGFBR2 present with more severe cardiovascular phenotypes than patients with TGFBR1 with larger aortic dimensions and increased aortic stiffness. Our findings suggest that genotypes should be taken into consideration in the clinical management of paediatric LDS patients.
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Affiliation(s)
- Nairy Khodabakhshian
- Department of Pediatrics, Labatt Family Heart Centre, the Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Alison J. Howell
- Department of Pediatrics, Labatt Family Heart Centre, the Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Pablo Perez Lopez
- Department of Pediatrics, Labatt Family Heart Centre, the Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Madrid, Spain
- Faculty of Medicine, Universidad Autonoma de Madrid, Madrid, Spain
| | - Wei Hui
- Department of Pediatrics, Labatt Family Heart Centre, the Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Luc L. Mertens
- Department of Pediatrics, Labatt Family Heart Centre, the Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Vitor C. Guerra
- Department of Pediatrics, Labatt Family Heart Centre, the Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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2
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Dey S, Cheikhali R, Frishman WH, Aronow WS. Genetic Problems, Diagnosis, and Cardiovascular Manifestations of Loeys-Dietz Syndrome. Cardiol Rev 2023:00045415-990000000-00104. [PMID: 37126428 DOI: 10.1097/crd.0000000000000544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Loeys-Dietz Syndrome (LDS) is an autosomal dominant connective tissue disorder with multisystem involvement of wide spectrum, found to be associated with transforming growth factor-β pathway. LDS is characterized by craniofacial, skeletal, cutaneous, vascular abnormalities along with aortic aneurysm and aortic dissection contributing to mortality and morbidity at a young age. Therefore, timely diagnosis and intervention in patients with LDS is vital. Several gene mutations have been described as contributing factors of LDS, causing widespread and aggressive vascular disease. Based on these gene mutations, 5 types of LDS have been described so far. Besides aortic aneurysm and dissection, some of the other cardiac manifestations of LDS involve cardiomyopathy, valvular abnormality, atrial fibrillation, patent ductus arteriosus, atrial septal defects, etc. Routine imaging of patients' vasculatures and aggressive medical and surgical management are key factors in managing patients with LDS.
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Affiliation(s)
- Subo Dey
- From the Departments of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Ryan Cheikhali
- From the Departments of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - William H Frishman
- From the Departments of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Wilbert S Aronow
- From the Departments of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
- Departments of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
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3
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Al Ghamdi A, Parramón MM, Cavallé-Garrido T. Unexplained Cardiovascular Collapse After Scoliosis Surgery in a Patient With Loeys-Dietz Syndrome. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:82-85. [PMID: 37970529 PMCID: PMC10642104 DOI: 10.1016/j.cjcpc.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 11/18/2022] [Indexed: 11/17/2023]
Affiliation(s)
- Abdulrahman Al Ghamdi
- Division of General Pediatrics, Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, Montréal, Québec, Canada
| | - Marina Mir Parramón
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Montreal Children Hospital, McGill University Health Centre, Montréal, Québec, Canada
| | - Tíscar Cavallé-Garrido
- Division of Cardiology, Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, Montréal, Québec, Canada
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4
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Parikh M, Seidman M, Oudit GY. Critical Role of Extracellular Matrix Remodeling in Dilated Cardiomyopathy: Lessons from Connective Tissue Disorders. Can J Cardiol 2022; 38:309-310. [DOI: 10.1016/j.cjca.2022.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/03/2022] [Accepted: 01/06/2022] [Indexed: 12/24/2022] Open
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Yokota T, Koiwa H, Matsushima S, Tsujinaga S, Naya M, Morisaki H, Morisaki T. Loeys-Dietz Cardiomyopathy? Long-Term Follow-Up After Onset of Acute Decompensated Heart Failure. Can J Cardiol 2021; 38:389-391. [PMID: 34843907 DOI: 10.1016/j.cjca.2021.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 11/22/2021] [Accepted: 11/23/2021] [Indexed: 11/25/2022] Open
Abstract
Loeys-Dietz syndrome (LDS) is an inherited connective tissue disorder the phenotype of which resembles Marfan syndrome (MFS). LDS frequently affects the cardiovascular system leading to aortic aneurysm or dissection, but unlike MFS, primary cardiomyopathy is very rare in LDS, and thus the detailed clinical course of LDS-associated cardiomyopathy is unknown. We report the first case of a patient with LDS-associated cardiomyopathy whose left ventricular systolic function was reduced at the onset of acute heart failure (HF) but markedly improved by pharmacological therapy including an angiotensin-receptor blocker with no recurrence of worsening HF during 7 years of follow-up.
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Affiliation(s)
- Takashi Yokota
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan.
| | - Hiroaki Koiwa
- Department of Cardiovascular Medicine, Chitose City Hospital, Chitose, Japan
| | - Shouji Matsushima
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Shingo Tsujinaga
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Masanao Naya
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroko Morisaki
- Department of Medical Genetics, Sakakibara Heart Institute, Tokyo, Japan
| | - Takayuki Morisaki
- Department of Internal Medicine, IMSUT Hospital, Institute of Medical Science, The University of Tokyo, Tokyo, Japan
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6
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Abstract
Loeys-Dietz syndrome is an autosomal dominant aortic aneurysm syndrome characterized by multisystemic involvement. The most typical clinical triad includes hypertelorism, bifid uvula or cleft palate and aortic aneurysm with tortuosity. Natural history is significant for aortic dissection at smaller aortic diameter and arterial aneurysms throughout the arterial tree. The genetic cause is heterogeneous and includes mutations in genes encoding for components of the transforming growth factor beta (TGFβ) signalling pathway: TGFBR1, TGFBR2, SMAD2, SMAD3, TGFB2 and TGFB3. Despite the loss of function nature of these mutations, the patient-derived aortic tissues show evidence of increased (rather than decreased) TGFβ signalling. These insights offer new options for therapeutic interventions.
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7
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Muiño-Mosquera L, De Backer J. Cardiomyopathy in Genetic Aortic Diseases. Front Pediatr 2021; 9:682390. [PMID: 34336739 PMCID: PMC8319542 DOI: 10.3389/fped.2021.682390] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/22/2021] [Indexed: 11/13/2022] Open
Abstract
Genetic aortic diseases are a group of illnesses characterized by aortic aneurysms or dissection in the presence of an underlying genetic defect. They are part of the broader spectrum of heritable thoracic aortic disease, which also includes those cases of aortic aneurysm or dissection with a positive family history but in whom no genetic cause is identified. Aortic disease in these conditions is a major cause of mortality, justifying clinical and scientific emphasis on the aorta. Aortic valve disease and atrioventricular valve abnormalities are known as important additional manifestations that require careful follow-up and management. The archetype of genetic aortic disease is Marfan syndrome, caused by pathogenic variants in the Fibrillin-1 gene. Given the presence of fibrillin-1 microfibers in the myocardium, myocardial dysfunction and associated arrhythmia are conceivable and have been shown to contribute to morbidity and mortality in patients with Marfan syndrome. In this review, we will discuss data on myocardial disease from human studies as well as insights obtained from the study of mouse models of Marfan syndrome. We will elaborate on the various phenotypic presentations in childhood and in adults and on the topic of arrhythmia. We will also briefly discuss the limited data available on other genetic forms of aortic disease.
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Affiliation(s)
- Laura Muiño-Mosquera
- Department of Pediatrics, Division of Pediatric Cardiology, Ghent University Hospital, Ghent, Belgium.,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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8
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Aftab M, Reece TB, Svensson LG. Heart Transplantation in Patients With Loeys-Dietz Syndrome: Is It a Novel Cardiomyopathy? Ann Thorac Surg 2019; 109:306. [PMID: 31077663 DOI: 10.1016/j.athoracsur.2019.03.107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 03/29/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Muhammad Aftab
- Comprehensive Aortic Program, Division of Cardiothoracic Surgery, University of Colorado, 12631 E 17th Ave, MS C310, AO1 Rm 6602, Aurora, CO 80045.
| | - T Brett Reece
- Comprehensive Aortic Program, Division of Cardiothoracic Surgery, University of Colorado, 12631 E 17th Ave, MS C310, AO1 Rm 6602, Aurora, CO 80045
| | - Lars G Svensson
- Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
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9
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Aftab M, Cikach FS, Zhu Y, Idrees JJ, Rigelsky CM, Kalahasti V, Roselli EE, Svensson LG. Loeys-Dietz syndrome: Intermediate-term outcomes of medically and surgically managed patients. J Thorac Cardiovasc Surg 2019; 157:439-450.e5. [DOI: 10.1016/j.jtcvs.2018.03.172] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 03/21/2018] [Accepted: 03/29/2018] [Indexed: 12/23/2022]
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10
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Baban A, Magliozzi M, Loeys B, Adorisio R, Alesi V, Secinaro A, Corica B, Vricella L, Dietz HC, Drago F, Novelli A, Amodeo A. First evidence of maternally inherited mosaicism in TGFBR1 and subtle primary myocardial changes in Loeys-Dietz syndrome: a case report. BMC MEDICAL GENETICS 2018; 19:170. [PMID: 30219046 PMCID: PMC6139163 DOI: 10.1186/s12881-018-0661-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 08/02/2018] [Indexed: 11/15/2022]
Abstract
Background Loeys-Dietz syndrome (LDS) is a rare multisystemic disorder characterized by vascular and skeletal abnormalities, with considerable intra- and interfamilial variability. Case presentation We report the case of an 8-year-old male with clinical features of two distinct genetic disorders, namely LDS, manifesting in the first months by progressive aortic root dilatation, arterial tortuosity, bifid uvula, and inguinal hernias and oculocutaneous albinism (OCA) manifesting by white hair and skin that does not tan, nystagmus, reduced iris pigment with iris translucency, and reduced retinal pigment). We identified previously reported, homozygous mutations of TYR, c.1A > G (p.Met1Val) and heterozygous, missense mutation of TGFBR1, c.1460G > A (p.Arg487Gln). Family history revealed that his mother underwent multiple surgical repairs for recurrent hemorrhage originating from the buccal artery. Molecular studies confirmed a maternally inherited low grade TGFBR1 mutation somatic mosaicism (18% in peripheral blood leukocytes, 18% in buccal cells and 10% in hair root cells). Maternal cardiac investigations revealed peculiar cardiovascular features: mild tortuosity at the aortic arch, dilatation of the proximal abdominal aorta, multiple deep left ventricular myocardial crypts, and dysplastic mitral valve. TGFBR2 germline mosaicism has been described in three fathers of children carrying TGFBR2 mutations but, to the best of our knowledge, no case of maternally inherited TGFBR1 mutation mosaicism has been reported so far. Conclusions This case report suggests that individuals with somatic mosaicism might be at risk for mild and unusual forms of LDS but germline mosaicism can lead to full blown picture of the disease in offspring. Electronic supplementary material The online version of this article (10.1186/s12881-018-0661-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anwar Baban
- Pediatric Cardiology and Cardiac Arrhythmia/Syncope Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital and Research Institute, Piazza S. Onofrio, 4, 00165, Rome, Italy.
| | - Monia Magliozzi
- Laboratory of Medical Genetics, Bambino Gesù Children's Hospital and Research Institute, Rome, Italy
| | - Bart Loeys
- Center of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Rachele Adorisio
- Pediatric Cardiology and Cardiac Arrhythmia/Syncope Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital and Research Institute, Piazza S. Onofrio, 4, 00165, Rome, Italy
| | - Viola Alesi
- Laboratory of Medical Genetics, Bambino Gesù Children's Hospital and Research Institute, Rome, Italy
| | - Aurelio Secinaro
- Department of Imaging, Bambino Gesù Children's Hospital and Research Institute, IRCCS, Rome, Italy
| | - Bernadette Corica
- Pediatric Cardiology and Cardiac Arrhythmia/Syncope Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital and Research Institute, Piazza S. Onofrio, 4, 00165, Rome, Italy
| | - Luca Vricella
- Division of Cardiothoracic Surgery, Department of Surgery, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Harry C Dietz
- Department of Medicine, The McKusick-Nathans Institute of Genetic Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Fabrizio Drago
- Pediatric Cardiology and Cardiac Arrhythmia/Syncope Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital and Research Institute, Piazza S. Onofrio, 4, 00165, Rome, Italy
| | - Antonio Novelli
- Laboratory of Medical Genetics, Bambino Gesù Children's Hospital and Research Institute, Rome, Italy
| | - Antonio Amodeo
- Mechanical Assistance Device and Artificial Heart Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital and Research Institute, Rome, Italy
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11
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Jeewa A, Morris SA, Dreyer WJ, Adachi I, Denfield SW, McKenzie ED. Visual Diagnosis: A Child with Presumed Reactive Airway Disease, Pectus Carinatum, and Aortic Root Dilation. Pediatr Rev 2017; 38:e1-e5. [PMID: 28044041 DOI: 10.1542/pir.2015-0129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Aamir Jeewa
- Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics
| | - Shaine A Morris
- Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics
| | - William J Dreyer
- Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics
| | - Iki Adachi
- Michael E. DeBakey Department of Surgery, Division of Congenital Heart Surgery, Baylor College of Medicine, Houston, TX
| | - Susan W Denfield
- Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics
| | - E Dean McKenzie
- Michael E. DeBakey Department of Surgery, Division of Congenital Heart Surgery, Baylor College of Medicine, Houston, TX
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Bradley TJ, Bowdin SC, Morel CFJ, Pyeritz RE. The Expanding Clinical Spectrum of Extracardiovascular and Cardiovascular Manifestations of Heritable Thoracic Aortic Aneurysm and Dissection. Can J Cardiol 2015; 32:86-99. [PMID: 26724513 DOI: 10.1016/j.cjca.2015.11.007] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 11/09/2015] [Accepted: 11/09/2015] [Indexed: 01/09/2023] Open
Abstract
More than 30 heritable conditions are associated with thoracic aortic aneurysm and dissection (TAAD). Heritable syndromic conditions, such as Marfan syndrome, Loeys-Dietz syndrome, and vascular Ehlers-Danlos syndrome, have somewhat overlapping systemic features, but careful clinical assessment usually enables a diagnosis that can be validated with genetic testing. Nonsyndromic FTAAD can also occur and in 20%-25% of these probands mutations exist in genes that encode elements of the extracellular matrix, signalling pathways (especially involving transforming growth factor-β), and vascular smooth muscle cytoskeletal and contractile processes. Affected individuals with either a syndromic presentation or isolated TAAD can have mutations in the same gene. In this review we focus on the genes currently known to have causal mutations for syndromic and isolated FTAAD and outline the range of associated extracardiovascular and cardiovascular manifestations with each.
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Affiliation(s)
- Timothy J Bradley
- Division of Cardiology, Department of Paediatrics, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
| | - Sarah C Bowdin
- Division of Cardiology, Department of Paediatrics, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Division of Clinical and Metabolic Genetics, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Chantal F J Morel
- Fred A. Litwin Family Center in Genetic Medicine, Department of Medicine, University Health Network and Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Reed E Pyeritz
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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13
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Williams JA, Hanna JM, Shah AA, Andersen ND, McDonald MT, Jiang YH, Wechsler SB, Zomorodi A, McCann RL, Hughes GC. Adult surgical experience with Loeys-Dietz syndrome. Ann Thorac Surg 2015; 99:1275-81. [PMID: 25678502 DOI: 10.1016/j.athoracsur.2014.11.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 11/02/2014] [Accepted: 11/17/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND Loeys-Dietz syndrome (LDS) results from mutations in receptors for the cytokine transforming growth factor-β leading to aggressive aortic pathology sometimes accompanied by specific phenotypic features including bifid uvula, hypertelorism, cleft palate, and generalized arterial tortuosity. We reviewed our adult surgical experience with LDS in order to validate current recommendations regarding management of this newly described disease. METHODS All adult (≥ 18 years old) patients with LDS undergoing surgical treatment at a single referral institution from September 1999 to May 2013 were retrospectively reviewed. RESULTS Eleven adult LDS patients were identified by clinical criteria and genotyping. Seven (64%) experienced acute type A dissection at some point in their lives. All eventually required aortic root replacement, and 73% required multiple vascular surgical interventions. Over a mean follow-up of 65 ± 49 months, 2.8 cardiovascular procedures per patient were performed. In patients with type A dissection, a mean of 3.4 operations were performed versus 1.8 operations for patients without dissection. Total aortic replacement was required in 5 patients (45%) and 2 (18%) required neurosurgical intervention for cerebrovascular pathology. There was 1 late death from infectious complications, and no deaths from vascular catastrophe. CONCLUSIONS These results confirm the aggressive nature of LDS aortic pathology. However, the improved survival compared with earlier LDS reports suggest that aggressive treatment strategies may alter outcomes and improve the natural history of this syndrome.
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Affiliation(s)
- Jason A Williams
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jennifer M Hanna
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Asad A Shah
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Nicholas D Andersen
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Marie T McDonald
- Department of Pediatrics, Division of Medical Genetics, Duke University Medical Center, Durham, North Carolina
| | - Yong-Hui Jiang
- Department of Pediatrics, Division of Medical Genetics, Duke University Medical Center, Durham, North Carolina
| | - Stephanie Burns Wechsler
- Department of Pediatrics, Division of Medical Genetics, Duke University Medical Center, Durham, North Carolina; Department of Pediatrics, Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Ali Zomorodi
- Division of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Richard L McCann
- Division of Vascular Surgery, Duke University Medical Center, Durham, North Carolina
| | - G Chad Hughes
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina.
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14
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Cook JR, Carta L, Galatioto J, Ramirez F. Cardiovascular manifestations in Marfan syndrome and related diseases; multiple genes causing similar phenotypes. Clin Genet 2014; 87:11-20. [PMID: 24867163 DOI: 10.1111/cge.12436] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 05/23/2014] [Accepted: 05/23/2014] [Indexed: 01/08/2023]
Abstract
Cardiovascular abnormalities are the major cause of morbidity and mortality in Marfan syndrome (MFS) and a few clinically related diseases that share, with MFS, the pathogenic contribution of dysregulated transforming growth factor β (TGFβ) signaling. They include Loeys-Dietz syndrome, Shprintzen-Goldberg syndrome, aneurysm-osteoarthritis syndrome and syndromic thoracic aortic aneurysms. Unlike the causal association of MFS with mutations in an extracellular matrix protein (ECM), the aforementioned conditions are due to defects in components of the TGFβ pathway. While TGFβ antagonism is being considered as a potential new therapy for these heritable syndromes, several points still need to be clarified in relevant animal models before this strategy could be safely applied to patients. Among others, unresolved issues include whether elevated TGFβ signaling is responsible for all MFS manifestations and is the common trigger of disease in MFS and related conditions. The scope of our review is to highlight the clinical and experimental findings that have forged our understanding of the natural history and molecular pathogenesis of cardiovascular manifestations in this group of syndromic conditions.
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Affiliation(s)
- J R Cook
- Department of Pharmacology and Systems Therapeutics, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
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15
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MacCarrick G, Black JH, Bowdin S, El-Hamamsy I, Frischmeyer-Guerrerio PA, Guerrerio AL, Sponseller PD, Loeys B, Dietz HC. Loeys-Dietz syndrome: a primer for diagnosis and management. Genet Med 2014; 16:576-87. [PMID: 24577266 PMCID: PMC4131122 DOI: 10.1038/gim.2014.11] [Citation(s) in RCA: 306] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 01/13/2014] [Indexed: 12/20/2022] Open
Abstract
Loeys-Dietz syndrome is a connective tissue disorder predisposing individuals to aortic and arterial aneurysms. Presenting with a wide spectrum of multisystem involvement, medical management for some individuals is complex. This review of literature and expert opinion aims to provide medical guidelines for care of individuals with Loeys-Dietz syndrome.
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Affiliation(s)
- Gretchen MacCarrick
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Sarah Bowdin
- Division of Clinical and Metabolic Genetics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ismail El-Hamamsy
- Department of Cardiac Surgery, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | | | - Anthony L Guerrerio
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Paul D Sponseller
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Bart Loeys
- Center for Medical Genetics, University of Antwerp, Antwerp, Belgium
| | - Harry C Dietz
- 1] McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA [2] Howard Hughes Institute, Chevy Chase, Maryland, USA
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16
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Halushka MK. Single gene disorders of the aortic wall. Cardiovasc Pathol 2011; 21:240-4. [PMID: 22036072 DOI: 10.1016/j.carpath.2011.09.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Revised: 08/08/2011] [Accepted: 09/13/2011] [Indexed: 01/15/2023] Open
Abstract
Genetic diseases that affect the vasculature primarily affect the aortic root and ascending aorta. These conditions lead to aortic root dilatation, which, if not treated, will result in dissection and death. Often, aortic disease is just one manifestation of a syndrome with diverse findings. Some of these diseases were described over 100 years ago based on physical manifestations, and their causative genes are among the first described Mendelian causes of cardiovascular disease. Within the pediatric and young adult population, there are over 15 causes of ascending aortic disease. Previously, these diverse diseases, along with their histopathology, have been extensively characterized. Most genetic causes of root aneurysm are extremely rare. Amongst these, five diseases are relatively common with known genetic mutations for which pathologists should be familiar. These are Marfan syndrome, vascular Ehlers-Danlos syndrome, Loeys-Dietz syndrome, Turner syndrome, and familial thoracic aneurysm and dissection. This review will focus on these important causes of genetic aortic disease. The aim is to briefly describe the historical record and physical manifestations and then focus on cardiovascular complications, the causative genes, and current research into these entities.
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Affiliation(s)
- Marc K Halushka
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Doetschman T, Barnett JV, Runyan RB, Camenisch TD, Heimark RL, Granzier HL, Conway SJ, Azhar M. Transforming growth factor beta signaling in adult cardiovascular diseases and repair. Cell Tissue Res 2011; 347:203-23. [PMID: 21953136 DOI: 10.1007/s00441-011-1241-3] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Accepted: 09/02/2011] [Indexed: 01/15/2023]
Abstract
The majority of children with congenital heart disease now live into adulthood due to the remarkable surgical and medical advances that have taken place over the past half century. Because of this, adults now represent the largest age group with adult cardiovascular diseases. It includes patients with heart diseases that were not detected or not treated during childhood, those whose defects were surgically corrected but now need revision due to maladaptive responses to the procedure, those with exercise problems and those with age-related degenerative diseases. Because adult cardiovascular diseases in this population are relatively new, they are not well understood. It is therefore necessary to understand the molecular and physiological pathways involved if we are to improve treatments. Since there is a developmental basis to adult cardiovascular disease, transforming growth factor beta (TGFβ) signaling pathways that are essential for proper cardiovascular development may also play critical roles in the homeostatic, repair and stress response processes involved in adult cardiovascular diseases. Consequently, we have chosen to summarize the current information on a subset of TGFβ ligand and receptor genes and related effector genes that, when dysregulated, are known to lead to cardiovascular diseases and adult cardiovascular deficiencies and/or pathologies. A better understanding of the TGFβ signaling network in cardiovascular disease and repair will impact genetic and physiologic investigations of cardiovascular diseases in elderly patients and lead to an improvement in clinical interventions.
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Arthur HM, Bamforth SD. TGFβ signaling and congenital heart disease: Insights from mouse studies. BIRTH DEFECTS RESEARCH. PART A, CLINICAL AND MOLECULAR TERATOLOGY 2011; 91:423-34. [PMID: 21538815 DOI: 10.1002/bdra.20794] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Revised: 01/17/2011] [Accepted: 01/28/2011] [Indexed: 12/14/2022]
Abstract
Transforming growth factor β (TGFβ) regulates one of the major signaling pathways that control tissue morphogenesis. In vitro experiments using heart explants indicated the importance of this signaling pathway for the generation of cushion mesenchymal cells, which ultimately contribute to the valves and septa of the mature heart. Recent advances in mouse genetics have enabled in vivo investigation into the roles of individual ligands, receptors, and coreceptors of this pathway, including investigation of the tissue specificity of these roles in heart development. This work has revealed that (1) cushion mesenchyme can form in the absence of TGFβ signaling, although mesenchymal cell numbers may be misregulated; (2) TGFβ signaling is essential for correct remodeling of the cushions, particularly those of the outflow tract; (3) TGFβ signaling also has a role in ensuring accurate remodeling of the pharyngeal arch arteries to form the mature aortic arch; and (4) mesenchymal cells derived from the epicardium require TGFβ signaling to promote their differentiation to vascular smooth muscle cells to support the coronary arteries. In addition, a mouse genetics approach has also been used to investigate the disease pathogenesis of Loeys-Dietz syndrome, a familial autosomal dominant human disorder characterized by a dilated aortic root, and associated with mutations in the two TGFβ signaling receptor genes, TGFBR1 and TGFBR2. Further important insights are likely as this exciting work progresses.
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Affiliation(s)
- Helen M Arthur
- Institute of Human Genetics, Newcastle University, Newcastle upon Tyne, United Kingdom.
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