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Whelan AR, Thorsen MM, MacCarrick G, Russo ML. Cardiovascular and obstetrical outcomes among delivering patients with Marfan or Loeys-Dietz syndrome: a retrospective analysis by hospital delivery setting. Am J Obstet Gynecol MFM 2024; 6:101340. [PMID: 38460826 DOI: 10.1016/j.ajogmf.2024.101340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/26/2024] [Accepted: 03/04/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND Pregnancy is a high-risk time for patients with Marfan syndrome or Loeys-Dietz syndrome because of the risk for cardiovascular complications, including the risk for aortic dissection. Little is known about the differences in obstetrical and cardiac outcomes based on delivery hospital setting (academic or academic-affiliated vs community medical centers). OBJECTIVE This study aimed to evaluate the obstetrical and cardiac outcomes of patients with Marfan syndrome or Loeys-Dietz syndrome based on delivery hospital setting. STUDY DESIGN This was a secondary analysis of a retrospective, observational cohort study of singleton pregnancies among patients with a diagnosis of Marfan syndrome or Loeys-Dietz syndrome from 1990 to 2016. Patients were identified through the Marfan Foundation, the Loeys-Dietz Syndrome Foundation, or the Cardiovascular Connective Tissue Clinic at Johns Hopkins Hospital. Data were obtained via self-reported obstetrical history and verified by review of medical records. Nonparametric analyses were performed using Fisher's exact tests and Wilcoxon rank-sum tests. RESULTS A total of 273 deliveries among patients with Marfan syndrome or Loeys-Dietz syndrome were included in this analysis (Table 1). More patients who had a known diagnosis before delivery of either Marfan syndrome or Loeys-Dietz syndrome delivered at an academic hospital as opposed to a community hospital (78.6% vs 59.9%; P=.001). Patients with Marfan syndrome or Loeys-Dietz syndrome who delivered at academic centers were more likely to have an operative vaginal delivery than those who delivered at community centers (23.7% vs 8.6%; P=.002). When the indications for cesarean delivery were assessed, connective tissue disease was the primary indication for the mode of delivery at community centers when compared with academic centers (55.6% vs 43.5%; P=.02). There were higher rates of cesarean delivery for arrest of labor and/or malpresentation at community hospitals than at academic centers (23.6% vs 5.3%; P=.01). There were no differences between groups in terms of the method of anesthesia used for delivery. Among those with a known diagnosis of Marfan syndrome or Loeys-Dietz syndrome before delivery, there were increased operative vaginal delivery rates at academic hospitals than at community hospitals (27.2% vs 15.1%; P=.03) (Table 2). More patients with an aortic root measuring ≥4 cm before or after pregnancy delivered at academic centers as opposed to community centers (33.0% vs 10.2%; P=.01), but there were no significant differences in the median size of the aortic root during pregnancy or during the postpartum assessment between delivery locations. Cardiovascular complications were rare; 8 patients who delivered at academic centers and 7 patients who delivered at community centers had an aortic dissection either in pregnancy or the postpartum period (P=.79). CONCLUSION Patients with Marfan syndrome or Loeys-Dietz syndrome and more severe aortic phenotypes were more likely to deliver at academic hospitals. Those who delivered at academic hospitals had higher rates of operative vaginal delivery. Despite lower frequencies of aortic root diameter >4.0 cm, those who delivered at community hospitals had higher rates of cesarean delivery for the indication of Marfan syndrome or Loeys-Dietz syndrome. Optimal delivery management of these patients requires further prospective research.
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Affiliation(s)
- Anna R Whelan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Massachusetts Medical School; Worcester, MA (Dr. Whelan)
| | - Margaret M Thorsen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, RI (Drs. Thorsen, and Russo).
| | - Gretchen MacCarrick
- Department of Genetic Medicine, Johns Hopkins School of Medicine, Baltimore, MD (Ms MacCarrick)
| | - Melissa L Russo
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, RI (Drs. Thorsen, and Russo)
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Yagyu T, Noguchi T. Diagnosis and treatment of cardiovascular disease in patients with heritable connective tissue disorders or heritable thoracic aortic diseases. Cardiovasc Interv Ther 2024; 39:126-136. [PMID: 38182694 DOI: 10.1007/s12928-023-00977-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 11/28/2023] [Indexed: 01/07/2024]
Abstract
Patients with heritable connective tissue disorders (HCTDs), represented by Marfan syndrome, can develop fatal aortic and/or arterial complications before age 50. Therefore, accurate diagnosis, appropriate medical treatment, and early prophylactic surgical treatment of aortic and arterial lesions are essential to improve prognosis. Patients with HCTDs generally present with specific physical features due to connective tissue abnormalities, while some patients with heritable thoracic aortic diseases (HTADs) have few distinctive physical characteristics. The development of genetic testing has made it possible to provide accurate diagnoses for patients with HCTDs/HTADs. This review provides an overview of the diagnosis and treatment of HCTDs/HTADs, including current evidence on cardiovascular interventions for this population.
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Affiliation(s)
- Takeshi Yagyu
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1, Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan.
- Department of Genomic Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1, Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
- Department of Genomic Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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Sada V, Puliani G, Feola T, Pirchio R, Pofi R, Sesti F, De Alcubierre D, Amodeo ME, D'Aniello F, Vincenzi L, Gianfrilli D, Isidori AM, Grossman AB, Sbardella E. Tall stature and gigantism in transition age: clinical and genetic aspects-a literature review and recommendations. J Endocrinol Invest 2024; 47:777-793. [PMID: 37891382 DOI: 10.1007/s40618-023-02223-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023]
Abstract
PURPOSE Tall stature is defined as height greater than the threshold of more than 2 standard deviations above the average population height for age, sex, and ethnicity. Many studies have described the main aspects of this condition during puberty, but an analysis of the characteristics that the physician should consider in the differential diagnosis of gigantism-tall stature secondary to a pituitary tumour-during the transition age (15-25 years) is still lacking. METHODS A comprehensive search of English-language original articles was conducted in the MEDLINE database (December 2021-March 2022). We selected all studies regarding epidemiology, genetic aspects, and the diagnosis of tall stature and gigantism during the transition age. RESULTS Generally, referrals for tall stature are not as frequent as expected because most cases are familial and are usually unreported by parents and patients to endocrinologists. For this reason, lacking such experience of tall stature, familiarity with many rarer overgrowth syndromes is essential. In the transition age, it is important but challenging to distinguish adolescents with high constitutional stature from those with gigantism. Pituitary gigantism is a rare disease in the transition age, but its systemic complications are very relevant for future health. Endocrine evaluation is crucial for identifying conditions that require hormonal treatment so that they can be treated early to improve the quality of life and prevent comorbidities of individual patient in this age range. CONCLUSION The aim of our review is to provide a practical clinical approach to recognise adolescents, potentially affected by gigantism, as early as possible.
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Affiliation(s)
- V Sada
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - G Puliani
- Oncological Endocrinology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - T Feola
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
- Neuroendocrinology, Neuromed Institute, IRCCS, Pozzilli, Italy
| | - R Pirchio
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Degli Studi di Napoli "Federico II", Naples, Italy
| | - R Pofi
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
- Oxford Centre for Diabetes, Endocrinology, and Metabolism, Churchill Hospital, Oxford University Hospitals, NHS Trust, Oxford, UK
| | - F Sesti
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - D De Alcubierre
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - M E Amodeo
- Dipartimento Pediatrico Universitario Ospedaliero, Bambino Gesù Children Hospital, Rome, Italy
| | - F D'Aniello
- Dipartimento Pediatrico Universitario Ospedaliero, Bambino Gesù Children Hospital, Rome, Italy
| | - L Vincenzi
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - D Gianfrilli
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - A M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
- Centre for Rare Diseases (ENDO-ERN Accredited), Policlinico Umberto I, Rome, Italy
| | - A B Grossman
- Green Templeton College, University of Oxford, Oxford, UK
- Centre for Endocrinology, Barts and the London School of Medicine, London, UK
| | - E Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy.
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Sama C, Fongwen NT, Chobufo MD, Ajibade A, Roberts M, Greathouse M, Ngonge AL, Adekolu A, Hamirani YS. Frequency of Cardiac Valvulopathies in Patients With Marfan Syndrome: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e54141. [PMID: 38487153 PMCID: PMC10940034 DOI: 10.7759/cureus.54141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2023] [Indexed: 03/17/2024] Open
Abstract
Marfan syndrome (MFS) is a progressive connective tissue disease with a broad range of clinical manifestations. We sought to establish the spectrum of structural valvular abnormalities as cardiovascular involvement has been identified as the most life-threatening aspect of the syndrome. This was a systematic review with a meta-analysis of studies indexed in Medline from the inception of the database to November 7, 2022. Using the random-effects model, separate Forest and Galbraith plots were generated for each valvular abnormality assessed. Heterogeneity was assessed using the I2 statistics whilst funnel plots and Egger's test were used to assess for publication bias. From a total of 35 studies, a random-effects meta-analysis approximated the pooled summary estimates for the prevalence of cardiac valve abnormalities as mitral valve prolapse 65% (95% CI: 57%-73%); mitral valve regurgitation 40% (95% CI: 29%-51%); aortic valve regurgitation 40% (95% CI: 28%-53%); tricuspid valve prolapse 35% (95% CI: 15%-55%); and tricuspid valve regurgitation 43% (95% CI: 8%-78%). Only one study reported on the involvement of the pulmonary valve (pulmonary valve prolapse was estimated at 5.3% (95% CI: 1.9%-11.1%) in a cohort of 114 patients with MFS). We believe this study provides a description of the structural valvular disease spectrum and may help inform providers and patients in understanding the clinical history of MFS in the current treatment era with its increased life expectancy.
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Affiliation(s)
- Carlson Sama
- Internal Medicine, West Virginia University School of Medicine, Morgantown, USA
| | - Noah T Fongwen
- Public Health Sciences, Africa Centre for Disease Control and Prevention (Africa CDC), Addis Ababa, ETH
| | | | - Ademola Ajibade
- Internal Medicine, West Virginia University School of Medicine, Morgantown, USA
| | - Melissa Roberts
- Cardiology, West Virginia University School of Medicine, Morgantown, USA
| | - Mark Greathouse
- Cardiology, West Virginia University School of Medicine, Morgantown, USA
| | | | - Ayowumi Adekolu
- Internal Medicine, West Virginia University School of Medicine, Morgantown, USA
| | - Yasmin S Hamirani
- Cardiology, West Virginia University School of Medicine, Morgantown, USA
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Maigrot JLA, Vargo PR, Kramer B, Rigelsky C, Ghobrial J, Zahka K, Najm H, Roselli EE. Multifocal disease progression and subsequent intervention in patients with actin alpha-2 variants: A single-center experience. J Thorac Cardiovasc Surg 2023:S0022-5223(23)01128-5. [PMID: 38065521 DOI: 10.1016/j.jtcvs.2023.11.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/28/2023] [Accepted: 11/29/2023] [Indexed: 12/29/2023]
Abstract
OBJECTIVES To describe patient characteristics and indications for surgical intervention, reoperation, and outcomes in patients with actin alpha-2 (ACTA2) variants. METHODS A single-center retrospective cohort study with prospective follow-up was performed for 38 patients with an ACTA2 variant. RESULTS From 1999 to 2020, 26 (70%) patients underwent surgery; 11 remain under surveillance (mean follow-up, 7.5 ± 5 years). Median age at index operation was 42 (range, 10-69) years, with 4 pediatric cases. Thoracic aortic aneurysm was present in 19 (73%) patients (mean adult max diameter, 5.2 ± 0.8 cm; pediatric z score, 10.7 ± 5.4). Aortic dissection was present in 13 (50%) patients, with 4 (15%) having type A dissection. Operations included replacement of the aortic root in 16 (17%), ascending aorta in 20 (77%), and aortic arch in 14 (54%) patients. Four (15%) patients had coronary artery disease, and 2 (7.7%) underwent concomitant coronary artery bypass grafting. There was no operative mortality, stroke, reoperation for bleeding, or dialysis-dependent renal failure; One (3.8%) patient developed acute on chronic kidney injury. Three patients (12%) required prolonged ventilation. Eleven (42%) patients underwent 26 reoperations, median time 45 (range, 4-147) months, including 5 open thoracoabdominal aneurysm repairs. CONCLUSIONS Patients with ACTA2 variants frequently develop aortic aneurysm and are at risk of aortic dissection and coronary artery disease. However, age at diagnosis and symptoms at presentation are highly variable. Multiple operations are often required for disease management, particularly after dissection. Close monitoring and timely intervention are important in mitigating disease progression and improving outcomes.
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Affiliation(s)
- Jean-Luc A Maigrot
- Department of Thoracic and Cardiovascular Surgery, Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Patrick R Vargo
- Department of Thoracic and Cardiovascular Surgery, Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Benjamin Kramer
- Department of Thoracic and Cardiovascular Surgery, Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Christina Rigelsky
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joanna Ghobrial
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kenneth Zahka
- Department of Thoracic and Cardiovascular Surgery, Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Hani Najm
- Department of Thoracic and Cardiovascular Surgery, Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Division of Pediatric and Congenital Heart Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Division of Pediatric and Congenital Heart Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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Ronco D, Buttiglione G, Garatti A, Parolari A. Biology of mitral valve prolapse: from general mechanisms to advanced molecular patterns-a narrative review. Front Cardiovasc Med 2023; 10:1128195. [PMID: 37332582 PMCID: PMC10272793 DOI: 10.3389/fcvm.2023.1128195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 05/11/2023] [Indexed: 06/20/2023] Open
Abstract
Mitral valve prolapse (MVP) represents the most frequent cause of primary mitral regurgitation. For several years, biological mechanisms underlying this condition attracted the attention of investigators, trying to identify the pathways responsible for such a peculiar condition. In the last ten years, cardiovascular research has moved from general biological mechanisms to altered molecular pathways activation. Overexpression of TGF-β signaling, for instance, was shown to play a key role in MVP, while angiotensin-II receptor blockade was found to limit MVP progression by acting on the same signaling pathway. Concerning extracellular matrix organization, the increased valvular interstitial cells density and dysregulated production of catalytic enzymes (matrix metalloproteinases above all) altering the homeostasis between collagen, elastin and proteoglycan components, have been shown to possibly provide a mechanistic basis contributing to the myxomatous MVP phenotype. Moreover, it has been observed that high levels of osteoprotegerin may contribute to the pathogenesis of MVP by increasing collagen deposition in degenerated mitral leaflets. Although MVP is believed to represent the result of multiple genetic pathways alterations, it is important to distinguish between syndromic and non-syndromic conditions. In the first case, such as in Marfan syndrome, the role of specific genes has been clearly identified, while in the latter a progressively increasing number of genetic loci have been thoroughly investigated. Moreover, genomics is gaining more interest as potential disease-causing genes and loci possibly associated with MVP progression and severity have been identified. Animal models could be of help in better understanding the molecular basis of MVP, possibly providing sufficient information to tackle specific mechanisms aimed at slowing down MVP progression, therefore developing non-surgical therapies impacting on the natural history of this condition. Although continuous progress has been made in this field, further translational studies are advocated to improve our knowledge of biological mechanisms underlying MVP development and progression.
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Affiliation(s)
- Daniele Ronco
- Department of Congenital Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
- Department of Universitary Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Gianpiero Buttiglione
- Department of Universitary Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Andrea Garatti
- Department of Universitary Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
| | - Alessandro Parolari
- Department of Universitary Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
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Yagyu T, Noguchi T, Asano Y, Ida K, Ogata S, Nishimura K, Matsuda H. Association Between Genetic Diagnosis and Clinical Outcomes in Patients With Heritable Thoracic Aortic Disease. J Am Heart Assoc 2023; 12:e028625. [PMID: 37042257 PMCID: PMC10227281 DOI: 10.1161/jaha.122.028625] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 03/16/2023] [Indexed: 04/13/2023]
Abstract
Background Differences in the clinical course of heritable thoracic aortic disease based on the disease-causing gene have not been fully evaluated. To clarify the clinical relevance of causative genes in heritable thoracic aortic disease, we assessed the clinical course of patients categorized based on genetic diagnosis. Methods and Results We investigated cardiovascular events and mortality in 518 genetically diagnosed patients in 4 groups: Group 1, FBN1 (n=344); Group 2, TGFBR1, TGFBR2, SMAD3, or TGFB2 (n=74); Group 3, COL3A1 (n=60); and Group 4, ACTA2 or MYH11 (n=40). The median age at the first cardiovascular event ranged from 30.0 to 35.5 years (P=0.36). Patients with gene variants related to transforming growth factor-β signaling had a significantly higher rate of subsequent events than those with FBN1 variants (adjusted hazard ratio, 2.33 [95% CI, 1.60-3.38]; P<0.001). Regarding the incidence of aortic dissection, there were no significant differences among the 4 groups in male patients (36.3%, 34.3%, 21.4%, and 54.2%, respectively; P=0.06). Female patients with COL3A1 variants had a significantly lower incidence than female patients in the other 3 groups (34.2%, 59.0%, 3.1%, and 43.8%, respectively; P<0.001). Conclusions Gene variants related to transforming growth factor-β signaling are associated with a higher incidence of subsequent cardiovascular events than FBN1 variants. COL3A1 variants might be related to a lower incidence of aortic dissection than other gene variants in women only. Identifying the genetic background of patients with heritable thoracic aortic disease is important for determining appropriate treatment.
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Affiliation(s)
- Takeshi Yagyu
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
- Department of Genomic MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Teruo Noguchi
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
- Department of Genomic MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Yoshihiro Asano
- Department of Genomic MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Kazufumi Ida
- Department of Genomic MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Soshiro Ogata
- Department of Preventive Medicine and EpidemiologyNational Cerebral and Cardiovascular Center Research InstituteSuitaJapan
| | - Kunihiro Nishimura
- Department of Preventive Medicine and EpidemiologyNational Cerebral and Cardiovascular Center Research InstituteSuitaJapan
| | - Hitoshi Matsuda
- Department of Cardiovascular SurgeryNational Cerebral and Cardiovascular CenterSuitaJapan
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Tsao CW, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Beaton AZ, Boehme AK, Buxton AE, Commodore-Mensah Y, Elkind MSV, Evenson KR, Eze-Nliam C, Fugar S, Generoso G, Heard DG, Hiremath S, Ho JE, Kalani R, Kazi DS, Ko D, Levine DA, Liu J, Ma J, Magnani JW, Michos ED, Mussolino ME, Navaneethan SD, Parikh NI, Poudel R, Rezk-Hanna M, Roth GA, Shah NS, St-Onge MP, Thacker EL, Virani SS, Voeks JH, Wang NY, Wong ND, Wong SS, Yaffe K, Martin SS. Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association. Circulation 2023; 147:e93-e621. [PMID: 36695182 DOI: 10.1161/cir.0000000000001123] [Citation(s) in RCA: 1491] [Impact Index Per Article: 1491.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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de Koning L, Warnink-Kavelaars J, van Rossum M, Limmen S, Van der Looven R, Muiño-Mosquera L, van der Hulst A, Oosterlaan J, Rombaut L, Engelbert R. Physical activity and physical fitness in children with heritable connective tissue disorders. Front Pediatr 2023; 11:1057070. [PMID: 37009265 PMCID: PMC10065825 DOI: 10.3389/fped.2023.1057070] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 02/21/2023] [Indexed: 04/04/2023] Open
Abstract
Objectives Health problems in patients with heritable connective tissue disorders (HCTD) are diverse and complex and might lead to lower physical activity (PA) and physical fitness (PF). This study aimed to investigate the PA and PF of children with heritable connective tissue disorders (HCTD). Methods PA was assessed using an accelerometer-based activity monitor (ActivPAL) and the mobility subscale of the Pediatric Evaluation of Disability Inventory Computer Adaptive Test (PEDI-CAT). PF was measured in terms of cardiovascular endurance using the Fitkids Treadmill Test (FTT); maximal hand grip strength, using hand grip dynamometry (HGD) as an indicator of muscle strength; and motor proficiency, using the Bruininks-Oseretsky Test of Motor Proficiency-2 (BOTMP-2). Results A total of 56 children, with a median age of 11.6 (interquartile range [IQR], 8.8-15.8) years, diagnosed with Marfan syndrome (MFS), n = 37, Loeys-Dietz syndrome (LDS), n = 6, and genetically confirmed Ehlers-Danlos (EDS) syndromes, n = 13 (including classical EDS n = 10, vascular EDS n = 1, dermatosparaxis EDS n = 1, arthrochalasia EDS n = 1), participated. Regarding PA, children with HCTD were active for 4.5 (IQR 3.5-5.2) hours/day, spent 9.2 (IQR 7.6-10.4) hours/day sedentary, slept 11.2 (IQR 9.5-11.5) hours/day, and performed 8,351.7 (IQR 6,456.9-1,0484.6) steps/day. They scored below average (mean (standard deviation [SD]) z-score -1.4 (1.6)) on the PEDI-CAT mobility subscale. Regarding PF, children with HCTD scored well below average on the FFT (mean (SD) z-score -3.3 (3.2)) and below average on the HGD (mean (SD) z-score -1.1 (1.2)) compared to normative data. Contradictory, the BOTMP-2 score was classified as average (mean (SD) z-score.02 (.98)). Moderate positive correlations were found between PA and PF (r(39) = .378, p < .001). Moderately sized negative correlations were found between pain intensity and fatigue and time spent actively (r(35) = .408, p < .001 and r(24) = .395 p < .001, respectively). Conclusion This study is the first to demonstrate reduced PA and PF in children with HCTD. PF was moderately positively correlated with PA and negatively correlated with pain intensity and fatigue. Reduced cardiovascular endurance, muscle strength, and deconditioning, combined with disorder-specific cardiovascular and musculoskeletal features, are hypothesized to be causal. Identifying the limitations in PA and PF provides a starting point for tailor-made interventions.
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Affiliation(s)
- Lisanne de Koning
- Center of Expertise Urban Vitality, Faculty of Health, University of Applied Sciences Amsterdam, Amsterdam, Netherlands
- Department of Rehabilitation Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
- Correspondence: Lisanne de Koning
| | - Jessica Warnink-Kavelaars
- Department of Rehabilitation Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, Netherlands
| | - Marion van Rossum
- Department of Pediatrics, Emma Children's Hospital, Academic Medical Center, Amsterdam, Netherlands
- Amsterdam Rheumatology and Immunology Center, Reade, Amsterdam, Netherlands
| | - Selina Limmen
- Center of Expertise Urban Vitality, Faculty of Health, University of Applied Sciences Amsterdam, Amsterdam, Netherlands
| | - Ruth Van der Looven
- Department of Physical and Rehabilitation Medicine, Child Rehabilitation, Ghent University Hospital, Ghent, Belgium
| | - Laura Muiño-Mosquera
- Department of Pediatrics, Division of Pediatric Cardiology, Ghent University Hospital, Ghent, Belgium
- Center for Medical Genetics, Ghent University Hospital/Ghent University, Ghent, Belgium
| | - Annelies van der Hulst
- Department of Pediatric Cardiology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, Netherlands
| | - Jaap Oosterlaan
- Department of Pediatrics, Emma Children's Hospital Amsterdam UMC Follow-Me Program & Emma Neuroscience Group, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands
| | - Lies Rombaut
- Center for Medical Genetics, Ghent University Hospital/Ghent University, Ghent, Belgium
| | - Raoul Engelbert
- Center of Expertise Urban Vitality, Faculty of Health, University of Applied Sciences Amsterdam, Amsterdam, Netherlands
- Department of Rehabilitation Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, Netherlands
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Delwarde C, Capoulade R, Mérot J, Le Scouarnec S, Bouatia-Naji N, Yu M, Huttin O, Selton-Suty C, Sellal JM, Piriou N, Schott JJ, Dina C, Le Tourneau T. Genetics and pathophysiology of mitral valve prolapse. Front Cardiovasc Med 2023; 10:1077788. [PMID: 36873395 PMCID: PMC9978496 DOI: 10.3389/fcvm.2023.1077788] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 01/23/2023] [Indexed: 02/18/2023] Open
Abstract
Mitral valve prolapse (MVP) is a common condition affecting 2-3% of the general population, and the most complex form of valve pathology, with a complication rate up to 10-15% per year in advanced stages. Complications include mitral regurgitation which can lead to heart failure and atrial fibrillation, but also life-threatening ventricular arrhythmia and cardiovascular death. Sudden death has been recently brought to the forefront of MVP disease, increasing the complexity of management and suggesting that MVP condition is not properly understood. MVP can occur as part of syndromic conditions such as Marfan syndrome, but the most common form is non-syndromic, isolated or familial. Although a specific X-linked form of MVP was initially identified, autosomal dominant inheritance appears to be the primary mode of transmission. MVP can be stratified into myxomatous degeneration (Barlow), fibroelastic deficiency, and Filamin A-related MVP. While FED is still considered a degenerative disease associated with aging, myxomatous MVP and FlnA-MVP are recognized as familial pathologies. Deciphering genetic defects associated to MVP is still a work in progress; although FLNA, DCHS1, and DZIP1 have been identified as causative genes in myxomatous forms of MVP thanks to familial approaches, they explain only a small proportion of MVP. In addition, genome-wide association studies have revealed the important role of common variants in the development of MVP, in agreement with the high prevalence of this condition in the population. Furthermore, a potential genetic link between MVP and ventricular arrhythmia or a specific type of cardiomyopathy is considered. Animal models that allow to advance in the genetic and pathophysiological knowledge of MVP, and in particular those that can be easily manipulated to express a genetic defect identified in humans are detailed. Corroborated by genetic data and animal models, the main pathophysiological pathways of MVP are briefly addressed. Finally, genetic counseling is considered in the context of MVP.
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Affiliation(s)
- Constance Delwarde
- Nantes Université, CHU Nantes, CNRS, INSERM, L'institut du Thorax, Nantes, France
| | - Romain Capoulade
- Nantes Université, CHU Nantes, CNRS, INSERM, L'institut du Thorax, Nantes, France
| | - Jean Mérot
- Nantes Université, CHU Nantes, CNRS, INSERM, L'institut du Thorax, Nantes, France
| | - Solena Le Scouarnec
- Nantes Université, CHU Nantes, CNRS, INSERM, L'institut du Thorax, Nantes, France
| | | | - Mengyao Yu
- Human Phenome Institute, Fudan University, Shanghai, China
| | - Olivier Huttin
- Service de Cardiologie, Institut Lorrain du Coeur et des Vaisseaux Louis Mathieu, CHU de Nancy, Nancy, France
| | - Christine Selton-Suty
- Service de Cardiologie, Institut Lorrain du Coeur et des Vaisseaux Louis Mathieu, CHU de Nancy, Nancy, France
| | - Jean-Marc Sellal
- Service de Cardiologie, Institut Lorrain du Coeur et des Vaisseaux Louis Mathieu, CHU de Nancy, Nancy, France
| | - Nicolas Piriou
- Nantes Université, CHU Nantes, CNRS, INSERM, L'institut du Thorax, Nantes, France
| | - Jean-Jacques Schott
- Nantes Université, CHU Nantes, CNRS, INSERM, L'institut du Thorax, Nantes, France
| | - Christian Dina
- Nantes Université, CHU Nantes, CNRS, INSERM, L'institut du Thorax, Nantes, France
| | - Thierry Le Tourneau
- Nantes Université, CHU Nantes, CNRS, INSERM, L'institut du Thorax, Nantes, France
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11
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HTAD patient pathway: Strategy for diagnostic work-up of patients and families with (suspected) heritable thoracic aortic diseases (HTAD). A statement from the HTAD working group of VASCERN. Eur J Med Genet 2022; 66:104673. [PMID: 36460281 DOI: 10.1016/j.ejmg.2022.104673] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/06/2022] [Accepted: 11/27/2022] [Indexed: 11/30/2022]
Abstract
Heritable thoracic aortic diseases (HTAD) are rare pathologies associated with thoracic aortic aneurysms and dissection, which can be syndromic or non-syndromic. They may result from genetic defects. Associated genes identified to date are classified into those encoding components of the (a) extracellular matrix (b) TGFβ pathway and (c) smooth muscle contractile mechanism. Timely diagnosis allows for prompt aortic surveillance and prophylactic surgery, hence improving life expectancy and reducing maternal complications as well as providing reassurance to family members when a diagnosis is ruled out. This document is an expert opinion reflecting strategies put forward by medical experts and patient representatives involved in the HTAD Rare Disease Working Group of VASCERN. It aims to provide a patient pathway that improves patient care by diminishing time to diagnosis, facilitating the establishment of a correct diagnosis using molecular genetics when possible, excluding the diagnosis in unaffected persons through appropriate family screening and avoiding overuse of resources. It is being recommended that patients are referred to an expert centre for further evaluation if they meet at least one of the following criteria: (1) thoracic aortic dissection (<70 years if hypertensive; all ages if non-hypertensive), (2) thoracic aortic aneurysm (all adults with Z score >3.5 or 2.5-3.5 if non-hypertensive or hypertensive and <60 years; all children with Z score >3), (3) family history of HTAD with/without a pathogenic variant in a gene linked to HTAD, (4) ectopia lentis without other obvious explanation and (5) a systemic score of >5 in adults and >3 in children. Aortic imaging primarily relies on transthoracic echocardiography with magnetic resonance imaging or computed tomography as needed. Genetic testing should be considered in those with a high suspicion of underlying genetic aortopathy. Though panels vary among centers, for patients with thoracic aortic aneurysm or dissection or systemic features these should include genes with a definitive or strong association to HTAD. Genetic cascade screening and serial aortic imaging should be considered for family screening and follow-up. In conclusion, the implementation of these strategies should help standardise the diagnostic work-up and follow-up of patients with suspected HTAD and the screening of their relatives.
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Vascular Involvements Are Common in the Branch Arteries of the Abdominal Aorta Rather Than in the Aorta in Vascular Ehlers-Danlos Syndrome. CJC Open 2022; 5:72-76. [PMID: 36700191 PMCID: PMC9869355 DOI: 10.1016/j.cjco.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022] Open
Abstract
Background Vascular Ehlers-Danlos syndrome (vEDS) is a rare disorder with poor prognosis, owing to associated vascular complications. However, the most prevalent arterial problems in patients with vEDS are not well known. Methods We retrospectively examined 20 consecutive patients diagnosed with vEDS and examined their clinical events, image findings, and therapies. Results The age at first complication requiring admission was 29 ± 13 years. The observational period was 67 ± 30 months. Of the 20 patients, 17 took celiprolol at final assessment. At the final follow-up, the total number of complications relating to lesions and requiring admission was 16 for pulmonary lesions (8 patients), 16 for bowel lesions (8 patients), 5 for tendon/ligament lesions (2 patients), 18 for the branch arteries of the abdominal aorta (10 patients), 2 for the aorta (2 patients), and 7 for other arteries (6 patients). Of 54 arterial involvements (aneurysms, dissections, and ruptures), both with and without symptoms, 43 (80%) were in branches of the abdominal aorta (celiac artery and branches, 8; superior mesenteric artery, 4; renal arteries, 3; iliac arteries and branches, 28), 2 (4%) were in the aorta, and 9 were in other arteries. The diameter of the sinus of Valsalva was 29 ± 5 mm, within the normal range. During follow-up, 3 patients died due to suspected ruptures in a branch of the celiac artery, the superior mesenteric artery, and the aorta. Conclusion Our findings indicate that lesions involving the branch arteries of the abdominal aorta, rather than aorta, were the most prevalent lesion type in patients with vEDS.
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Khiatah B, Jazayeri S, Yamamoto N, Burt T, Frugoli A, Brooks DL. Cardiovascular disease in women: A review of spontaneous coronary artery dissection. Medicine (Baltimore) 2022; 101:e30433. [PMID: 36197250 PMCID: PMC9509023 DOI: 10.1097/md.0000000000030433] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 07/28/2022] [Indexed: 11/27/2022] Open
Abstract
Research has demonstrated the disproportionate quality of care for women with cardiovascular disease. These findings have prompted a renewed focus on cardiovascular disease awareness and disease prevention in women. Spontaneous coronary artery dissection (SCAD) is a significant cause of myocardial infarction (MI) and sudden death that primarily affects women. ongoing research has led to improved diagnostic capabilities and changes in approaches to initial and long-term management most importantly this research has provided evidence that SCAD is more common than previously thought and must be evaluated and treated differently from atherosclerotic MI. The difference between SCAD and atherosclerotic MI is highlighted in high rates of recurrent disease, gender distribution, association with exogenous hormones, pregnancy, migraine, physical and emotional stress triggers, concurrent systemic arteriopathies, and connective tissue disease. In this review, we provide updated insights and a summary of the epidemiology, risk factors, clinical presentation, diagnosis, treatment options, prognosis, and recurrence prevention of SCAD. We aim to provide a review of SCAD as a focus on cardiovascular disease awareness and disease prevention in women.
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Affiliation(s)
- Bashar Khiatah
- Community Memorial Hospital, Internal Medicine Department, Ventura, CA, USA
| | - Sam Jazayeri
- Community Memorial Hospital, Internal Medicine Department, Ventura, CA, USA
| | - Naofumi Yamamoto
- College of Osteopathic Medicine of the Pacific, Western University, Pomona, CA, USA
| | - Tristen Burt
- College of Osteopathic Medicine of the Pacific, Western University, Pomona, CA, USA
| | - Amanda Frugoli
- Community Memorial Hospital, Internal Medicine Department, Ventura, CA, USA
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Gouda P, Kay R, Habib M, Aziz A, Aziza E, Welsh R. Clinical features and complications of Loeys-Dietz syndrome: A systematic review. Int J Cardiol 2022; 362:158-167. [PMID: 35662564 DOI: 10.1016/j.ijcard.2022.05.065] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 05/23/2022] [Accepted: 05/29/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Loeys-Dietz syndrome (LDS) is a connective tissue disorder that arises from mutations altering the transforming growth factor β signalling pathway. Due to the recent discovery of the underlying genetic mutations leading to LDS, the spectrum of characteristics and complications is not fully understood. METHODS Our search included five databases (Pubmed, SCOPUS, Web of Science, EMBASE and google scholar) and included variations of "Loeys-Dietz Syndrome" as search terms, using all available data until February 2021. All study types were included. Three reviewers screened 1394 abstracts, of which 418 underwent full-text review and 392 were included in the final analysis. RESULTS We identified 3896 reported cases of LDS with the most commonly reported features and complications being: aortic aneurysms and dissections, arterial tortuosity, high arched palate, abnormal uvula and hypertelorism. LDS Types 1 and 2 share many clinical features, LDS Type 2 appears to have a more aggressive aortic disease. LDS Type 3 demonstrated an increased prevalence of mitral valve prolapse and arthritis. LDS Type 4 and 5 demonstrated a lower prevalence of musculoskeletal and cardiovascular involvement. Amongst 222 women who underwent 522 pregnancies, 4% experienced an aortic dissection and the peripartum mortality rate was 1%. CONCLUSION We observed that LDS is a multisystem connective tissue disorder that is associated with a high burden of complications, requiring a multidisciplinary approach. Ongoing attempts to better characterise these features will allow clinicians to appropriately screen and manage these complications.
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Affiliation(s)
- Pishoy Gouda
- University of Alberta, Division of Cariology, Edmonton, Alberta, Canada
| | - Robert Kay
- University of Alberta, Division of Cariology, Edmonton, Alberta, Canada
| | - Marina Habib
- Flinders University, School of Medicine, Adelaide, Australia
| | - Amir Aziz
- University of Alberta, Division of Cariology, Edmonton, Alberta, Canada
| | - Eitan Aziza
- University of Alberta, Division of Cariology, Edmonton, Alberta, Canada
| | - Robert Welsh
- University of Alberta, Division of Cariology, Edmonton, Alberta, Canada; Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
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15
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Comparative Risks of Initial Aortic Events Associated With Genetic Thoracic Aortic Disease. J Am Coll Cardiol 2022; 80:857-869. [PMID: 36007983 DOI: 10.1016/j.jacc.2022.05.054] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/26/2022] [Accepted: 05/20/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Pathogenic variants in 11 genes predispose individuals to heritable thoracic aortic disease (HTAD), but limited data are available to stratify the risk for aortic events associated with these genes. OBJECTIVES This study sought to compare the risk of first aortic event, specifically thoracic aortic aneurysm surgery or an aortic dissection, among 7 HTAD genes and variant types within each gene. METHODS A retrospective cohort of probands and relatives with rare variants in 7 genes for HTAD (n = 1,028) was assessed for the risk of first aortic events based on the gene altered, pathogenic variant type, sex, proband status, and location of recruitment. RESULTS Significant differences in aortic event risk were identified among the smooth muscle contraction genes (ACTA2, MYLK, and PRKG1; P = 0.002) and among the genes for Loeys-Dietz syndrome, which encode proteins in the transforming growth factor (TGF)-β pathway (SMAD3, TGFB2, TGFBR1, and TGFBR2;P < 0.0001). Cumulative incidence of type A aortic dissection was higher than elective aneurysm surgery in patients with variants in ACTA2, MYLK, PRKG1, and SMAD3; in contrast, patients with TGFBR2 variants had lower cumulative incidence of type A aortic dissection than elective aneurysm surgery. Cumulative incidence of type B aortic dissection was higher for ACTA2, PRKG1, and TGFBR2 than other genes. After adjusting for proband status, sex, and recruitment location, specific variants in ACTA2 and TGFBR2 were associated with substantially higher risk of aortic event with childhood onset. CONCLUSIONS Gene- and variant-specific data on aortic events in individuals with HTAD support personalized aortic surveillance and clinical management.
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16
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Maiello M, Zito A, Cecere A, Ciccone MM, Palmiero P. Chest pain and palpitations in postmenopausal women with mitral valve prolapse: is there a gastro-oesophageal origin? Intern Med J 2022; 52:848-852. [PMID: 33347741 DOI: 10.1111/imj.15174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/30/2020] [Accepted: 12/01/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND AIM Mitral valve prolapse (MVP) is a common disease in women, causing chest pain and palpitation due to structural and functional valve abnormality, and is sometimes associated with gastro-oesophageal reflux disease (GERD). This is a challenging clinical problem in clinical practice and requires targeted diagnostic assessment to identify the underlying causes of the symptoms, because treatment needs to be tailored, according to the causes themselves, to resolve the symptoms. AIM To assess the prevalence of GERD in a population of postmenopausal women affected by MVP and determine if there is any correlation between the two conditions. METHODS The MVP diagnosis was performed using echocardiograpy examination, according to American Society Echocardiography criteria. Two hundred and eighty-nine consecutive MVP women, symptomatic for chest pain and palpitation, were included; 250 consecutive women without MVP, symptomatic for chest pain and palpitation, were the control group (CG). The GERD diagnosis was made according to 2013 American College Gastroenterology criteria; women affected by thyroid disorders, all heart disease, including mitral disease with moderate or severe mitral regurgitation, and gastrointestinal diseases assessed using gastroscopy were excluded. RESULTS Among 289 women with MVP, 31 (11%) women were affected by GERD, and among 250 in the CG, 11 (4.4%) women were affected by GERD: Chi-squared 8.1; odds ratio 2.7; P < 0.0044. Twenty-six (9%) women affected by GERD, with MVP, presented with mild mitral regurgitation, and 7 (2.8%) women in the CG presented with mild mitral regurgitation as well: Chi-squared 8.95; odds ratio 3.4; 95% CI, P < 0.0028. DISCUSSION AND CONCLUSIONS GERD is relatively common in women with MVP. Moreover, women with MVP are approximately three times more likely to be affected by GERD; the two conditions are correlated in a statistically high significant way. GERD assessment needs to be included into routine follow-up strategies in women with MVP to optimise medical therapy, improvinge symptom relief for better quality of life.
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Affiliation(s)
- Maria Maiello
- ASL BRINDISI, Cardiology Equipe, District of Brindisi, Brindisi, Italy
| | - Annapaola Zito
- ASL BRINDISI, Cardiology Equipe, District of Francavilla Fontana, Francavilla Fontana, Italy
| | - Annagrazia Cecere
- Department of Cardiac-Thoracic-Vascular Science and Public Health, University of Padua, Padua, Italy
| | - Marco Matteo Ciccone
- Cardiovascular Diseases Section, Department of Emergency and Organ Transplantation (DETO), University of Bari, Bari, Italy
| | - Pasquale Palmiero
- ASL BRINDISI, Cardiology Equipe, District of Brindisi, Brindisi, Italy
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Acharya M, Maselli D, Mariscalco G. Genetic screening in heritable thoracic aortic disease—rationale, potentials and pitfalls. Indian J Thorac Cardiovasc Surg 2022; 38:24-35. [PMID: 35463717 PMCID: PMC8980988 DOI: 10.1007/s12055-020-01124-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/09/2020] [Accepted: 12/11/2020] [Indexed: 11/28/2022] Open
Abstract
Thoracic aortic aneurysms are silent yet deadly clinical entities which may elude detection until an acutely life-threatening aortic dissection or rupture occurs. Approximately 20% of patients with thoracic aortic aneurysms or dissection have a positive family history, indicating a strong genetic component to the aetiology. Genetic screening in such hereditary thoracic aortic disease (HTAD) may thus be beneficial in detecting causative genetic mutations in affected patients, identifying asymptomatic family members who may be at risk, and in guiding the optimal timing of preventative surgery in those with confirmed genetic aortopathy. Genetic screening can facilitate personalised aortic care tailored to an individual's specific genetic abnormality, with the aim of mitigating the significant morbidity burden and premature mortality associated with HTAD. This review examines the rationale for genetic screening in HTAD, its potential applications, current limitations and potential future directions.
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Affiliation(s)
- Metesh Acharya
- Department of Cardiac Surgery, Glenfield Hospital, Leicester, UK
| | - Daniele Maselli
- Department of Cardiac Surgery, European Hospital, Rome, Italy
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18
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Prajapati BB, Monti J. Myopia in the Diagnosis of Marfan Syndrome: An Important Early Sign of a Systemic Condition. Cureus 2022; 14:e23651. [PMID: 35505728 PMCID: PMC9053542 DOI: 10.7759/cureus.23651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2022] [Indexed: 11/05/2022] Open
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Sun L, Chang Y, Jiang P, Ma Y, Yuan Q, Ma X. Association of gene polymorphisms in FBN1 and TGF-β signaling with the susceptibility and prognostic outcomes of Stanford type B aortic dissection. BMC Med Genomics 2022; 15:65. [PMID: 35307021 PMCID: PMC8935688 DOI: 10.1186/s12920-022-01213-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 02/28/2022] [Indexed: 11/13/2022] Open
Abstract
Background This study is aimed at investigating the association of Fibrillin-1 (FBN1) and transforming growth factor β (TGF-β) signaling-related gene polymorphisms with the susceptibility of Stanford type B aortic dissection (AD) and its clinical prognostic outcomes. Methods Five single-nucleotide polymorphism (SNPs) (FBN1rs 145233125, rs201170905, rs11070646, TGFB1rs1800469, and TGFB2rs900) were analyzed in patients with Stanford type B AD (164) and healthy controls (317). Gene–gene and gene–environment interactions were assessed by generalized multifactor dimensionality reduction. A 4-year follow-up was performed for all AD patients. Results G carriers of FBN1 rs201170905 and TGFB1 rs1800469 have an increased risk of Stanford type B AD. The interaction of FBN1, TGFB1, TGFB2 and environmental promoted to the increased risk of type B AD (cross-validation consistency = 10/10, P = 0.001). Dominant models of FBN1rs145233125 TC + CC genotype (P = 0.028), FBN1 rs201170905 AG + GG (P = 0.047) and TGFB1 rs1800469 AG + GG (P = 0.052) were associated with an increased risk of death of Stanford type B AD. The recessive model of FBN1 rs145233125 CC genotype (P < 0.001), FBN1rs201170905 GG (P < 0.001), TGFB1 rs1800469 AG + GG genotype (P = 0.011) was associated with an increased risk of recurrence of chest pain in Stanford type B AD. Conclusions The interactions of gene–gene and gene–environment are related with the risk of Stanford type B AD. C carriers of rs145233125, G carriers of rs201170905 and G carriers of rs1800469 may be the poor clinical outcome indicators of mortality and recurrent chest pain in Stanford type B AD. Supplementary Information The online version contains supplementary material available at 10.1186/s12920-022-01213-z.
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Russo M, Boehler-Tatman M, Albright C, David C, Kennedy L, Roberts AW, Shalhub S, Afifi R. Aortic dissection in pregnancy and the postpartum period. Semin Vasc Surg 2022; 35:60-68. [PMID: 35501042 DOI: 10.1053/j.semvascsurg.2022.02.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/16/2022] [Accepted: 02/16/2022] [Indexed: 01/18/2023]
Abstract
Pregnancy-associated aortic dissection (AD) is a rare event, with an incidence of 0.0004% per pregnancy. The work of the Aortic Dissection Collaborative identified pregnancy-associated AD as a high-priority topic, despite its rarity. The Pregnancy Working Group, which included physicians and patient stakeholders, performed a systematic literature review of pregnancy-associated AD from 1960 to 2021 and identified 6,333 articles through PubMed, OVID MEDLINE, Cochrane, Embase, CINAHL and Web of Science. The inclusion criterion was AD in pregnant populations and exclusion criteria were case reports, conference abstracts, and languages other than English. Assessment of full-text articles for eligibility after removal of duplicates from all databases yielded 68 articles to be included in the final review. Topics included were timing of AD in pregnancy, type of AD, and management considerations of pregnancy-associated AD. The Pregnancy Working Group identified gaps in knowledge and future areas of research for pregnancy-associated AD, including clinical management, mental health outcomes post AD, reproductive and genetic counseling, and contraception after AD. Future collaborative projects could be a multicenter, international registry for all pregnancy-associated AD to refine the risk factors, best practice and management of AD in pregnancy. In addition, future mixed methodology studies may be useful to explore social, mental, and emotional factors related to pregnancy-associated AD and to determine support groups' effect on anxiety and depression related to these events in the pregnancy and postpartum period.
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Affiliation(s)
- Melissa Russo
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Women and Infants Hospital, Providence, Warren Alpert Medical School of Brown University, Providence, RI
| | | | - Catherine Albright
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Washington Medical Center, Seattle, WA
| | - Carmen David
- Aortic Dissection Collaborative Patient Stakeholder Group, Bedford, TX
| | | | - Aaron W Roberts
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center, Houston, TX
| | - Sherene Shalhub
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA
| | - Rana Afifi
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), 6400 Fannin Street, Suite #2850, Houston, TX 77030.
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Kimura N, Itagaki R, Nakamura M, Tofrizal A, Yatabe M, Yoshizaki T, Kokubo R, Hishikawa S, Kunita S, Adachi H, Misawa Y, Yashiro T, Kawahito K. Limbicuspidalization of the Native Tricuspid Aortic Valve: A Porcine in Vivo Model of Bicuspid Aortopathy. Ann Vasc Dis 2022; 15:37-44. [PMID: 35432643 PMCID: PMC8958402 DOI: 10.3400/avd.oa.21-00116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 02/01/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Naoyuki Kimura
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University
| | - Ryo Itagaki
- Department of Surgery, Division of Cardiovascular Surgery, Jichi Medical University
| | - Masanori Nakamura
- Department of Electrical and Mechanical Engineering, Nagoya Institute of Technology
| | - Alimuddin Tofrizal
- Department of Anatomy, Division of Histology and Cell Biology, Jichi Medical University
| | - Megumi Yatabe
- Department of Anatomy, Division of Histology and Cell Biology, Jichi Medical University
| | - Takamichi Yoshizaki
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University
| | - Ryo Kokubo
- Department of Medical Engineering, Saitama Medical Center, Jichi Medical University
| | - Shuji Hishikawa
- Medical Education and Training Core, Center for Development of Advanced Medical Technology, Jichi Medical University
| | - Satoshi Kunita
- Animal Resource Laboratory, Center for Development of Advanced Medical Technology, Jichi Medical University
| | - Hideo Adachi
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University
| | - Yoshio Misawa
- Department of Surgery, Division of Cardiovascular Surgery, Jichi Medical University
| | - Takashi Yashiro
- Department of Anatomy, Division of Histology and Cell Biology, Jichi Medical University
| | - Koji Kawahito
- Department of Surgery, Division of Cardiovascular Surgery, Jichi Medical University
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Connective Tissue Disorders and Cardiovascular Complications: The Indomitable Role of Transforming Growth Factor-β Signaling. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1348:161-184. [PMID: 34807419 DOI: 10.1007/978-3-030-80614-9_7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Marfan Syndrome (MFS) and Loeys-Dietz Syndrome (LDS) represent heritable connective tissue disorders that segregate with a similar pattern of cardiovascular defects (thoracic aortic aneurysm, mitral valve prolapse/regurgitation, and aortic dilatation with regurgitation). This pattern of cardiovascular defects appears to be expressed along a spectrum of severity in many heritable connective tissue disorders and raises suspicion of a relationship between the normal development of connective tissues and the cardiovascular system. With overwhelming evidence of the involvement of aberrant Transforming Growth Factor-beta (TGF-β) signaling in MFS and LDS, this signaling pathway may represent the common link in the relationship between connective tissue disorders and their associated cardiovascular complications. To further explore this hypothetical link, this chapter will review the TGF-β signaling pathway, the heritable connective tissue syndromes related to aberrant TGF-β signaling, and will discuss the pathogenic contribution of TGF-β to these syndromes with a primary focus on the cardiovascular system.
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Abstract
The inherited connective tissue disorders (Marfan syndrome, Loeys-Dietz syndrome [LDS], and Ehlers-Danlos syndrome [EDS]) involve connective tissue of various organ systems. These pathologies share many common features, nonetheless compared to Marfan syndrome, LDS' cardiovascular manifestations tend to be more severe. In contrast, no association is reported between LDS and the presence of ectopia lentis. The EDS are currently classified into thirteen subtypes. There is substantial symptoms overlap between the EDS subtypes, and they are associated with an increased incidence of cardiovascular abnormalities, such as mitral valve prolapse and aortic dissection.
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Abstract
Marfan syndrome (MFS) is an autosomal dominant, age-related but highly penetrant condition with substantial intrafamilial and interfamilial variability. MFS is caused by pathogenetic variants in FBN1, which encodes fibrillin-1, a major structural component of the extracellular matrix that provides support to connective tissues, particularly in arteries, the pericondrium and structures in the eye. Up to 25% of individuals with MFS have de novo variants. The most prominent manifestations of MFS are asymptomatic aortic root aneurysms, aortic dissections, dislocation of the ocular lens (ectopia lentis) and skeletal abnormalities that are characterized by overgrowth of the long bones. MFS is diagnosed based on the Ghent II nosology; genetic testing confirming the presence of a FBN1 pathogenetic variant is not always required for diagnosis but can help distinguish MFS from other heritable thoracic aortic disease syndromes that can present with skeletal features similar to those in MFS. Untreated aortic root aneurysms can progress to life-threatening acute aortic dissections. Management of MFS requires medical therapy to slow the rate of growth of aneurysms and decrease the risk of dissection. Routine surveillance with imaging techniques such as transthoracic echocardiography, CT or MRI is necessary to monitor aneurysm growth and determine when to perform prophylactic repair surgery to prevent an acute aortic dissection.
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Morningstar JE, Nieman A, Wang C, Beck T, Harvey A, Norris RA. Mitral Valve Prolapse and Its Motley Crew-Syndromic Prevalence, Pathophysiology, and Progression of a Common Heart Condition. J Am Heart Assoc 2021; 10:e020919. [PMID: 34155898 PMCID: PMC8403286 DOI: 10.1161/jaha.121.020919] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/21/2021] [Indexed: 01/01/2023]
Abstract
Mitral valve prolapse (MVP) is a commonly occurring heart condition defined by enlargement and superior displacement of the mitral valve leaflet(s) during systole. Although commonly seen as a standalone disorder, MVP has also been described in case reports and small studies of patients with various genetic syndromes. In this review, we analyzed the prevalence of MVP within syndromes where an association to MVP has previously been reported. We further discussed the shared biological pathways that cause MVP in these syndromes, as well as how MVP in turn causes a diverse array of cardiac and noncardiac complications. We found 105 studies that identified patients with mitral valve anomalies within 18 different genetic, developmental, and connective tissue diseases. We show that some disorders previously believed to have an increased prevalence of MVP, including osteogenesis imperfecta, fragile X syndrome, Down syndrome, and Pseudoxanthoma elasticum, have few to no studies that use up-to-date diagnostic criteria for the disease and therefore may be overestimating the prevalence of MVP within the syndrome. Additionally, we highlight that in contrast to early studies describing MVP as a benign entity, the clinical course experienced by patients can be heterogeneous and may cause significant cardiovascular morbidity and mortality. Currently only surgical correction of MVP is curative, but it is reserved for severe cases in which irreversible complications of MVP may already be established; therefore, a review of clinical guidelines to allow for earlier surgical intervention may be warranted to lower cardiovascular risk in patients with MVP.
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Affiliation(s)
- Jordan E. Morningstar
- Department of Regenerative Medicine and Cell BiologyMedical University of South CarolinaCharlestonSC
| | - Annah Nieman
- Department of Regenerative Medicine and Cell BiologyMedical University of South CarolinaCharlestonSC
| | - Christina Wang
- Department of Regenerative Medicine and Cell BiologyMedical University of South CarolinaCharlestonSC
| | - Tyler Beck
- Department of Regenerative Medicine and Cell BiologyMedical University of South CarolinaCharlestonSC
| | - Andrew Harvey
- Department of Regenerative Medicine and Cell BiologyMedical University of South CarolinaCharlestonSC
| | - Russell A. Norris
- Department of Regenerative Medicine and Cell BiologyMedical University of South CarolinaCharlestonSC
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Berger JA, Huh DD, Lee T, Wadia RS, Bembea MM, Goswami DK. Perioperative management and considerations in pediatric patients with connective tissue disorders undergoing cardiac surgery. Paediatr Anaesth 2021; 31:820-826. [PMID: 33884693 DOI: 10.1111/pan.14196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 03/08/2021] [Accepted: 03/30/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Marfan syndrome and Loeys-Dietz syndrome are connective tissue disorders associated with cardiac and vascular disease. Patients often require surgical repair, but limited data exist to describe their perioperative management. AIMS Our goals were to review the perioperative features of patients with Marfan and Loeys-Dietz syndrome that may affect anesthesia care and to describe the differences in preoperative clinical characteristics and intra-operative anesthetic management. METHODS We conducted a retrospective cohort study of patients with Marfan and Loeys-Dietz syndrome who underwent cardiac surgery at a single institution. We collected demographic and perioperative data from the electronic medical record and performed descriptive statistics to characterize the patient populations and describe their anesthetic management. RESULTS In 71 patients (40 Marfan, 31 Loeys-Dietz), we found significant differences between the Marfan and Loeys-Dietz patients in airway difficulty, preoperative weight, blood utilization, valvular disease, and age at first cardiac surgery. Patients with Loeys-Dietz syndrome had higher preoperative rates of severe noncardiac comorbidities, including gastroesophageal reflux and asthma that required chronic medical therapy. CONCLUSIONS Despite undergoing similar surgical procedures, patients with Marfan and Loeys-Dietz syndrome have different intrinsic patient characteristics and comorbidities that may affect their perioperative care. This retrospective cohort study identified some factors, but additional collection and reporting of patient data based on multicenter experience are essential for the ongoing optimization of perioperative care in these patient populations.
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Affiliation(s)
- Jessica A Berger
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Dana D Huh
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Teresa Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rajeev S Wadia
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dheeraj K Goswami
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Baumgartner H, De Backer J, Babu-Narayan SV, Budts W, Chessa M, Diller GP, Iung B, Kluin J, Lang IM, Meijboom F, Moons P, Mulder BJ, Oechslin E, Roos-Hesselink JW, Schwerzmann M, Sondergaard L, Zeppenfeld K, Ernst S, Ladouceur M, Aboyans V, Alexander D, Christodorescu R, Corrado D, D’Alto M, de Groot N, Delgado V, Di Salvo G, Dos Subira L, Eicken A, Fitzsimons D, Frogoudaki AA, Gatzoulis M, Heymans S, Hörer J, Houyel L, Jondeau G, Katus HA, Landmesser U, Lewis BS, Lyon A, Mueller CE, Mylotte D, Petersen SE, Petronio AS, Roffi M, Rosenhek R, Shlyakhto E, Simpson IA, Sousa-Uva M, Torp-Pedersen CT, Touyz RM, Van De Bruaene A. Guía ESC 2020 para el tratamiento de las cardiopatías congénitas del adulto. Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.10.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Baumgartner H, De Backer J, Babu-Narayan SV, Budts W, Chessa M, Diller GP, Lung B, Kluin J, Lang IM, Meijboom F, Moons P, Mulder BJM, Oechslin E, Roos-Hesselink JW, Schwerzmann M, Sondergaard L, Zeppenfeld K. 2020 ESC Guidelines for the management of adult congenital heart disease. Eur Heart J 2021; 42:563-645. [PMID: 32860028 DOI: 10.1093/eurheartj/ehaa554] [Citation(s) in RCA: 924] [Impact Index Per Article: 308.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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Clinically relevant variants in a large cohort of Indian patients with Marfan syndrome and related disorders identified by next-generation sequencing. Sci Rep 2021; 11:764. [PMID: 33436942 PMCID: PMC7804850 DOI: 10.1038/s41598-020-80755-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 12/23/2020] [Indexed: 11/16/2022] Open
Abstract
Marfan syndrome and related disorders are a group of heritable connective tissue disorders and share many clinical features that involve cardiovascular, skeletal, craniofacial, ocular, and cutaneous abnormalities. The majority of affected individuals have aortopathies associated with early mortality and morbidity. Implementation of targeted gene panel next-generation sequencing in these individuals is a powerful tool to obtain a genetic diagnosis. Here, we report on clinical and genetic spectrum of 53 families from India with a total of 83 patients who had a clinical diagnosis suggestive of Marfan syndrome or related disorders. We obtained a molecular diagnosis in 45/53 (85%) index patients, in which 36/53 (68%) had rare variants in FBN1 (Marfan syndrome; 63 patients in total), seven (13.3%) in TGFBR1/TGFBR2 (Loeys–Dietz syndrome; nine patients in total) and two patients (3.7%) in SKI (Shprintzen–Goldberg syndrome). 21 of 41 rare variants (51.2%) were novel. We did not detect a disease-associated variant in 8 (15%) index patients, and none of them met the Ghent Marfan diagnostic criteria. We found the homozygous FBN1 variant p.(Arg954His) in a boy with typical features of Marfan syndrome. Our study is the first reporting on the spectrum of variants in FBN1, TGFBR1, TGFBR2, and SKI in Indian individuals.
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Neurologic complications of diseases of the aorta. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:221-239. [PMID: 33632441 DOI: 10.1016/b978-0-12-819814-8.00028-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Neurologic complications of diseases of the aorta are common, as the brain and spinal cord function is highly dependent on the aorta and its branches for blood supply. Any disease impacting the aorta may have significant impact on the ability to deliver oxygenated blood to the central nervous system, resulting in ischemia-and if prolonged-cerebral and spinal infarct. The breadth of pathology affecting the aorta is diverse and neurologic complications can vary dramatically based on the location, severity, and underlying etiology. This chapter outlines the major pathology of the aorta while highlighting the associated neurologic complications. This chapter covers the entire spectrum of neurologic complications associated with aortic disease by beginning with a detailed overview of the spinal cord vascular anatomy followed by a discussion of the most common aortic pathologies affecting the nervous system, including aortic aneurysm, aortic dissection, aortic atherosclerosis, inflammatory and infectious aortopathies, congenital abnormalities, and aortic surgery.
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Du Q, Zhang D, Zhuang Y, Xia Q, Wen T, Jia H. The Molecular Genetics of Marfan Syndrome. Int J Med Sci 2021; 18:2752-2766. [PMID: 34220303 PMCID: PMC8241768 DOI: 10.7150/ijms.60685] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 05/18/2021] [Indexed: 12/27/2022] Open
Abstract
Marfan syndrome (MFS) is a complex connective tissue disease that is primarily characterized by cardiovascular, ocular and skeletal systems disorders. Despite its rarity, MFS severely impacts the quality of life of the patients. It has been shown that molecular genetic factors serve critical roles in the pathogenesis of MFS. FBN1 is associated with MFS and the other genes such as FBN2, transforming growth factor beta (TGF-β) receptors (TGFBR1 and TGFBR2), latent TGF-β-binding protein 2 (LTBP2) and SKI, amongst others also have their associated syndromes, however high overlap may exist between these syndromes and MFS. Abnormalities in the TGF-β signaling pathway also contribute to the development of aneurysms in patients with MFS, although the detailed molecular mechanism remains unclear. Mutant FBN1 protein may cause unstableness in elastic structures, thereby perturbing the TGF-β signaling pathway, which regulates several processes in cells. Additionally, DNA methylation of FBN1 and histone acetylation in an MFS mouse model demonstrated that epigenetic factors play a regulatory role in MFS. The purpose of the present review is to provide an up-to-date understanding of MFS-related genes and relevant assessment technologies, with the aim of laying a foundation for the early diagnosis, consultation and treatment of MFS.
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Affiliation(s)
- Qiu Du
- Marfan Research Group, College of Medical Technology, Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, Sichuan, China
| | - Dingding Zhang
- Marfan Research Group, College of Medical Technology, Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, Sichuan, China.,Sichuan Provincial Key Laboratory for Genetic Disease, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, Sichuan, China
| | - Yue Zhuang
- Department of Rheumatology and Immunology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 611731, Sichuan, China
| | - Qiongrong Xia
- Marfan Research Group, College of Medical Technology, Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, Sichuan, China
| | - Taishen Wen
- Sichuan Provincial Key Laboratory for Genetic Disease, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, Sichuan, China
| | - Haiping Jia
- Department of Immunology, North Sichuan Medical College, Nanchong, 637100, Sichuan, China
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Arnaoutakis GJ, Sultan I. Commentary: Personalized medicine for genetically triggered thoracic aortic aneurysms. JTCVS Tech 2020; 6:42-43. [PMID: 34318136 PMCID: PMC8300884 DOI: 10.1016/j.xjtc.2020.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 12/06/2020] [Accepted: 12/18/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
- George J Arnaoutakis
- Division of Cardiovascular Surgery, University of Florida Health, University of Florida College of Medicine, Gainesville, Fla
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Milleron O, Arnoult F, Delorme G, Detaint D, Pellenc Q, Raffoul R, Tchitchinadze M, Langeois M, Guien C, Beroud C, Ropers J, Hanna N, Arnaud P, Gouya L, Boileau C, Jondeau G. Pathogenic FBN1 Genetic Variation and Aortic Dissection in Patients With Marfan Syndrome. J Am Coll Cardiol 2020; 75:843-853. [PMID: 32130918 DOI: 10.1016/j.jacc.2019.12.043] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 11/21/2019] [Accepted: 12/21/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND Aortic risk has not been evaluated in patients with Marfan syndrome and documented pathogenic variants in the FBN1 gene. OBJECTIVES This study sought to describe aortic risk in a population with Marfan syndrome with pathogenic variants in the FBN1 gene as a function of aortic root diameter. METHODS Patients carrying an FBN1 pathogenic variant who visited our reference center at least twice were included, provided they had not undergone aortic surgery or had an aortic dissection before their first visit. Aortic events (aortic surgery or aortic dissection) and deaths were evaluated during the 2 years following each patient visit. The risk was calculated as the number of events divided by the number of years of follow-up. RESULTS A total of 954 patients were included (54% women; mean age 23 years). During follow-up (9.1 years), 142 patients underwent prophylactic aortic root surgery, 5 experienced type A aortic dissection, and 12 died (noncardiovascular causes in 3, unknown etiology in 3, post-operative in 6). When aortic root diameter was <50 mm, risk for proven type A dissection (0.4 events/1,000 patient-years) and risk for possible aortic dissection (proven aortic dissection plus death of unknown cause, 0.7 events/1,000 patients-years) remained low in this population that was treated according to guidelines. Three type A aortic dissections occurred in this population during the 8,594 years of follow-up, including 1 in a patient with a tubular aortic diameter of 50 mm, but none in patients with a family history of aortic dissection. The risk for type B aortic dissection in the same population was 0.5 events/1,000 patient-years. CONCLUSIONS In patients with FBN1 pathogenic variants who receive beta-blocker therapy and who limit strenuous exercise, aortic risk remains low when maximal aortic diameter is <50 mm. The risk of type B aortic dissection is close to the remaining risk of type A aortic dissection in this population, which underlines the global aortic risk.
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Affiliation(s)
- Olivier Milleron
- Centre de référence pour le syndrome de Marfan et apparentés, VASCERN HTAD European Reference Center, AP-HP, Hôpital Bichat, Paris, France
| | - Florence Arnoult
- Centre de référence pour le syndrome de Marfan et apparentés, VASCERN HTAD European Reference Center, AP-HP, Hôpital Bichat, Paris, France; Service des explorations fonctionnelles AP-HP, Hôpital Bichat, Paris, France
| | - Gabriel Delorme
- Centre de référence pour le syndrome de Marfan et apparentés, VASCERN HTAD European Reference Center, AP-HP, Hôpital Bichat, Paris, France
| | - Delphine Detaint
- Centre de référence pour le syndrome de Marfan et apparentés, VASCERN HTAD European Reference Center, AP-HP, Hôpital Bichat, Paris, France
| | - Quentin Pellenc
- Service de chirurgie vasculaire AP-HP, Hôpital Bichat, Paris, France
| | - Richard Raffoul
- Service de chirurgie cardiaque AP-HP, Hôpital Bichat, Paris, France
| | - Maria Tchitchinadze
- Centre de référence pour le syndrome de Marfan et apparentés, VASCERN HTAD European Reference Center, AP-HP, Hôpital Bichat, Paris, France
| | - Maud Langeois
- Centre de référence pour le syndrome de Marfan et apparentés, VASCERN HTAD European Reference Center, AP-HP, Hôpital Bichat, Paris, France
| | - Celine Guien
- Aix Marseille Université, INSERM, MMG, Bioinformatics & Genetics, Marseille, France
| | - Christophe Beroud
- Aix Marseille Université, INSERM, MMG, Bioinformatics & Genetics, Marseille, France
| | - Jacques Ropers
- Unité De Recherche Clinique, AP-HP, Pitié Salpêtrière-Charles Foix, Paris, France
| | - Nadine Hanna
- Département de génétique moléculaire AP-HP, Hôpital Bichat, Paris, France; INSERM U1148, LVTS, Hôpital Bichat, Paris, France
| | - Pauline Arnaud
- Département de génétique moléculaire AP-HP, Hôpital Bichat, Paris, France; INSERM U1148, LVTS, Hôpital Bichat, Paris, France; Université de Paris, Paris, France
| | - Laurent Gouya
- Centre de référence pour le syndrome de Marfan et apparentés, VASCERN HTAD European Reference Center, AP-HP, Hôpital Bichat, Paris, France; Université de Paris, Paris, France
| | - Catherine Boileau
- Centre de référence pour le syndrome de Marfan et apparentés, VASCERN HTAD European Reference Center, AP-HP, Hôpital Bichat, Paris, France; Département de génétique moléculaire AP-HP, Hôpital Bichat, Paris, France; INSERM U1148, LVTS, Hôpital Bichat, Paris, France; Université de Paris, Paris, France
| | - Guillaume Jondeau
- Centre de référence pour le syndrome de Marfan et apparentés, VASCERN HTAD European Reference Center, AP-HP, Hôpital Bichat, Paris, France; INSERM U1148, LVTS, Hôpital Bichat, Paris, France; Université de Paris, Paris, France.
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Chivulescu M, Krohg-Sørensen K, Scheirlynck E, Lindberg BR, Dejgaard LA, Lie ØH, Helle-Valle T, Skjølsvik ET, Estensen ME, Edvardsen T, Lingaas PS, Haugaa KH. Mitral annulus disjunction is associated with adverse outcome in Marfan and Loeys-Dietz syndromes. Eur Heart J Cardiovasc Imaging 2020; 22:1035-1044. [PMID: 33280029 PMCID: PMC8370565 DOI: 10.1093/ehjci/jeaa324] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 11/11/2020] [Indexed: 12/26/2022] Open
Abstract
AIMS We aimed to assess the prevalence of mitral annulus disjunction (MAD) and to explore the association with aortic disease and mitral valve surgery in patients with Marfan syndrome (MFS) and Loeys-Dietz syndrome (LDS). METHODS AND RESULTS We included consecutive MFS patients fulfilling Revised Ghent Criteria and LDS patients fulfilling Loeys-Dietz Revised Nosology. MAD was identified by echocardiography and was quantified as the longitudinal distance from the ventricular myocardium to the hinge point of the posterior mitral leaflet. Aortic events were defined as aortic dissection or prophylactic aortic surgery. We recorded the need of mitral valve surgery including mitral valve repair or replacement. We included 168 patients (103 with MFS and 65 with LDS). The prevalence of MAD was 41%. MAD was present in all age groups. Aortic events occurred in 112 (67%) patients (27 with dissections and 85 with prophylactic surgical interventions). Patients with MAD were younger at aortic event than those without MAD (log rank = 0.02) Patients with aortic events had greater MAD distance in posterolateral wall [8 (7-10) mm vs. 7 (6-8) mm, P = 0.04]. Mitral events occurred more frequently in patients with MAD (P < 0.001). CONCLUSION MAD was highly prevalent in patients with MFS and LDS. MAD was a marker of severe disease including aortic events at younger age and need of mitral valve surgery. Screening patients with MFS an LDS for MAD may provide prognostic information and may be relevant in planning surgical intervention. Detection of MAD in patients with MFS and LDS may infer closer clinical follow-up from younger age.
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Affiliation(s)
- Monica Chivulescu
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, PO Box 4950 Nydalen, 0424 Oslo, Norway.,Institute for Clinical Medicine, University of Oslo, PO Box 1171 Blindern, 0318 Oslo, Norway
| | - Kirsten Krohg-Sørensen
- Institute for Clinical Medicine, University of Oslo, PO Box 1171 Blindern, 0318 Oslo, Norway.,Departement of Thoracic Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Esther Scheirlynck
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, PO Box 4950 Nydalen, 0424 Oslo, Norway
| | - Beate R Lindberg
- Departement of Thoracic Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Lars A Dejgaard
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, PO Box 4950 Nydalen, 0424 Oslo, Norway.,Institute for Clinical Medicine, University of Oslo, PO Box 1171 Blindern, 0318 Oslo, Norway.,K. G. Jebsen Center for Cardiac Research, Institute for Clinical Medicine, Faculty of Medicine, University of Oslo, PO Box 1171 Blindern, 0318 Oslo, Norway
| | - Øyvind H Lie
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, PO Box 4950 Nydalen, 0424 Oslo, Norway.,Institute for Clinical Medicine, University of Oslo, PO Box 1171 Blindern, 0318 Oslo, Norway
| | - Thomas Helle-Valle
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, PO Box 4950 Nydalen, 0424 Oslo, Norway
| | - Eystein T Skjølsvik
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, PO Box 4950 Nydalen, 0424 Oslo, Norway.,Institute for Clinical Medicine, University of Oslo, PO Box 1171 Blindern, 0318 Oslo, Norway
| | - Mette E Estensen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, PO Box 4950 Nydalen, 0424 Oslo, Norway
| | - Thor Edvardsen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, PO Box 4950 Nydalen, 0424 Oslo, Norway.,Institute for Clinical Medicine, University of Oslo, PO Box 1171 Blindern, 0318 Oslo, Norway.,K. G. Jebsen Center for Cardiac Research, Institute for Clinical Medicine, Faculty of Medicine, University of Oslo, PO Box 1171 Blindern, 0318 Oslo, Norway
| | - Per S Lingaas
- Departement of Thoracic Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Kristina H Haugaa
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, PO Box 4950 Nydalen, 0424 Oslo, Norway.,Institute for Clinical Medicine, University of Oslo, PO Box 1171 Blindern, 0318 Oslo, Norway
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35
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Multimodality Imaging of Aortic Disease. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00831-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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36
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Chen SW, Kuo CF, Huang YT, Lin WT, Chien-Chia Wu V, Chou AH, Lin PJ, Chang SH, Chu PH. Association of Family History With Incidence and Outcomes of Aortic Dissection. J Am Coll Cardiol 2020; 76:1181-1192. [DOI: 10.1016/j.jacc.2020.07.028] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/30/2020] [Accepted: 07/07/2020] [Indexed: 01/23/2023]
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Seike Y, Matsuda H, Inoue Y, Sasaki H, Morisaki H, Morisaki T, Kobayashi J. The differences in surgical long-term outcomes between Marfan syndrome and Loeys–Dietz syndrome. J Thorac Cardiovasc Surg 2020; 164:16-25.e2. [DOI: 10.1016/j.jtcvs.2020.07.089] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 07/07/2020] [Accepted: 07/21/2020] [Indexed: 02/08/2023]
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Rohde S, Zafar MA, Ziganshin BA, Elefteriades JA. Thoracic aortic aneurysm gene dictionary. Asian Cardiovasc Thorac Ann 2020; 29:682-696. [PMID: 32689806 DOI: 10.1177/0218492320943800] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Thoracic aortic aneurysm is typically clinically silent, with a natural history of progressive enlargement until a potentially lethal complication such as rupture or dissection occurs. Underlying genetic predisposition strongly influences the risk of thoracic aortic aneurysm and dissection. Familial cases are more virulent, have a higher rate of aneurysm growth, and occur earlier in life. To date, over 30 genes have been associated with syndromic and non-syndromic thoracic aortic aneurysm and dissection. The causative genes and their specific variants help to predict the disease phenotype, including age at presentation, risk of dissection at small aortic sizes, and risk of other cardiovascular and systemic manifestations. This genetic "dictionary" is already a clinical reality, allowing us to personalize care based on specific causative mutations for a substantial proportion of these patients. Widespread genetic sequencing of thoracic aortic aneurysm and dissection patients has been and continues to be crucial to the rapid expansion of this dictionary and ultimately, the delivery of truly personalized care to every patient.
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Affiliation(s)
- Stefanie Rohde
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Mohammad A Zafar
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Bulat A Ziganshin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA.,Department of Cardiovascular and Endovascular Surgery, Kazan State Medical University, Kazan, Russia
| | - John A Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
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Stephenson KA, O'Keefe M, Keegan DJ. Surgical management of non-syndromic ectopia lentis. Int J Ophthalmol 2020; 13:1156-1160. [PMID: 32685406 DOI: 10.18240/ijo.2020.07.21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 03/27/2020] [Indexed: 11/23/2022] Open
Abstract
AIM To compare whether aphakic contact lenses or secondary iris-claw intraocular lenses are superior in the refractive management post-pars plana vitreolensectomy in a pedigree with an FBN1 mutation causing non-syndromic ectopia lentis (NSEL) with retinal detachment (RD). METHODS Eight affected individuals had pars plana vitreolensectomy for bilateral ectopia lentis (EL). Twelve eyes of 6 patients had secondary iris-claw intraocular lenses inserted and 4 eyes of 2 patients were managed with contact lenses. Rhegmatogenous retinal detachment (RRD) was treated when necessary. Pre- and post-operative assessment included visual acuity, endothelial cell count and dilated fundal examination. RESULTS Macula-on RRD was present in all individuals >18y, 64% (7/11 eyes) presenting post-vitreolensectomy with 57% having bilateral non-synchronous RRD. Surgical aphakia was managed with iris-fixated intraocular lenses (IOL group, n=6), or contact lenses (CL group, n=2). Visual acuity ≥0.3 logMAR (driving standard) was achieved in 75% of IOL group eyes and 25% of the CL group eyes. Mean loss of corneal endothelial cell count in the IOL group was 4% at 2y post-operative. CONCLUSION In this cohort, refractive management with iris-claw IOLs provided superior outcomes to contact lenses and the authors recommend this as the optimal refractive correction in EL patients.
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Affiliation(s)
- Kirk Aj Stephenson
- Retinal Research Group, Mater Misericordiae University Hospital & Mater Private Hospital, Dublin 7, Ireland
| | - Michael O'Keefe
- Retinal Research Group, Mater Misericordiae University Hospital & Mater Private Hospital, Dublin 7, Ireland
| | - David J Keegan
- Retinal Research Group, Mater Misericordiae University Hospital & Mater Private Hospital, Dublin 7, Ireland
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Affiliation(s)
- Guillaume Jondeau
- Centre national de référence pour le syndrome de Marfan et apparentés, VASCERN HTAD European Reference Center, AP-HP, Hôpital Bichat, Paris, France
- Service de Cardiologie, AP-HP, Hôpital Bichat, Paris, France
- INSERM U1148, Hôpital Bichat, Paris, France
- Université de Paris, Paris, France
| | - Olivier Milleron
- Centre national de référence pour le syndrome de Marfan et apparentés, VASCERN HTAD European Reference Center, AP-HP, Hôpital Bichat, Paris, France
- Service de Cardiologie, AP-HP, Hôpital Bichat, Paris, France
- INSERM U1148, Hôpital Bichat, Paris, France
| | - Catherine Boileau
- Centre national de référence pour le syndrome de Marfan et apparentés, VASCERN HTAD European Reference Center, AP-HP, Hôpital Bichat, Paris, France
- INSERM U1148, Hôpital Bichat, Paris, France
- Université de Paris, Paris, France
- Département de Génétique, AP-HP, Hôpital Bichat, Paris, France
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Clinical significance of family history and bicuspid aortic valve in children and young adult patients with Marfan syndrome. Cardiol Young 2020; 30:663-667. [PMID: 32290873 DOI: 10.1017/s1047951120000748] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Marfan syndrome is an autosomal dominant disorder of the connective tissue, whose cardinal features affect eyes, musculoskeletal, and cardiovascular system. Despite prevalence and natural history of cardiovascular manifestation are well known in adults, little is known about children and young adult patients. The aim of this study was to describe a well-characterised cohort of consecutive children and young patients with marfan syndrome, looking at the impact of family history and presence of bicuspid aortic valve on disease severity. METHODS A total of 30 consecutive children and young patients with Marfan syndrome were evaluated. All patients underwent a comprehensive clinical-instrumental-genetic evaluation. Particular attention was posed to identify differences in prevalence of cardiovascular abnormalities between patients with and without family history of Marfan syndrome or bicuspid aortic valve. RESULTS Of these 30 patients, family history of Marfan syndrome and bicuspid aortic valve were present in 76 and 13%, respectively. Compared to patients with family history of Marfan syndrome, those without showed higher prevalence of aortic sinus dilation (87 versus 32%, p-value = 0.009), greater aortic sinus diameters (4.2 ± 2.1 versus 1.9 ± 1.1 z score, p-value = 0.002), and higher rate of aortic surgery during follow-up (37 versus 0%, p-value = 0.002). Compared to patients with tricuspid aortic valve, those with bicuspid aortic valve were younger (3.2 ± 4.3 versus 10.7 ± 6.8 years old, p-value = 0.043), showed greater aortic sinus diameters (4.2 ± 0.9 versus 2.2 ± 1.6 z score, p-value = 0.033), and underwent more frequently aortic root replacement (50 versus 4%, p-value = 0.004). CONCLUSIONS In our cohort of patients with Marfan syndrome, the absence of family history and the presence of bicuspid aortic valve were associated to severe aortic phenotype and worse prognosis.
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Abstract
PURPOSE OF REVIEW Although the majority of thoracic aortic aneurysms and dissections (TAD) in the overall population are mainly related to arterial hypertension and atherosclerosis, Heritable Thoracic Aortic Disease (HTAD) are increasingly recognized, especially in younger individuals. As fatal events in the setting of HTAD are preventable with timely detection and appropriate management, this review aims to provide an overview of the genetic basis of HTAD and practical recommendations for genetic evaluation in this setting. RECENT FINDINGS Thanks in part to a number of important efforts to set up (inter)national networks and consortia for collecting clinical and genetic data from patients with these rare disorders, significant progress has been made in understanding the natural evolution of these disorders. These insights are now starting to enable the development of recommendations for the management of these patients.In addition, pathogenic variants in a number of new genes have been identified in HTAD patients. On the basis of more extensive genetic screening in cohorts of patients with TAD, it is becoming clear that there is no strict boundary between syndromal and nonsyndromal HTAD entities. It is, therefore, important to at least consider genetic evaluation, not only for patients presenting with syndromic forms but also for more isolated TAD.Finally, there are indications that we will -- up to a certain point -- soon be able to draw up a more precise policy for individual patients, based on the underlying genetic defects SUMMARY: Genetic evaluation in (young) patients with both syndromic and nonsyndromic forms of HTAD should be considered and is helpful for the development of more precise medicine.
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Affiliation(s)
- Julie De Backer
- VASCERN HTAD European Reference Centre, Department of Cardiology and Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium
| | - Guillaume Jondeau
- VASCERN HTAD European Reference Centre, Centre National Maladies Rares pour le Syndrome de Marfan et apparente[Combining Acute Accent]s
| | - Cathérine Boileau
- VASCERN HTAD European Reference Centre, Centre National Maladies Rares pour le Syndrome de Marfan et apparente[Combining Acute Accent]s.,De[Combining Acute Accent]partement de Ge[Combining Acute Accent]ne[Combining Acute Accent]tique, AP-HP.,LVTS, INSERM U1148, Universite[Combining Acute Accent] Paris Diderot, Ho[Combining Circumflex Accent]pital Bichat, Paris, France
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Kato T. A Diversified Approach for the Prevention of Pediatric Sudden Cardiovascular Death in Japan. Circ J 2020; 84:544-545. [DOI: 10.1253/circj.cj-20-0139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Taichi Kato
- Department of Pediatrics/Developmental Pediatrics, Nagoya University Graduate School of Medicine
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Shen YH, LeMaire SA, Webb NR, Cassis LA, Daugherty A, Lu HS. Aortic Aneurysms and Dissections Series: Part II: Dynamic Signaling Responses in Aortic Aneurysms and Dissections. Arterioscler Thromb Vasc Biol 2020; 40:e78-e86. [PMID: 32208998 DOI: 10.1161/atvbaha.120.313804] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Aortic structure and function are controlled by the coordinated actions of different aortic cells and the extracellular matrix. Several pathways have been identified that control the aortic wall in a cell-type-specific manner and play diverse roles in various phases of aortic injury, repair, and remodeling. This complexity of signaling in the aortic wall poses challenges to the development of therapeutic strategies for treating aortic aneurysms and dissections. Here, in part II of this Recent Highlights series on aortic aneurysms and dissections, we will summarize recent studies published in Arteriosclerosis, Thrombosis, and Vascular Biology that have contributed to our knowledge of the signaling pathway-related mechanisms of aortic aneurysms and dissections.
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Affiliation(s)
- Ying H Shen
- From the Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX (Y.H.S., S.A.L.).,Department of Cardiovascular Surgery, Texas Heart Institute, Houston (Y.H.S., S.A.L.)
| | - Scott A LeMaire
- From the Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX (Y.H.S., S.A.L.).,Department of Cardiovascular Surgery, Texas Heart Institute, Houston (Y.H.S., S.A.L.)
| | - Nancy R Webb
- Department of Pharmacology and Nutritional Sciences (N.R.W., L.A.C.), University of Kentucky, Lexington
| | - Lisa A Cassis
- Department of Pharmacology and Nutritional Sciences (N.R.W., L.A.C.), University of Kentucky, Lexington
| | - Alan Daugherty
- Department of Physiology and Saha Cardiovascular Research Center (A.D., H.S.L.), University of Kentucky, Lexington
| | - Hong S Lu
- Department of Physiology and Saha Cardiovascular Research Center (A.D., H.S.L.), University of Kentucky, Lexington
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Milleron O, Ropers J, Arnoult F, Bouleti C, Delorme G, Langeois M, Tchitchinadze M, Guien C, Beroud C, Boileau C, Jondeau G. Clinical Significance of Aortic Root Modification Associated With Bicuspid Aortic Valve in Marfan Syndrome. Circ Cardiovasc Imaging 2020; 12:e008129. [PMID: 30841707 DOI: 10.1161/circimaging.118.008129] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Both bicuspid aortic valve (BAV) and Marfan syndrome have been associated with aortic dissection risk, but it is unknown whether the presence of BAV is associated with an increased aortic risk in patients with an FBN1 gene mutation. We evaluated aortic diameters, aortic valve function, and aortic shape in Marfan syndrome patients with and without BAV and reported aortic events during follow-up. METHODS All patients with an FBN1 gene mutation evaluated in our clinic were included. Aortic root diameters were measured, and the aortic valve was studied using echocardiography at each visit. RESULTS Of the 1437 patients with an FBN1 gene mutation, 26 patients (1.8%) had a BAV. Both aortic root maximal diameter and normalized Z score were larger at all ages, in patients with BAV when compared with patients with tricuspid aortic valve. Prophylactic aortic root surgery tended to be performed in younger patients when BAV was present, although aortic diameter threshold was similar in the 2 populations. No aortic dissection was observed in Marfan syndrome patients with BAV. CONCLUSIONS In patients with a FBN1 mutation, BAV is associated with larger aortic root diameter, with no difference in evolution of Z score with age. We found a trend towards prophylactic aortic root surgery at younger ages but similar aortic diameter thresholds without occurrence of aortic dissection. We did not find any evidence for lowering aortic diameter thresholds used to propose preventive aortic root surgery in the presence of BAV in patients with FBN1 mutations.
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Affiliation(s)
- Olivier Milleron
- Centre National de Référence pour le syndrome de Marfan et apparentés, Paris, France (O.M., F.A., C. Bouleti, G.D., M.L., M.T., C. Boileau, G.J.).,AP-HP, Hôpital Bichat, Service de Cardiologie, Paris, France (O.M., C. Bouleti, G.J.).,DHU Fire, Paris-Diderot University, France (O.M., C. Bouleti, C. Boileau, G.J.).,INSERM LVTS U1148 75018 Paris (O.M., C. Bouleti, C. Boileau, G.J.)
| | - Jacques Ropers
- AP-HP, Hôpital Pitié- Salpêtrière, Unité de Recherche Clinique, Paris, France (J.R.)
| | - Florence Arnoult
- Centre National de Référence pour le syndrome de Marfan et apparentés, Paris, France (O.M., F.A., C. Bouleti, G.D., M.L., M.T., C. Boileau, G.J.).,AP-HP, Hôpital Bichat, Service d'explorations fonctionnelles, Paris, France (F.A.)
| | - Claire Bouleti
- Centre National de Référence pour le syndrome de Marfan et apparentés, Paris, France (O.M., F.A., C. Bouleti, G.D., M.L., M.T., C. Boileau, G.J.).,AP-HP, Hôpital Bichat, Service de Cardiologie, Paris, France (O.M., C. Bouleti, G.J.).,DHU Fire, Paris-Diderot University, France (O.M., C. Bouleti, C. Boileau, G.J.).,INSERM LVTS U1148 75018 Paris (O.M., C. Bouleti, C. Boileau, G.J.)
| | - Gabriel Delorme
- Centre National de Référence pour le syndrome de Marfan et apparentés, Paris, France (O.M., F.A., C. Bouleti, G.D., M.L., M.T., C. Boileau, G.J.)
| | - Maud Langeois
- Centre National de Référence pour le syndrome de Marfan et apparentés, Paris, France (O.M., F.A., C. Bouleti, G.D., M.L., M.T., C. Boileau, G.J.)
| | - Maria Tchitchinadze
- Centre National de Référence pour le syndrome de Marfan et apparentés, Paris, France (O.M., F.A., C. Bouleti, G.D., M.L., M.T., C. Boileau, G.J.)
| | - Celine Guien
- Aix Marseille University, INSERM, GMGF, Marseille, France (C.G. C. Beroud)
| | - Christophe Beroud
- Aix Marseille University, INSERM, GMGF, Marseille, France (C.G. C. Beroud).,AP-HM, Département de Génétique Médicale, Hôpital Timone Enfants, Marseille, France (C. Beroud)
| | - Catherine Boileau
- Centre National de Référence pour le syndrome de Marfan et apparentés, Paris, France (O.M., F.A., C. Bouleti, G.D., M.L., M.T., C. Boileau, G.J.).,DHU Fire, Paris-Diderot University, France (O.M., C. Bouleti, C. Boileau, G.J.).,INSERM LVTS U1148 75018 Paris (O.M., C. Bouleti, C. Boileau, G.J.).,AP-HP, Hôpital Bichat, Service de génétique, Paris, France (C. Boileau)
| | - Guillaume Jondeau
- Centre National de Référence pour le syndrome de Marfan et apparentés, Paris, France (O.M., F.A., C. Bouleti, G.D., M.L., M.T., C. Boileau, G.J.).,AP-HP, Hôpital Bichat, Service de Cardiologie, Paris, France (O.M., C. Bouleti, G.J.).,DHU Fire, Paris-Diderot University, France (O.M., C. Bouleti, C. Boileau, G.J.).,INSERM LVTS U1148 75018 Paris (O.M., C. Bouleti, C. Boileau, G.J.)
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Genetic profiling and cardiovascular phenotypic spectrum in a Chinese cohort of Loeys-Dietz syndrome patients. Orphanet J Rare Dis 2020; 15:6. [PMID: 31915033 PMCID: PMC6950884 DOI: 10.1186/s13023-019-1282-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 12/18/2019] [Indexed: 11/28/2022] Open
Abstract
Background Loeys-Dietz syndrome (LDS) is a rare connective tissue disorder for which 6 genes in the TGF-β pathway have been identified as causative. With the widespread use of genetic testing, the range of known clinical and genetic profiles has broadened, but these features have not been fully elucidated thus far. Methods and results Using gene panel sequencing or whole exome sequencing, we identified 54 unique rare variants in LDS genes in 57 patients with thoracic aneurysms/dissections, including 27 pathogenic mutations (P + LP) and 27 variants of unknown significance (VUSLP + VUS). Genotype-phenotype correlation analysis revealed that carriers with P/LP/ VUSLP variants in TGFBR1/TGFBR2/SMAD3 genes had significantly more severe cardiovascular features (cardiovascular death/dissection) than carriers with VUSs in these 3 genes at an early age and had less favorable event-free survival. Additionally, carriers with VUS in combination with other risk factors, such as hypertension, might be prone to developing an aortic dissection, as indicated by the fact that 5/8 (62.5%) patients with VUSs in our cohort developed aortic dissections in the presence of hypertension, compared with 25.0% (3/12) in the absence of hypertension (p = 0.047). Conclusions To date, this was the largest cohort of LDS patients ever reported in China, and the present study expanded the known mutation and phenotypic spectra of LDS, which might help refine our knowledge of LDS.
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Faggion Vinholo T, Brownstein AJ, Ziganshin BA, Zafar MA, Kuivaniemi H, Body SC, Bale AE, Elefteriades JA. Genes Associated with Thoracic Aortic Aneurysm and Dissection: 2019 Update and Clinical Implications. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2019; 7:99-107. [PMID: 31842235 PMCID: PMC6914358 DOI: 10.1055/s-0039-3400233] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Thoracic aortic aneurysm is a typically silent disease characterized by a lethal natural history. Since the discovery of the familial nature of thoracic aortic aneurysm and dissection (TAAD) almost 2 decades ago, our understanding of the genetics of this disorder has undergone a transformative amplification. To date, at least 37 TAAD-causing genes have been identified and an estimated 30% of the patients with familial nonsyndromic TAAD harbor a pathogenic mutation in one of these genes. In this review, we present our yearly update summarizing the genes associated with TAAD and the ensuing clinical implications for surgical intervention. Molecular genetics will continue to bolster this burgeoning catalog of culprit genes, enabling the provision of personalized aortic care.
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Affiliation(s)
- Thais Faggion Vinholo
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Adam J Brownstein
- Department of Medicine, Johns Hopkins Hospital and Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Bulat A Ziganshin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut.,Department of Cardiovascular and Endovascular Surgery, Kazan State Medical University, Kazan, Russia
| | - Mohammad A Zafar
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Helena Kuivaniemi
- Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, and Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Simon C Body
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Allen E Bale
- Department of Genetics, Yale School of Medicine, New Haven, Connecticut
| | - John A Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
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Case-matched Comparison of Cardiovascular Outcome in Loeys-Dietz Syndrome versus Marfan Syndrome. J Clin Med 2019; 8:jcm8122079. [PMID: 31795342 PMCID: PMC6947024 DOI: 10.3390/jcm8122079] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 11/15/2019] [Accepted: 11/19/2019] [Indexed: 02/07/2023] Open
Abstract
Background: Pathogenic variants in TGFBR1, TGFBR2 and SMAD3 genes cause Loeys-Dietz syndrome, and pathogenic variants in FBN1 cause Marfan syndrome. Despite their similar phenotypes, both syndromes may have different cardiovascular outcomes. Methods: Three expert centers performed a case-matched comparison of cardiovascular outcomes. The Loeys-Dietz group comprised 43 men and 40 women with a mean age of 34 ± 18 years. Twenty-six individuals had pathogenic variants in TGFBR1, 40 in TGFBR2, and 17 in SMAD3. For case-matched comparison we used 83 age and sex-frequency matched individuals with Marfan syndrome. Results: In Loeys-Dietz compared to Marfan syndrome, a patent ductus arteriosus (p = 0.014) was more prevalent, the craniofacial score was higher (p < 0.001), the systemic score lower (p < 0.001), and mitral valve prolapse less frequent (p = 0.003). Mean survival for Loeys-Dietz and Marfan syndrome was similar (75 ± 3 versus 73 ± 2 years; p = 0.811). Cardiovascular outcome was comparable between Loeys-Dietz and Marfan syndrome, including mean freedom from proximal aortic surgery (53 ± 4 versus 48 ± 3 years; p = 0.589), distal aortic repair (72 ± 3 versus 67 ± 2 years; p = 0.777), mitral valve surgery (75 ± 4 versus 65 ± 3 years; p = 0.108), and reintervention (20 ± 3 versus 14 ± 2 years; p = 0.112). In Loeys-Dietz syndrome, lower age at initial presentation predicted proximal aortic surgery (HR = 0.748; p < 0.001), where receiver operating characteristic analysis identified ≤33.5 years with increased risk. In addition, increased aortic sinus diameters (HR = 6.502; p = 0.001), and higher systemic score points at least marginally (HR = 1.175; p = 0.065) related to proximal aortic surgery in Loeys-Dietz syndrome. Conclusions: Cardiovascular outcome of Loeys-Dietz syndrome was comparable to Marfan syndrome, but the severity of systemic manifestations was a predictor of proximal aortic surgery.
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Stephenson KAJ, Dockery A, O'Keefe M, Green A, Farrar GJ, Keegan DJ. A FBN1 variant manifesting as non-syndromic ectopia lentis with retinal detachment: clinical and genetic characteristics. Eye (Lond) 2019; 34:690-694. [PMID: 31527767 PMCID: PMC7093504 DOI: 10.1038/s41433-019-0580-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 06/05/2019] [Accepted: 08/15/2019] [Indexed: 01/10/2023] Open
Abstract
Background/objectives Fibrillin-1 (FBN1) mutations cause connective tissue dysgenesis the main ocular manifestation being ectopia lentis (EL), which may be syndromic or non-syndromic. We describe a pedigree with a FBN1 mutation causing non-syndromic EL with retinal detachment (RRD) and their management. Subjects/methods Patients with familial EL with RRD were invited to participate (vitreoretinopathy branch of Target 5000, the Irish inherited retinal degeneration study). All patients signed full informed consent. The study was approved by the Institutional Review Board of the Mater Hospital, Dublin and abided by the Declaration of Helsinki. Results Seven adults were affected with bilateral EL. All subjects had RRD with bilateral non-synchronous RRD in 57%. Conclusions The FBN1 variant described herein confers an increased risk of both EL and RRD and can now be upgraded to ‘pathogenic’ ACMG status.
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Affiliation(s)
- Kirk A J Stephenson
- Retinal Research Group: Mater Misericordiae University Hospital & Mater Private Hospital, Dublin, Ireland.
| | - Adrian Dockery
- School of Genetics and Microbiology, Trinity College Dublin, Dublin, Ireland
| | - Michael O'Keefe
- Retinal Research Group: Mater Misericordiae University Hospital & Mater Private Hospital, Dublin, Ireland
| | - Andrew Green
- National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
| | - G Jane Farrar
- School of Genetics and Microbiology, Trinity College Dublin, Dublin, Ireland
| | - David J Keegan
- Retinal Research Group: Mater Misericordiae University Hospital & Mater Private Hospital, Dublin, Ireland
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50
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Kremer TM, Lindsay ME, Kinane TB, Hawley MH, Little BP, Mino-Kenudson M. Case 28-2019: A 22-Year-Old Woman with Dyspnea and Chest Pain. N Engl J Med 2019; 381:1059-1067. [PMID: 31509678 DOI: 10.1056/nejmcpc1904041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Ted M Kremer
- From the Department of Pediatrics, UMass Memorial Medical Center, and the Department of Pediatrics, University of Massachusetts Medical School, Worcester (T.M.K.), the Departments of Pediatrics (M.E.L., T.B.K.), Radiology (B.P.L.), and Pathology (M.M.-K.), Massachusetts General Hospital, and the Departments of Pediatrics (M.E.L., T.B.K.), Radiology (B.P.L.), and Pathology (M.M.-K.), Harvard Medical School, Boston, and the Laboratory for Molecular Medicine, Partners HealthCare Personalized Medicine, Cambridge (M.H.H.) - all in Massachusetts
| | - Mark E Lindsay
- From the Department of Pediatrics, UMass Memorial Medical Center, and the Department of Pediatrics, University of Massachusetts Medical School, Worcester (T.M.K.), the Departments of Pediatrics (M.E.L., T.B.K.), Radiology (B.P.L.), and Pathology (M.M.-K.), Massachusetts General Hospital, and the Departments of Pediatrics (M.E.L., T.B.K.), Radiology (B.P.L.), and Pathology (M.M.-K.), Harvard Medical School, Boston, and the Laboratory for Molecular Medicine, Partners HealthCare Personalized Medicine, Cambridge (M.H.H.) - all in Massachusetts
| | - T Bernard Kinane
- From the Department of Pediatrics, UMass Memorial Medical Center, and the Department of Pediatrics, University of Massachusetts Medical School, Worcester (T.M.K.), the Departments of Pediatrics (M.E.L., T.B.K.), Radiology (B.P.L.), and Pathology (M.M.-K.), Massachusetts General Hospital, and the Departments of Pediatrics (M.E.L., T.B.K.), Radiology (B.P.L.), and Pathology (M.M.-K.), Harvard Medical School, Boston, and the Laboratory for Molecular Medicine, Partners HealthCare Personalized Medicine, Cambridge (M.H.H.) - all in Massachusetts
| | - Megan H Hawley
- From the Department of Pediatrics, UMass Memorial Medical Center, and the Department of Pediatrics, University of Massachusetts Medical School, Worcester (T.M.K.), the Departments of Pediatrics (M.E.L., T.B.K.), Radiology (B.P.L.), and Pathology (M.M.-K.), Massachusetts General Hospital, and the Departments of Pediatrics (M.E.L., T.B.K.), Radiology (B.P.L.), and Pathology (M.M.-K.), Harvard Medical School, Boston, and the Laboratory for Molecular Medicine, Partners HealthCare Personalized Medicine, Cambridge (M.H.H.) - all in Massachusetts
| | - Brent P Little
- From the Department of Pediatrics, UMass Memorial Medical Center, and the Department of Pediatrics, University of Massachusetts Medical School, Worcester (T.M.K.), the Departments of Pediatrics (M.E.L., T.B.K.), Radiology (B.P.L.), and Pathology (M.M.-K.), Massachusetts General Hospital, and the Departments of Pediatrics (M.E.L., T.B.K.), Radiology (B.P.L.), and Pathology (M.M.-K.), Harvard Medical School, Boston, and the Laboratory for Molecular Medicine, Partners HealthCare Personalized Medicine, Cambridge (M.H.H.) - all in Massachusetts
| | - Mari Mino-Kenudson
- From the Department of Pediatrics, UMass Memorial Medical Center, and the Department of Pediatrics, University of Massachusetts Medical School, Worcester (T.M.K.), the Departments of Pediatrics (M.E.L., T.B.K.), Radiology (B.P.L.), and Pathology (M.M.-K.), Massachusetts General Hospital, and the Departments of Pediatrics (M.E.L., T.B.K.), Radiology (B.P.L.), and Pathology (M.M.-K.), Harvard Medical School, Boston, and the Laboratory for Molecular Medicine, Partners HealthCare Personalized Medicine, Cambridge (M.H.H.) - all in Massachusetts
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