Diagnosis and management of Marfan syndrome

Marfan syndrome in children: correlation between musculoskeletal features and cardiac Z-score

We investigated the correlation between the musculoskeletal features and the cardiovascular anomalies in pediatric patients affected by Marfan syndrome, in order to identify possible orthopedic deformities that could be a warning sign for severe aortic dilatation. Moreover, we analyzed the role of the orthopedic aspects in the early diagnosis of the disease in a pediatric population. Seventy-two patients from 3 to 14 years of age, underwent interdisciplinary evaluation that included an orthopedic and cardiological examination. At the orthopedic examination, we analyzed the musculoskeletal features included in the systemic score of the revised Ghent criteria. Cardiological evaluation included a transthoracic echocardiography with definition of the cardiac Z-score, which is an index that evaluates aortic diameter. A statistical analysis was performed. We identified a statistically significant correlation between the presence of pectus excavatum and cardiac Z-score ≥3 (P = 0.022). Clinically, this data means that pectus excavatum is frequently observed in patients with larger aortic root diameter. On the contrary, no statistically significant correlation was found between the other investigated musculoskeletal features and a pathological Z-score. In the pediatric population, the diagnosis of Marfan syndrome remains difficult because many clinical manifestations are age-dependent and the Ghent criteria, usually used for adults, are not reliable in children. Our results show that the presence of pectus excavatum could help in the early identification of patients at greater risk of developing possibly fatal aortic disease. However, it is always indicated to screen all patients with Marfan syndrome for cardiac abnormalities, even in absence of pectus excavatum.

The Genetics of Thoracic Aortic Aneurysms and Dissection: A Clinical Perspective

Thoracic aortic aneurysm and dissection (TAAD) affects many patients globally and has high mortality rates if undetected. Once thought to be solely a degenerative disease that afflicted the aorta due to high pressure and biomechanical stress, extensive investigation of the heritability and natural history of TAAD has shown a clear genetic basis for the disease. Here, we review both the cellular mechanisms and clinical manifestations of syndromic and non-syndromic TAAD. We particularly focus on genes that have been linked to dissection at diameters <5.0 cm, the current lower bound for surgical intervention. Genetic screening tests to identify patients with TAAD associated mutations that place them at high risk for dissection are also discussed.

Postural control abnormalities related to sleep deprivation in patients with Marfan Syndrome

BACKGROUND

Marfan syndrome (MFS) is a rare autosomal dominant connective tissue disorder affecting virtually every organ. Sleep disturbances, associated to high collapsibility in upper airways, are common in MFS; daytime sleepiness could lead to reduction in attention and motor coordination, with detrimental effects on balance.

OBJECTIVE

To evaluate otoneurological function in MFS patients, compared to healthy subjects, and to investigate possible correlations with sleep deprivation extent.

METHODS

Forty-one MFS patients underwent a thorough otoneurological examination, video Head Impulse Test (vHIT), and static posturography. Sleep parameters were recorded by home monitoring. Daytime sleepiness and dizziness-related handicap were screened by means of Dizziness Handicap Inventory (DHI) and Epworth Sleepiness Scale (ESS). Results were compared with 49 healthy controls (HC).

RESULTS

DHI and ESS scores were increased in MFS patients (p < 0,01). vHIT scores showed no between-group effect. Classical (surface and length) and frequency-domain posturographic parameters were significantly increased in MFS with respect to HC (p < 0,01). A positive correlation was found between ESS scores and posturographic parameters in MFS patients.

CONCLUSIONS

An impaired postural control, related to the extent of sleep deprivation, was found in MFS patients. Such results could advocate for screening and treating sleep deprivation and balance dysfunctions in MFS patients.

Sub-classification of non-inflammatory and inflammatory surgical aortic aneurysms and the association of histological characteristics with potential risk factors

The present study aimed to analyze the histological characteristics of surgical thoracic aortic aneurysm (TAA) and abdominal aortic aneurysm (AAA) specimens on the basis of the most recent consensus documents on non-inflammatory and inflammatory lesions. The current study also aimed to establish an association with various risk factors. Aortic wall specimens were collected from 52 patients (38 men and 14 women; age, 19-80 years) undergoing surgery for aortic dilatation at The Cardiovascular Disease Institute (Iasi, Romania). For histological evaluation, the aortic specimens (39 TAAs and 13 AAAs) were stained with hematoxylin-eosin, Van Giessen, alcian blue and Movat pentachrome. The specimens were evaluated and graded according to the severity of histopathological conditions: Fragmentation of elastic fibers, medial mucoid accumulation, smooth muscle cell loss and medial fibrosis. The severity of atherosclerotic lesions in surgically resected segments of the aorta were graded as follows: i) mild=1; ii) moderate=2; and iii) severe=3. The risk factors associated with TAA were the male sex (80%), smoking (56%), hypertension (33%) and bicuspid aortic valve (13%). Advanced age (70 years), male sex (69%) and smoking (54%) were determined to be the risk factors of AAA. The histopathological abnormalities included medial degeneration (MD) (82%), atherosclerosis (ATS) (42%) and aortitis (10%). MD was the leading histopathological diagnosis in TAA and the severity of lesions were graded as follows: Mild (8% of cases), moderate (44% of cases) and severe (31% of cases). Severe atherosclerotic lesions were identified in AAA (100% of cases). In the present study, medial degenerative aortic lesions (1, mild; 2, moderate; and 3, severe) significantly correlated with advanced age (>65 years; r=-0.39; P<0.01) and male sex (r=0.27; P<0.05). Significant correlations were also identified between atherosclerotic aortic lesions (1, mild; 2, moderate; and 3, severe) and advanced age (>65 years) (r=-0.40, P<0.01) or smoking (r=-0.29; P<0.05). Advanced age, male sex and smoking were determined to be the main risk factors for the development of degenerative aortic aneurysms.

Characterization of pain, disability, and psychological burden in Marfan syndrome

The clinical manifestations of Marfan syndrome frequently cause pain. This study aimed to characterize pain in a cohort of adults with Marfan syndrome and investigate demographic, physical, and psychological factors associated with pain and pain-related disability. Two hundred and forty-five participants (73% female, 89% non-Hispanic white, 90% North American) completed an online questionnaire assessing clinical features of Marfan syndrome, pain severity, pain-related disability, physical and mental health, depressive symptoms, pain catastrophizing, and insomnia. Eighty-nine percent of respondents reported having pain with 28% of individuals reporting pain as a presenting symptom of Marfan syndrome. Almost half of individuals reported that pain has spread from its initial site. Participants in our study reported poor physical and mental health functioning, moderate pain-related disability, and mild levels of depressive symptoms, sleep disturbances, and pain catastrophizing. Those who identified pain as an initial symptom of Marfan syndrome and those who reported that pain had spread from its initial site reported greater psychological burden compared with those without pain as an initial symptom or pain spreading. Physical health is the largest predictor of pain severity and pain-related disability. While pain catastrophizing and worse mental health functioning are significant correlates of pain severity and pain-related disability, respectively. Pain is a significant and persistent problem in Marfan syndrome and is associated with profound disability and psychological burden. Further studies are indicated to better characterize the directionality of pain, pain-related disability, and psychological burden in Marfan syndrome. © 2016 Wiley Periodicals, Inc.

Marfan's syndrome: an overview

Marfan's syndrome is an autosomal dominant condition with an estimated prevalence of one in 10,000 to 20,000 individuals. This rare hereditary connective tissue disorder affects many parts of the body. The diagnosis of Marfan's syndrome is established in accordance with a review of the diagnostic criteria, known as the Ghent nosology, through a comprehensive assessment largely based on a combination of major and minor clinical manifestations in various organ systems and the family history. Aortic root dilation and mitral valve prolapse are the main presentations among the cardiovascular malformations of Marfan's syndrome. The pathogenesis of Marfan's syndrome has not been fully elucidated. However, fibrillin-1 gene mutations are believed to exert a dominant negative effect. Therefore, Marfan's syndrome is termed a fibrillinopathy, along with other connective tissue disorders with subtle differences in clinical manifestations. The treatment may include prophylactic β-blockers and angiotensin II-receptor blockers in order to slow down the dilation of the ascending aorta, and prophylactic aortic surgery. Importantly, β-blocker therapy may reduce TGF-β activation, which has been recognized as a contributory factor in Marfan's syndrome. The present article aims to provide an overview of this rare hereditary disorder.