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Maternal cardiovascular morbidity and mortality associated with pregnancy in individuals with Turner syndrome: a committee opinion. Fertil Steril 2024:S0015-0282(24)00522-3. [PMID: 38980250 DOI: 10.1016/j.fertnstert.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Accepted: 06/04/2024] [Indexed: 07/10/2024]
Abstract
In individuals with Turner syndrome, the risk of death from aortic dissection or rupture during pregnancy may be as high as 1%, and it is unclear whether this risk persists during the postpartum period owing to pregnancy-related aortic changes. Turner syndrome is a relative contraindication for pregnancy; however, it is an absolute contraindication for pregnancy in a patient with an aortic size index of >2.5 cm/m2 or an aortic size index of ≥2.0 cm/m2 with a documented cardiac anomaly or other risk factors. This document replaces the 2012 document of the same name.
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Gravholt CH, Andersen NH, Christin-Maitre S, Davis SM, Duijnhouwer A, Gawlik A, Maciel-Guerra AT, Gutmark-Little I, Fleischer K, Hong D, Klein KO, Prakash SK, Shankar RK, Sandberg DE, Sas TCJ, Skakkebæk A, Stochholm K, van der Velden JA, Backeljauw PF. Clinical practice guidelines for the care of girls and women with Turner syndrome. Eur J Endocrinol 2024; 190:G53-G151. [PMID: 38748847 DOI: 10.1093/ejendo/lvae050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 04/19/2024] [Indexed: 06/16/2024]
Abstract
Turner syndrome (TS) affects 50 per 100 000 females. TS affects multiple organs through all stages of life, necessitating multidisciplinary care. This guideline extends previous ones and includes important new advances, within diagnostics and genetics, estrogen treatment, fertility, co-morbidities, and neurocognition and neuropsychology. Exploratory meetings were held in 2021 in Europe and United States culminating with a consensus meeting in Aarhus, Denmark in June 2023. Prior to this, eight groups addressed important areas in TS care: (1) diagnosis and genetics, (2) growth, (3) puberty and estrogen treatment, (4) cardiovascular health, (5) transition, (6) fertility assessment, monitoring, and counselling, (7) health surveillance for comorbidities throughout the lifespan, and (8) neurocognition and its implications for mental health and well-being. Each group produced proposals for the present guidelines, which were meticulously discussed by the entire group. Four pertinent questions were submitted for formal GRADE (Grading of Recommendations, Assessment, Development and Evaluation) evaluation with systematic review of the literature. The guidelines project was initiated by the European Society for Endocrinology and the Pediatric Endocrine Society, in collaboration with members from the European Society for Pediatric Endocrinology, the European Society of Human Reproduction and Embryology, the European Reference Network on Rare Endocrine Conditions, the Society for Endocrinology, and the European Society of Cardiology, Japanese Society for Pediatric Endocrinology, Australia and New Zealand Society for Pediatric Endocrinology and Diabetes, Latin American Society for Pediatric Endocrinology, Arab Society for Pediatric Endocrinology and Diabetes, and the Asia Pacific Pediatric Endocrine Society. Advocacy groups appointed representatives for pre-meeting discussions and the consensus meeting.
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Affiliation(s)
- Claus H Gravholt
- Department of Endocrinology, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Department of Molecular Medicine, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark
| | - Niels H Andersen
- Department of Cardiology, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - Sophie Christin-Maitre
- Endocrine and Reproductive Medicine Unit, Center of Rare Endocrine Diseases of Growth and Development (CMERCD), FIRENDO, Endo ERN Hôpital Saint-Antoine, Sorbonne University, Assistance Publique-Hôpitaux de Paris, 75012 Paris, France
| | - Shanlee M Davis
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO 80045, United States
- eXtraOrdinarY Kids Clinic, Children's Hospital Colorado, Aurora, CO 80045, United States
| | - Anthonie Duijnhouwer
- Department of Cardiology, Radboud University Medical Center, Nijmegen 6500 HB, The Netherlands
| | - Aneta Gawlik
- Departments of Pediatrics and Pediatric Endocrinology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
| | - Andrea T Maciel-Guerra
- Area of Medical Genetics, Department of Translational Medicine, School of Medical Sciences, State University of Campinas, 13083-888 São Paulo, Brazil
| | - Iris Gutmark-Little
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio 45229, United States
| | - Kathrin Fleischer
- Department of Reproductive Medicine, Nij Geertgen Center for Fertility, Ripseweg 9, 5424 SM Elsendorp, The Netherlands
| | - David Hong
- Division of Interdisciplinary Brain Sciences, Stanford University School of Medicine, Stanford, CA 94304, United States
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA 94304, United States
| | - Karen O Klein
- Rady Children's Hospital, University of California, San Diego, CA 92123, United States
| | - Siddharth K Prakash
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX 77030, United States
| | - Roopa Kanakatti Shankar
- Division of Endocrinology, Children's National Hospital, The George Washington University School of Medicine, Washington, DC 20010, United States
| | - David E Sandberg
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, MI 48109-2800, United States
- Division of Pediatric Psychology, Department of Pediatrics, University of Michigan, Ann Arbor, MI 48109-2800, United States
| | - Theo C J Sas
- Department the Pediatric Endocrinology, Sophia Children's Hospital, Rotterdam 3015 CN, The Netherlands
- Department of Pediatrics, Centre for Pediatric and Adult Diabetes Care and Research, Rotterdam 3015 CN, The Netherlands
| | - Anne Skakkebæk
- Department of Molecular Medicine, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark
- Department of Clinical Genetics, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Kirstine Stochholm
- Department of Endocrinology, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Center for Rare Diseases, Department of Pediatrics, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Janielle A van der Velden
- Department of Pediatric Endocrinology, Radboud University Medical Center, Amalia Children's Hospital, Nijmegen 6500 HB, The Netherlands
| | - Philippe F Backeljauw
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio 45229, United States
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Su W, Sun L, Li Z, Liu X, Zhang L, Zhao X, Fan S, Li B, Xie Y, Xiao W, Su Z. Assessment of aortic dilatation in Chinese children and adolescents with Turner syndrome: a single center experience. BMC Pediatr 2024; 24:317. [PMID: 38720245 PMCID: PMC11077734 DOI: 10.1186/s12887-024-04783-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 04/22/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Patients with Turner syndrome (TS) face an increased risk of developing aortic dilatation (AD), but diagnosing AD in children presents greater complexity compared to adults. This study aimed to investigate the application of various assessment indicators of AD in Chinese children and adolescents with TS. METHODS This study included TS patients admitted to Shenzhen Children's Hospital from 2017 to 2022. Cardiovascular lesions were diagnosed by experienced radiologists. Patients without structural heart disease were divided into different body surface area groups, then the Chinese TS population Z-score (CHTSZ-score) of the ascending aorta was calculated and compared with other indicators such as aortic size index (ASI), ratio of the ascending to descending aortic diameter (A/D ratio), and TSZ-score (Quezada's method). RESULTS A total of 115 TS patients were included, with an average age of 10.0 ± 3.7 years. The incidences of the three most serious cardiovascular complications were 9.6% (AD), 10.4% (coarctation of the aorta, CoA), and 7.0% (bicuspid aortic valve, BAV), respectively. The proportion of developing AD in TS patients aged ≥ 10 years was higher than that in those < 10 years old (16.6% vs. 1.8%, P = 0.009), and the proportion of patients with CoA or BAV who additionally exhibited AD was higher than those without these conditions (31.6% vs. 5.2%, P < 0.001). The ASI, A/D ratio, TSZ-score, and CHTSZ-score of the 11 patients with AD were 2.27 ± 0.40 cm/m2, 1.90 ± 0.37, 1.28 ± 1.08, and 3.07 ± 2.20, respectively. Among the AD patients, only 3 cases had a TSZ-score ≥ 2, and 2 cases had a TSZ-score ≥ 1. However, based on the assessment using the CHTSZ-score, 6 patients scored ≥ 2, and 5 patients scored ≥ 1. In contrast, the TSZ-score generally underestimated the aortic Z-scores in Chinese children with TS compared to the CHTSZ-score. CONCLUSIONS The applicability of ASI and A/D ratio to children with TS is questionable, and racial differences can affect the assessment of TSZ-score in the Chinese population. Therefore, establishing the CHTSZ-score specifically tailored for Chinese children and adolescents is of paramount importance.
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Affiliation(s)
- Wei Su
- Department of Endocrinology, Shenzhen Children's Hospital, Shenzhen, China
| | - Longwei Sun
- Department of Radiology, Shenzhen Children's Hospital, Shenzhen, China
| | - Zhuoguang Li
- Department of Endocrinology, Shenzhen Children's Hospital, Shenzhen, China
| | - Xia Liu
- Department of Endocrinology, Shenzhen Children's Hospital, Shenzhen, China
| | - Longjiang Zhang
- Department of Endocrinology, Shenzhen Children's Hospital, Shenzhen, China
| | - Xiu Zhao
- Department of Endocrinology, Shenzhen Children's Hospital, Shenzhen, China
| | - Shumin Fan
- Department of Ultrasound, Shenzhen Children's Hospital, Shenzhen, China
| | - Boning Li
- Department of Cardiology, Shenzhen Children's Hospital, Shenzhen, China
| | - Ying Xie
- Department of Cardiology, Shenzhen Children's Hospital, Shenzhen, China
| | - Weiwei Xiao
- Department of Laboratory, Shenzhen Children's Hospital, Shenzhen, China
| | - Zhe Su
- Department of Endocrinology, Shenzhen Children's Hospital, Shenzhen, China.
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Suntratonpipat S, Pajunen K, Rosolowsky E, Escudero CA, Girgis R, Thompson RB, Pagano JJ, Tham EB. Cardiac MRI evaluation of aortic biophysical properties in paediatric Turner syndrome. Cardiol Young 2024:1-7. [PMID: 38606642 DOI: 10.1017/s1047951124000799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
BACKGROUND Aortopathy in Turner syndrome is associated with aortic dilation, and the risk of dissection is increased when the aortic size index is ≥ 2-2.5 cm/m2. We evaluated the aortic biophysical properties in paediatric Turner syndrome using cardiac MRI to determine their relationship to aortic size index. METHODS Turner syndrome patients underwent cardiac MRI to evaluate ventricular function, aortic dimensions, and biophysical properties (aortic stiffness index, compliance, distensibility, pulse wave velocity, and aortic and left ventricular elastance). Spearman correlation examined correlations between these properties and aortic size index. Data was compared to 10 controls. RESULTS Of 25 Turner syndrome patients, median age 14.7 years (interquartile range: 11.0-16.8), height z score -2.7 (interquartile range: -2.92 - -1.54), 24% had a bicuspid aortic valve. Turner syndrome had increased diastolic blood pressure (p < 0.001) and decreased left ventricular end-diastolic (p < 0.001) and end-systolic (p = 0.002) volumes compared to controls. Median aortic size index was 1.81 cm/m2 (interquartile range: 1.45-2.1) and 7 had an aortic size index > 2 cm/m2. Aortic and left ventricular elastance were greater in Turner syndrome compared to controls (both p < 0.001). Increased aortic size index correlated with increased aortic elastance (r = 0.5, p = 0.01) and left ventricular elastance (r = 0.59, p = 0.002) but not aortic compliance. Higher ascending aortic areas were associated with increased aortic compliance (r = 0.44, p = 0.03) and left ventricular elastance (r = 0.49, p = 0.01). CONCLUSION Paediatric Turner syndrome with similar aortic size index to controls showed MRI evidence of abnormal aortic biophysical properties. These findings point to an underlying aortopathy and provide additional parameters that may aid in determining risk factors for aortic dissection.
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Affiliation(s)
- Somjate Suntratonpipat
- Division of Pediatric Cardiology, Stollery Children's Hospital & Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada
| | - Kiera Pajunen
- Division of Pediatric Cardiology, Stollery Children's Hospital & Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada
| | - Elizabeth Rosolowsky
- Division of Pediatric Endocrinology, Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
| | - Carolina A Escudero
- Division of Pediatric Cardiology, Stollery Children's Hospital & Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada
| | - Rose Girgis
- Division of Pediatric Endocrinology, Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
| | - Richard B Thompson
- Department of Biomedical Engineering, University of Alberta, Edmonton, AB, Canada
| | - Joseph J Pagano
- Division of Pediatric Cardiology, Stollery Children's Hospital & Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada
| | - Edythe B Tham
- Division of Pediatric Cardiology, Stollery Children's Hospital & Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada
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Hunter-Adamson L, Tierney S. Echogenomics: Echocardiography in Heritable Aortopathies. Curr Cardiol Rep 2024; 26:179-189. [PMID: 38372858 DOI: 10.1007/s11886-024-02024-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/18/2024] [Indexed: 02/20/2024]
Abstract
PURPOSE OF REVIEW The aim of this article is to review the current echocardiographic considerations in the diagnosis and monitoring of patients with inherited aortopathies. RECENT FINDINGS Aortic dilation is a key feature in heritable aortopathies, and dissection is a leading cause of morbidity and mortality. New genetic and histopathologic findings are helpful in better understanding these conditions. Non-invasive imaging modalities, including echocardiogram, computerized tomography, and magnetic resonance imaging, are essential in monitoring these patients, as well as providing new prognostic factors of arterial stiffness that may help with risk stratification in the future. Diagnosis of heritable aortopathies should be considered with identification of aortic root dilation, particularly in children and young adults, or when there is a family history of aortic disease. Recent adult consensus guidelines highlight the importance of underlying genotype and phenotypic features when considering prophylactic surgical intervention. There are currently no consensus pediatric guidelines.
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Affiliation(s)
- Lyndsey Hunter-Adamson
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University, 750 Welch Road, Palo Alto, CA, 94304, USA
| | - Seda Tierney
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University, 750 Welch Road, Palo Alto, CA, 94304, USA.
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Glatzel H, Njue F, Turner HE, Orchard E. Analysis of a streamlined pathway for aortic surveillance for Turner syndrome in a single centre. Clin Endocrinol (Oxf) 2023; 99:579-585. [PMID: 37694690 DOI: 10.1111/cen.14968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 08/08/2023] [Accepted: 08/25/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND AND OBJECTIVE The risk of aortic dissection (AoD) is increased in women with Turner syndrome (TS) but predicting those with this heightened risk is difficult. In response to this, we sought to create a pathway to monitor TS patients to improve efficiency and resource utilisation in our dedicated TS clinic, and to monitor more closely those women thought to be at increased risk of AoD. DESIGN AND PATIENTS Our pathway was designed based on evidence derived from International Guidelines for the management of aortic disease in women with TS. Women were divided according to those with known risk factors for AoD, and those with no known risk factors. These groups were further subdivided into 4 pathways depending on ascending aortic size which in-turn determined the frequency of outpatient appointments and imaging. RESULTS Out of the 168 patients included in the analysis, 7 have had ascending aorta replacements, all in the highest risk group. Of the remaining 4 patients in the highest risk groups: 1 dissected whilst awaiting planned aortic surgery, 1 is currently awaiting surgery, 1 has low body mass index, therefore, making her aorta proportionally larger but not necessitating surgery and one has declined surgery. No women changed pathways. CONCLUSION The risk-stratified pathway safely allowed consolidation of resources to women perceived to be at highest risk of AoD (excluding pregnancy), supporting the efficacy of the pathway and allowing the diversion of resources to those most at risk of AoD.
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Affiliation(s)
- Hannah Glatzel
- Department of Cardiology, Stoke Mandeville Hospital, Buckinghamshire, UK
| | - Faith Njue
- Department of ACHD Cardiology, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Helen E Turner
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Elizabeth Orchard
- Department of ACHD Cardiology, Oxford University Hospitals NHS Trust, Oxford, UK
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McCarrison S, Carr A, Wong SC, Mason A. The prevalence of hypertension in paediatric Turner syndrome: a systematic review and meta-analysis. J Hum Hypertens 2023; 37:675-688. [PMID: 36471031 PMCID: PMC10403354 DOI: 10.1038/s41371-022-00777-8] [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: 04/29/2022] [Revised: 10/21/2022] [Accepted: 11/08/2022] [Indexed: 12/10/2022]
Abstract
Cardiovascular related deaths account for over 40% of the excess mortality in Turner syndrome (TS). Hypertension, a modifiable risk factor for both aortic dilatation and dissection, is more commonly encountered in TS during childhood and adolescence. Treatment of hypertension is currently recommended beyond the age of 16 years in TS to help reduce the risk of aortic dissection. This study aims to determine the prevalence of hypertension in paediatric patients with TS and explore the associated methodologies of blood pressure evaluation reported in these studies. Three online databases were searched (Medline, Embase and Web of Science) for literature which reported a prevalence, or allowed calculation of prevalence, of hypertension in patients with TS who were 18 years of age or younger. Seventeen studies which met the primary eligibility criteria, with a total of 1948 patients, were included. The estimated pooled prevalence of hypertension in children and adolescents with TS was 16% (95% CI: 8.9-24.6%). There was significant heterogeneity detected between the studies. The prevalence of hypertension in those studies which assessed 24-h Ambulatory Blood Pressure Monitoring (ABPM) was 21.1% (95% CI: 15.2-27.6%) compared those which used another method of blood pressure measurement which was 13.5% (95% CI: 5.2-24.4%). Given the impact of hypertension with long-term health outcomes and the reversibility of these same outcomes by addressing abnormal blood pressure, prompt and early diagnosis of hypertension in young girls with TS should be prioritised. We recommend the use of 24-h ABPM in screening for hypertension in the paediatric TS population.
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Affiliation(s)
- Sarah McCarrison
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, UK
| | - Aoife Carr
- School of Medicine, University of Glasgow, Glasgow, UK
| | - Sze Choong Wong
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, UK
| | - Avril Mason
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, UK.
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Attridge MM, Hopkins KA, Mangold K, Brickman WJ, Patel SR. Diagnosis and Management of Aortic Dissection in a Pediatric Patient With Turner Syndrome: A Simulation. Cureus 2023; 15:e41725. [PMID: 37575692 PMCID: PMC10414799 DOI: 10.7759/cureus.41725] [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: 12/18/2022] [Accepted: 07/07/2023] [Indexed: 08/15/2023] Open
Abstract
Aortic dissection is exceedingly rare in the pediatric population. However, it is much more common among children and adolescents with certain underlying syndromes, including Turner syndrome. Furthermore, aortic dissection carries significant mortality without prompt diagnosis and management. Therefore, pediatric emergency providers should know how to recognize and treat pediatric aortic dissection in a patient with Turner syndrome. We designed this simulation for pediatric emergency medicine fellows. A simulated adolescent female patient with a known history of Turner syndrome presents with chest pain, tachycardia, and hypertension. Participants must order and interpret the appropriate diagnostics, diagnose aortic dissection, and manage aortic dissection adequately. This simulation was completed by six pediatric emergency medicine fellows and one pediatric resident. After completing the simulation, six participants (85.7%) provided anonymous feedback on a five-point Likert scale (one = strongly disagree, five = strongly agree). Feedback was positive, and participants agreed that the case content was relevant to their clinical practice and that the event will improve their clinical practice. This simulation encourages participants to recognize and manage pediatric aortic dissection in patients with Turner syndrome. Participants felt that the simulation was relevant and will improve their clinical practice.
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Affiliation(s)
- Megan M Attridge
- Pediatric Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, USA
- Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Kali A Hopkins
- Adult Congenital Cardiology, Division of Cardiology, Mount Sinai Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Karen Mangold
- Pediatric Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, USA
- Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Wendy J Brickman
- Pediatric Endocrinology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, USA
- Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Sheetal R Patel
- Pediatric Cardiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, USA
- Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, USA
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Birjiniuk A, Weisman AG, Laternser C, Camarda J, Brickman WJ, Habiby R, Patel SR. Cardiovascular Manifestations of Turner Syndrome: Phenotypic Differences Between Karyotype Subtypes. Pediatr Cardiol 2023:10.1007/s00246-023-03159-0. [PMID: 37147524 DOI: 10.1007/s00246-023-03159-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 04/01/2023] [Indexed: 05/07/2023]
Abstract
Turner syndrome (TS) is a genetic disorder presenting in phenotypic females with total or partial monosomy of the X chromosome. Cardiovascular abnormalities are common, including congenital heart defects (CHD) and aortic dilation. Although mosaic TS is suspected to have less severe phenotype as compared to non-mosaic TS, differences in cardiovascular manifestations between karyotypes are not well studied. This is a single-center retrospective cohort study including patients with TS seen from 2000 to 2022. Demographic data, chromosomal analysis, and imaging were reviewed. Karyotypes were categorized as monosomy X (45X), 45X mosaicism, isochromosome Xq, partial X deletions, ring X (r(X)), TS with Y material, and others. Prevalence of CHD and aortic dilation were compared between monosomy X and other subtypes using Pearson's chi-square test and Welch two-sample t-test. We included 182 TS patients with median age 18 (range 4-33) years. CHD was more common in monosomy X as compared with others (61.4% vs. 26.8%, p < 0.001), including bicuspid aortic valve (44.3% vs. 16.1%, p < 0.001), partial anomalous pulmonary venous return (12.9% vs. 2.7%, p = 0.023), persistent left superior vena cava (12.9% vs. 1.8%, p = 0.008), and coarctation of the aorta (20.0% vs. 4.5%, p = 0.003). Cardiac surgery (24.3% vs. 8.9%, p = 0.017) was more prevalent in the monosomy X group. There was no statistically significant difference for presence of aortic dilation (7.1% vs 1.8%, p = 0.187). Although CHD and need for cardiac surgery are more common in TS with monosomy X as compared to others, all TS subtypes may have similar risk of developing aortic dilation. All TS patients should have similar cardiovascular surveillance testing to monitor for aortic dilation.
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Affiliation(s)
- Alona Birjiniuk
- Division of Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Avenue, Box 21, Chicago, IL, 60611-2991, USA
- Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Allison Goetsch Weisman
- Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
- Division of Genetics, Birth Defects and Metabolism, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Christina Laternser
- Division of Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Avenue, Box 21, Chicago, IL, 60611-2991, USA
| | - Joseph Camarda
- Division of Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Avenue, Box 21, Chicago, IL, 60611-2991, USA
- Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Wendy J Brickman
- Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
- Division of Endocrinology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Reema Habiby
- Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
- Division of Endocrinology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Sheetal R Patel
- Division of Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Avenue, Box 21, Chicago, IL, 60611-2991, USA.
- Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA.
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Jones L, Blair J, Hawcutt DB, Lip GYH, Shantsila A. Hypertension in Turner syndrome: a review of proposed mechanisms, management and new directions. J Hypertens 2023; 41:203-211. [PMID: 36583347 DOI: 10.1097/hjh.0000000000003321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Acquired cardiovascular diseases account for much of the increased risk of premature death in patients with Turner syndrome (TS). Hypertension is a major modifiable cardiovascular risk factor. It has a high prevalence in TS developing at an early age and thus leading to prolonged exposure to high blood pressure. The aetiology for hypertension in TS is largely unknown. It is likely multifactorial, and recent hypotheses include altered sympathetic tone, vasculopathy and endocrine factors. In this review article we aim to provide a comprehensive review of data on mechanisms of hypertension in TS and their implication for diagnostics and optimal choice of antihypertensive treatments. Ultimately this knowledge should help prevent hypertension-related complications, and improve quality of life and life expectancy for patients with TS.
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Affiliation(s)
- Lily Jones
- Department of Women's and Children's Health, University of Liverpool
| | - Joanne Blair
- Department of Endocrinology, Alder Hey Children's NHS Foundation Trust
| | - Daniel B Hawcutt
- Department of Women's and Children's Health, University of Liverpool
- NIHR Alder Hey Clinical Research Facility, Alder Hey Children's NHS Foundation Trust
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Alena Shantsila
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
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11
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Genetics of Heritable Thoracic Aortic Disease. CARDIOGENETICS 2022. [DOI: 10.3390/cardiogenetics12010006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Genetic testing plays an increasing diagnostic and prognostic role in the management of patients with heritable thoracic aortic disease (HTAD). The identification of a specific variant can establish or confirm the diagnosis of syndromic HTAD, dictate extensive evaluation of the arterial tree in HTAD with known distal vasculature involvement and justify closer follow-up and earlier surgical intervention in HTAD with high risk of dissection of minimal or normal aortic size. Evolving phenotype–genotype correlations lead us towards more precise and individualized management and treatment of patients with HTAD. In this review, we present the latest evidence regarding the role of genetics in patients with HTAD.
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12
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Stefil M, Kotalczyk A, Blair J, Lip GYH. Cardiovascular considerations in management of patients with Turner syndrome. Trends Cardiovasc Med 2021; 33:150-158. [PMID: 34906657 DOI: 10.1016/j.tcm.2021.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/30/2021] [Accepted: 12/08/2021] [Indexed: 01/15/2023]
Abstract
Turner syndrome (TS) is a chromosomal disorder that affects 25-50 per 100,000 live born females. Patients with TS face a heavy burden of cardiovascular disease (congenital and acquired) with an increased risk of mortality and morbidity compared to the general population. Cardiovascular diseases are a major cause of death in females with TS. Approximately 50% of TS patients have a congenital heart abnormality, with a high incidence of bicuspid aortic valve (BAV), coarctation of the aorta (CoA) and generalised arteriopathy. Frequently, females with TS have systemic hypertension, which is also a risk factor for progressive cardiac dysfunction and aortopathy. This paper aims to provide an overview of the cardiovascular assessment, management and follow up strategies in this high-risk population of TS patients.
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Affiliation(s)
- Maria Stefil
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool United Kingdom; Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom; Department of Endocrinology, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom.
| | - Agnieszka Kotalczyk
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool United Kingdom; Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom; Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Joanne Blair
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool United Kingdom; Department of Endocrinology, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool United Kingdom; Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom; Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Sivasubramanian R, Meyers KE. Hypertension in Children and Adolescents with Turner Syndrome (TS), Neurofibromatosis 1 (NF1), and Williams Syndrome (WS). Curr Hypertens Rep 2021; 23:18. [PMID: 33779870 DOI: 10.1007/s11906-021-01136-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2021] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW Turner syndrome (TS), neurofibromatosis type 1(NF1), and William Syndrome (WS) are 3 genetic conditions that are all associated with a substantial increase in risk of hypertension. In this review, we focus on factors leading to hypertension and on clinical manifestations and management of hypertension in children and adolescents with these genetic conditions RECENT FINDINGS: In most instances, hypertension is secondary. There is a high prevalence of masked hypertension in TS; however, the extent to which control of the BP helps reduce the risk of aortic dissection/aneurysm in TS is not yet fully elucidated. Vasculopathies are the least emphasized but most important manifestation of NF1. Of note, routine screening for pheochromocytoma in NFI is not recommended as it is not cost-effective. Cardiovascular complications are the major cause of death in patients with WBS. ABPM identifies patients without overt aortic or renovascular narrowing. Antihypertensive agents such as ARBs that have direct vascular wall effects and agents that inhibit oxidative stress (minoxidil) should be considered, even in those who do not exhibit overt hypertension. Elevated blood pressure in children and adolescence manifests early with end-organ changes and when left untreated, increases risk for premature onset of cardiovascular disease. Vigilant monitoring of the blood pressure is recommended. Accurate early diagnosis and management of hypertension will delay or prevent target organ damage and ensure a healthier transition to adulthood among children afflicted with these conditions.
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Affiliation(s)
- Ramya Sivasubramanian
- Division of Pediatric Nephrology, Department of Pediatrics, Children's Hospital of Philadelphia, 9th Floor Beurger Building, 3405 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Kevin E Meyers
- Division of Pediatric Nephrology, Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, 9th Floor Beurger Building, 3405 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
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Creamer TJ, Bramel EE, MacFarlane EG. Insights on the Pathogenesis of Aneurysm through the Study of Hereditary Aortopathies. Genes (Basel) 2021; 12:183. [PMID: 33514025 PMCID: PMC7912671 DOI: 10.3390/genes12020183] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/20/2021] [Accepted: 01/22/2021] [Indexed: 12/15/2022] Open
Abstract
Thoracic aortic aneurysms (TAA) are permanent and localized dilations of the aorta that predispose patients to a life-threatening risk of aortic dissection or rupture. The identification of pathogenic variants that cause hereditary forms of TAA has delineated fundamental molecular processes required to maintain aortic homeostasis. Vascular smooth muscle cells (VSMCs) elaborate and remodel the extracellular matrix (ECM) in response to mechanical and biochemical cues from their environment. Causal variants for hereditary forms of aneurysm compromise the function of gene products involved in the transmission or interpretation of these signals, initiating processes that eventually lead to degeneration and mechanical failure of the vessel. These include mutations that interfere with transduction of stimuli from the matrix to the actin-myosin cytoskeleton through integrins, and those that impair signaling pathways activated by transforming growth factor-β (TGF-β). In this review, we summarize the features of the healthy aortic wall, the major pathways involved in the modulation of VSMC phenotypes, and the basic molecular functions impaired by TAA-associated mutations. We also discuss how the heterogeneity and balance of adaptive and maladaptive responses to the initial genetic insult might contribute to disease.
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Affiliation(s)
- Tyler J. Creamer
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (T.J.C.); (E.E.B.)
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Emily E. Bramel
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (T.J.C.); (E.E.B.)
- Predoctoral Training in Human Genetics and Molecular Biology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Elena Gallo MacFarlane
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (T.J.C.); (E.E.B.)
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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Abstract
Patients with a known genetic cause of aortic root dilation usually have a single underlying aetiology, either a single gene defect as in Marfan syndrome or chromosomal anomaly as in Turner syndrome. However, it is possible, although unlikely, for a patient to inherit multiple independent risk factors for aortic root dilation. We describe such a patient, who inherited Marfan syndrome and a very unusual form of mosaic Turner syndrome. Long-term follow-up of this patient may provide insight into the natural history of this unique genetic combination.
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Dyrka K, Rozkiewicz N, Obara-Moszynska M, Niedziela M. The influence of growth hormone therapy on the cardiovascular system in Turner syndrome. J Pediatr Endocrinol Metab 2020; 33:1363-1372. [PMID: 33151179 DOI: 10.1515/jpem-2020-0266] [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] [Received: 05/13/2020] [Accepted: 08/17/2020] [Indexed: 12/11/2022]
Abstract
Short stature, ovarian dysgenesis, infertility, and cardiovascular malformations are classic features in Turner syndrome (TS), but the phenotypical spectrum is wide. Through early diagnosis and appropriate treatment, TS patients have a chance to achieve satisfactory adult height and sexual development. The doses of recombinant growth hormone (rGH) used are usually higher than the substitution dose. The safety aspects of this therapy are very important, especially in terms of the cardiovascular system. The presented study aimed to analyze how the rGH therapy may influence the cardiovascular system in TS based on current literature data. We conducted a systematic search for studies related to TS, cardiovascular system, and rGH therapy. The results show that rGH seems to have a positive effect on lipid parameters, reducing the risk of ischemic disease. It is additionally optimized by estradiol therapy. Although rGH may increase insulin resistance, the metabolic derangement is rare, probably due to lower fat content and an increase in lean body mass. Several studies showed that rGH treatment could cause aorta widening or increase the aorta growth rate. IGF-1 can be independently associated with increased aortic diameters. The studies analyzing the impact of GH on blood pressure show conflicting data. The proper cardiovascular imaging before and during rGH treatment and detecting the known risk factors for aorta dissection in every individual is very important. The long-term effects of growth hormone treatment on the heart and arteries are still not available and clearly estimated and have to be monitored in the future.
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Affiliation(s)
- Kamil Dyrka
- Student Scientific Society of Pediatric Endocrinology, Poznan University of Medical Sciences, Poznan, Poland
| | - Nikola Rozkiewicz
- Student Scientific Society of Pediatric Endocrinology, Poznan University of Medical Sciences, Poznan, Poland
| | - Monika Obara-Moszynska
- Department of Pediatric Endocrinology and Rheumatology, Poznan University of Medical Sciences, Poznan, Poland
| | - Marek Niedziela
- Department of Pediatric Endocrinology and Rheumatology, Poznan University of Medical Sciences, Poznan, Poland
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17
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Lin A, Rajagopalan A, Nguyen HH, White AJ, Vincent AJ, Mottram PM. Dilatation of the Ascending Aorta in Turner Syndrome: Influence of Bicuspid Aortic Valve Morphology and Body Composition. Heart Lung Circ 2020; 30:e29-e36. [PMID: 33132052 DOI: 10.1016/j.hlc.2020.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 09/30/2020] [Accepted: 10/07/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Aortic dilatation and bicuspid aortic valve (BAV) are frequent in Turner syndrome (TS). Due to short stature, aortic size index (ASI)-ascending aortic diameter (AD)/body surface area (BSA)-is used to identify aortic dilatation in TS patients. We sought to: 1) describe echocardiographic findings in the largest cohort of Australian women with TS; 2) assess if ASI progresses differently with age in TS BAV compared to non-syndromic BAV; and 3) determine whether adjustment of AD for body composition may be superior to BSA indexation. METHODS Transthoracic echocardiography (TTE) data were retrospectively collected on 125 women with TS. Body composition was quantified by dual energy X-ray absorptiometry (DXA) in 60 women within 6 months of baseline TTE. Age-matched females with non-syndromic BAV (n=170) were used as controls for TS patients with BAV. RESULTS Mean age of TS women was 28±16 years, and mean height and BSA were 141.6±21.7 cm and 1.4±0.4 m2, respectively. Mean AD was 2.5±0.8 cm, and ASI 2.0±0.6 cm/m2. Aortic dilatation (ASI >2.0 cm/m2) was present in 42 (34%) patients. Turner syndrome women with BAV (n=34; 27%) had a larger ASI than those with tri-leaflet AV (2.2±0.4 cm/m2 vs. 1.7±0.3 cm/m2, p<0.001). In the pooled BAV cohort, TS patients had a higher baseline ASI (2.2±0.4 cm/m2 vs. 2.1±0.3 cm/m2, p=0.02) and greater increase in ASI with age (0.21 mm/m2/year vs. 0.10 mm/m2/year, p=0.01) compared to non-syndromic BAV patients. DXA fat-free mass (r=0.33, p=0.01) and lean mass (r=0.32, p=0.02) correlated with AD, as did BSA (r=0.62, p<0.001). CONCLUSION Turner syndrome women with BAV have a greater degree of baseline aortic dilatation and a twofold faster increase in aortic dimension with age when compared to matched women with non-syndromic BAV. Several DXA-derived body composition parameters correlate with aortic size in TS, however BSA appears to be the most robust method of indexation.
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Affiliation(s)
- Andrew Lin
- Monash Cardiovascular Research Centre, Monash University and Monash Heart, Monash Health, Melbourne, Vic, Australia; Department of Medicine, Monash University, Melbourne, Vic, Australia.
| | | | - Hanh H Nguyen
- Department of Medicine, Monash University, Melbourne, Vic, Australia; Department of Endocrinology, Monash Health, Melbourne, Vic, Australia
| | - Anthony J White
- Monash Cardiovascular Research Centre, Monash University and Monash Heart, Monash Health, Melbourne, Vic, Australia; Department of Medicine, Monash University, Melbourne, Vic, Australia
| | - Amanda J Vincent
- Department of Endocrinology, Monash Health, Melbourne, Vic, Australia; Monash Centre for Health Research and Implementation, Monash University, Melbourne, Vic, Australia
| | - Philip M Mottram
- Monash Cardiovascular Research Centre, Monash University and Monash Heart, Monash Health, Melbourne, Vic, Australia; Department of Medicine, Monash University, Melbourne, Vic, Australia
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18
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Pater CM, Gutmark-Little I, Tretter JT, Martin LJ, Backeljauw P, Brown NM. Clinical characteristics and rate of dilatation in Turner syndrome patients treated for aortic dilatation. Am J Med Genet A 2020; 185:141-149. [PMID: 33118324 DOI: 10.1002/ajmg.a.61931] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/09/2020] [Accepted: 10/06/2020] [Indexed: 01/15/2023]
Abstract
Turner syndrome is associated with an increased risk of aortic aneurysms and dissection. Recent 2017 clinical care guidelines recommend medical therapy to treat aortic dilatation, although whether this slows dilatation is unknown. We aimed to describe a pre-guideline cohort of Turner syndrome patients with aortic dilatation, the rate of dilatation following diagnosis, and post therapy dilatation rates. We conducted a retrospective review of Turner syndrome patients with a dilated aortic root or ascending aorta by current definitions. In total, 40 patients were included with 22 treated patients. Most patients had 45,X karyotype, were white, non-Hispanic, and received both growth hormone and estrogen. Except for hypertension, there were no differences in risk factors among treated and untreated groups. Bicuspid aortic valve was very common. Treatment group patients had significantly more dilated ascending aortas by absolute measurements and aortic size index. In an adjusted model, there was minimal change in aortic measures over time and this was not associated with medication use. In conclusion, in this cohort, Turner syndrome patients with aortic dilatation were more likely to be treated if they had hypertension and if they met multiple dilatation criteria. Further study is needed to establish medical therapy efficacy on dilatation progression.
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Affiliation(s)
- Colleen M Pater
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Iris Gutmark-Little
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Justin T Tretter
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Lisa J Martin
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Philippe Backeljauw
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Nicole M Brown
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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19
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Sandahl K, Wen J, Erlandsen M, Andersen NH, Gravholt CH. Natural History of Hypertension in Turner Syndrome During a 12-Year Pragmatic Interventional Study. Hypertension 2020; 76:1608-1615. [PMID: 32895020 DOI: 10.1161/hypertensionaha.120.15292] [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: 01/15/2023]
Abstract
Turner syndrome is caused by complete or partial X monosomy in some or all cells. Cardiovascular complications are dominant, including increased blood pressure (BP), leading to early-onset hypertension. The aim is to describe the debut, development, and treatment of hypertension in Turner syndrome during a 12-year pragmatic interventional study to help identify risk factors associated with hypertension. One hundred and two women (aged 38±11 years, range: 18-62 years) with Turner syndrome verified by karyotyping (45, X: n=58 [57%]) were included consecutively. Ambulatory BPs were recorded over 24 hours with oscillometric measurements every 20 minutes. Antihypertensive treatment was recommended if the BP was above 135/85 mm Hg during the daytime. Overall, systolic BP, diastolic BP, and pulse pressure increased during the study, while heart rate decreased. The number of patients treated with antihypertensive medicine increased from 29 (28.71%) at baseline to 34 (53.13%) at the end of study. Twenty-four-hour systolic BP and 24-hour pulse pressure increased significantly with age, while 24-hour heart rate decreased with age, and diastolic BP was insignificantly affected by age. Antihypertensive treatment lowered systolic BP (24-hour: -5 mm Hg), diastolic BP (24-hour: -5 mm Hg), and diminished the pulse pressure (24-hour: -6 mm Hg) but did not affect nighttime systolic BP. Antihypertensive treatment did not affect heart rate. Our study showed that both systolic and diastolic BP increases significantly in women with Turner syndrome resulting in an increased risk of cardiovascular comorbidities. This increment should be considered of multifactorial origin with many contributing factors which is supported by our results.
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Affiliation(s)
- Kristian Sandahl
- From the Department of Endocrinology and Internal Medicine and Medical Research Laboratories (K.S., J.W., C.H.G.)
| | - Jan Wen
- From the Department of Endocrinology and Internal Medicine and Medical Research Laboratories (K.S., J.W., C.H.G.)
| | | | | | - Claus H Gravholt
- From the Department of Endocrinology and Internal Medicine and Medical Research Laboratories (K.S., J.W., C.H.G.).,Department of Molecular Medicine (C.H.G.), Aarhus University Hospital, Denmark and Section for Biostatistics
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20
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Fuchs MM, Attenhofer Jost C, Babovic-Vuksanovic D, Connolly HM, Egbe A. Long-Term Outcomes in Patients With Turner Syndrome: A 68-Year Follow-Up. J Am Heart Assoc 2020; 8:e011501. [PMID: 31131660 PMCID: PMC6585378 DOI: 10.1161/jaha.118.011501] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background Turner syndrome ( TS ) is the most common sex chromosome abnormality in women and is associated with increased morbidity and mortality. We describe long-term outcomes in a large cohort of patients with TS . Methods and Results Retrospective review of patients with TS followed at Mayo Clinic Rochester from 1950 to 2017 was performed. Clinical, imaging, surgical, and genetic data were analyzed. Survival analysis was performed with the Kaplan-Meier method using age- and sex-matched Olmsted County residents as the reference group. The study cohort comprised 317 patients with TS . Average age at diagnosis was 9 (range, 2-12) years, genetic testing was performed in 202 (64%), and pure monosomy X was present in 75 (37%). Congenital heart disease occurred in 131 (41%), with the most frequent lesions being bicuspid aortic valve (n=102, 32%) and coarctation of the aorta (n=43, 14%). Ascending aortic dilation was common, with mean aortic root size index 2 cm/m2, and aortic dissection occurred in 6 (2%) patients. The average follow-up was 11 (range, 2-26) years, yielding 3898 patient-years, and during this period 46 (14%) patients died; mean age at the time of death was 53±17 years. Patients with TS had reduced survival compared with the control group (82% versus 94% at 30 years; P<0.001), and the leading causes of death were cardiovascular disease, liver disease, and malignancy. Conclusions Patients with TS have reduced survival compared with age-matched controls, and cardiovascular disease is the major cause of death. Further studies are required to determine if targeted cardiovascular risk factor modification will result in improved survival in this population.
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Affiliation(s)
- Margaret M Fuchs
- 1 Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | | | | | - Heidi M Connolly
- 1 Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | - Alexander Egbe
- 1 Department of Cardiovascular Medicine Mayo Clinic Rochester MN
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21
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Fuchs MM, Attenhofer Jost CH, Said SM, Hagler DJ, Connolly HM, Dearani JA, Egbe AC. Cardiovascular surgery in Turner syndrome - early outcome and long-term follow-up. World J Cardiol 2020; 12:97-106. [PMID: 32280428 PMCID: PMC7138866 DOI: 10.4330/wjc.v12.i3.97] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 01/08/2020] [Accepted: 01/28/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cardiovascular disease is the leading cause of death in patients with Turner syndrome (TS), and cardiovascular surgery is frequently required for management of these patients. TS is associated with medical comorbidities than can complicate the care of this patient population.
AIM To describe the cardiovascular surgical outcomes of patients with TS.
METHODS A retrospective case series was compiled of 51 consecutive TS patients who had at least one cardiovascular surgery at Mayo Clinic Rochester from 1977-2017. The baseline clinical data of these patients were reviewed including demographics, medical comorbidities, congenital heart disease history, and medications. Echocardiographic reports were analyzed in detail. Operative reports and surgical hospital courses were reviewed. Long-term mortality was determined using medical records and the Social Security Death Index. Survival analysis was performed with the Kaplan Meier method.
RESULTS The cohort comprised 51 TS patients, average age at the time of surgery at Mayo Clinic was 28 (8-41) years, and 23 (45%) patients were under the age of 18. At the time of first Mayo Clinic surgery, 18 (35%) patients had previously undergone cardiac surgery at another institution. The most common procedures were repair of aortic coarctation in 14 (28%) patients, aortic valve replacement in 6 (12%) patients, and composite aortic root/ascending aorta replacement in 7 (14%) patients, with 7 patients undergoing repair of more than one lesion. Aortic dissection required operative intervention in 5 patients. After initial Mayo Clinic surgery, subsequent operations were required in 6 (13%) patients. Average hospital length of stay was 6 ± 2 d. There were 4 (8%) early surgical deaths. Freedom from death was 97% and 89% at 10 and 20 years, and the freedom from reoperation was 93% and 81% at 10 and 20 years.
CONCLUSION Cardiovascular surgery is associated with 8% early mortality given the medical complexity of TS patients. Those who survive to dismissal have good survival. Later cardiovascular reoperations are not rare.
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Affiliation(s)
- Margaret M Fuchs
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | | | - Sameh M Said
- Division of Pediatric Cardiothoracic Surgery, Masonic Children’s Hospital, University of Minnesota, Minneapolis, MN 55905, United States
| | - Donald J Hagler
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, United States
- Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN 55905, United States
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN 55905, United States
| | - Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, United States
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22
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Chou EL, Lindsay ME. The genetics of aortopathies: Hereditary thoracic aortic aneurysms and dissections. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2020; 184:136-148. [PMID: 32034893 DOI: 10.1002/ajmg.c.31771] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 01/28/2020] [Indexed: 12/15/2022]
Abstract
Aortopathies encompass a variety of inherited and acquired pathologies that increase risk of life-threatening dissection or rupture. Identifying individuals with hereditary thoracic aortic aneurysm and dissection (HTAAD) for longitudinal monitoring, medical therapy, or elective and preventative repair is paramount to reduce risk of cardiovascular-related mortality and complications from dissection and rupture. Over the past couple of decades, pathogenic variants in numerous genes have been identified in relation to HTAAD. The genetic diagnosis can help stratify patient risk and provide guidance on medical treatment, timing of prophylactic surgical repair, as well as longitudinal surveillance and imaging. Implicated genes and their associated proteins have been found to act on a diverse variety of pathways, cells and structural components linked to transforming growth factor beta (TGF-β) signaling pathways, disruption of the vascular smooth muscle cell contractile apparatus, and primary disruption of extracellular matrix homeostasis. This review describes relevant genetic variants that may help identify and guide the management of hereditary thoracic aortic aneurysms and dissections.
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Affiliation(s)
- Elizabeth L Chou
- Division of Vascular Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Thoracic Aortic Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mark E Lindsay
- Thoracic Aortic Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Cardiovascular Genetics Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Pediatric Cardiology Division, Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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23
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Gravholt CH, Viuff MH, Brun S, Stochholm K, Andersen NH. Turner syndrome: mechanisms and management. Nat Rev Endocrinol 2019; 15:601-614. [PMID: 31213699 DOI: 10.1038/s41574-019-0224-4] [Citation(s) in RCA: 146] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/23/2019] [Indexed: 12/12/2022]
Abstract
Turner syndrome is a rare condition in women that is associated with either complete or partial loss of one X chromosome, often in mosaic karyotypes. Turner syndrome is associated with short stature, delayed puberty, ovarian dysgenesis, hypergonadotropic hypogonadism, infertility, congenital malformations of the heart, endocrine disorders such as type 1 and type 2 diabetes mellitus, osteoporosis and autoimmune disorders. Morbidity and mortality are increased in women with Turner syndrome compared with the general population and the involvement of multiple organs through all stages of life necessitates a multidisciplinary approach to care. Despite an often conspicuous phenotype, the diagnostic delay can be substantial and the average age at diagnosis is around 15 years of age. However, numerous important clinical advances have been achieved, covering all specialty fields involved in the care of girls and women with Turner syndrome. Here, we present an updated Review of Turner syndrome, covering advances in genetic and genomic mechanisms of disease, associated disorders and multidisciplinary approaches to patient management, including growth hormone therapy and hormone replacement therapy.
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Affiliation(s)
- Claus H Gravholt
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark.
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark.
| | - Mette H Viuff
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Sara Brun
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Kirstine Stochholm
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Centre for Rare Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Niels H Andersen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
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Lee YJ, Kim SM, Lee YA, Kim GB, Shin CH, Yang SW. Relationship between systolic hypertension assessed by 24-hour ambulatory blood pressure monitoring and aortic diameters in young women with Turner syndrome. Clin Endocrinol (Oxf) 2019; 91:156-162. [PMID: 31001842 DOI: 10.1111/cen.13995] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 04/15/2019] [Accepted: 04/15/2019] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Patients with Turner syndrome (TS) are at high risk for cardiovascular morbidity and mortality due to aortic dilation. We evaluated the prevalence of hypertension and its risk factors and investigated the relationship between systolic hypertension and aortic diameter in young patients with TS. DESIGN Observational, cross-sectional study. PATIENTS AND MEASUREMENTS Forty-two patients with TS (15-35 years) who had achieved final adult heights underwent 24-h ambulatory blood pressure monitoring (ABPM). Fasting glucose, insulin and lipid profiles were measured. The homeostasis model assessment of insulin resistance (HOMA-IR) was calculated. Echocardiography was performed to evaluate aortic diameters (aortic annulus, aortic root at the sinuses of Valsalva, sinotubular junction and ascending aorta), which were converted into Turner-specific z-scores. RESULTS Systolic and/or diastolic hypertension was identified in 71.4% (n = 30) of patients, as assessed by 24-hour ABPM. Twenty-eight patients (66.7%) were nondippers. Patients with systolic hypertension (n = 8, 19.0%) had a higher weight, waist circumference and HOMA-IR levels than those without hypertension (P < 0.05 for all). After adjusting for covariates, HOMA-IR was independently associated with systolic hypertension (odds ratio 10.1, P = 0.043). After adjusting for age and bicuspid aortic valve, systolic hypertension was independently related to increased aortic diameter at the aortic annulus (β = 1.064, P = 0.009) and sinotubular junction (β = 1.124, P = 0.016). CONCLUSIONS Hypertension is highly prevalent and independently associated with IR in young patients with TS. The significant relationship between systolic hypertension and aortic diameters underscores the importance of BP and IR control.
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Affiliation(s)
- Yun Jeong Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Shin Mi Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Young Ah Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Gi Beom Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Choong Ho Shin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Sei Won Yang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
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Fox DA, Kang KT, Potts JE, Bradley TJ, Stewart LL, Dionne JM, Sandor GGS. Non-invasive assessment of aortic stiffness and blood pressure in young Turner syndrome patients. J Pediatr Endocrinol Metab 2019; 32:489-498. [PMID: 31042642 DOI: 10.1515/jpem-2018-0346] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 03/14/2019] [Indexed: 01/15/2023]
Abstract
Background Females with Turner syndrome (TS) carry an elevated risk of aortic dissection. The objective of the study was to assess the biophysical properties of the aorta and ambulatory blood pressure (BP) in females with TS and compare these findings to those in healthy female age-matched controls. Methods This was a prospective cohort study including subjects aged 8-25 years. Utilizing two-dimensional (2D) echocardiography and Doppler, proximal aortic dimensions were measured and biophysical properties of the aorta were calculated including pulse wave velocity (PWV), arterial pressure-strain elastic modulus and stiffness index. Resting BP was measured and ambulatory blood pressure monitoring (ABPM) was performed. Results Of 23 TS patients and 46 controls (median age 16.3 years), aortic annulus, sinus of Valsalva and sinotubular (ST) junction diameters, as well as left ventricular (LV) mass, were significantly greater in TS patients compared with controls when scaled for height2.7, but not for body surface area (BSA), although ascending aorta diameter was greater when scaled for both. Median PWV was faster in TS patients compared to controls (451 vs. 360 cm/s) while arterial pressure-strain elastic modulus and stiffness index were similar. Resting BP was abnormal in seven out of 22 patients and ABPM was abnormal in 16 out of 21 patients. Conclusions Young patients with TS had dilated proximal aortas when scaled for height2.7 and stiffer aortas when compared with healthy female age-matched controls. Moreover, resting BP underdiagnosed pre-hypertension and hypertension compared to ABPM. These findings are consistent with the presence of a primary aortopathy in TS.
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Affiliation(s)
- Danya A Fox
- Department of Pediatrics, Division of Endocrinology and Diabetes, University of British Columbia, Vancouver, BC, Canada
| | - Kristopher T Kang
- Department of Pediatrics, Division of General Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - James E Potts
- Department of Pediatrics, Division of Cardiology, University of British Columbia, Vancouver, BC, Canada
| | - Timothy J Bradley
- Department of Pediatrics, Division of Cardiology, University of Saskatchewan, Saskatoon, SK, Canada
| | - Laura L Stewart
- Department of Pediatrics, Division of Endocrinology and Diabetes, University of British Columbia, Vancouver, BC, Canada
| | - Janis M Dionne
- Department of Pediatrics, Division of Nephrology, University of British Columbia, Vancouver, BC, Canada
| | - George G S Sandor
- Department of Pediatrics, Division of Cardiology, University of British Columbia, Vancouver, BC, Canada
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Computed Tomography and Magnetic Resonance Imaging of Cardiovascular Anomalies Associated With Turner Syndrome. J Thorac Imaging 2019; 34:W23-W35. [DOI: 10.1097/rti.0000000000000372] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Evaluation of cardiac MRI and ambulatory blood pressure monitoring in a pediatric Turner syndrome population. PROGRESS IN PEDIATRIC CARDIOLOGY 2019. [DOI: 10.1016/j.ppedcard.2018.08.005] [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: 11/19/2022]
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Brun S, Cleemann L, Holm K, Salskov G, Erlandsen M, Berglund A, Andersen NH, Gravholt CH. Five-Year Randomized Study Demonstrates Blood Pressure Increases in Young Women With Turner Syndrome Regardless of Estradiol Dose. Hypertension 2019; 73:242-248. [DOI: 10.1161/hypertensionaha.118.11742] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Sara Brun
- From the Department of Pediatrics, Nordsjællands Hospital, Copenhagen University Hospital, Hillerød, Denmark (S.B., L.C., K.H., G.S.)
- Department of Endocrinology and Internal Medicine and the Medical Research Laboratories (S.B., A.B., C.H.G.), Aarhus University Hospital, Denmark
| | - Line Cleemann
- From the Department of Pediatrics, Nordsjællands Hospital, Copenhagen University Hospital, Hillerød, Denmark (S.B., L.C., K.H., G.S.)
| | - Kirsten Holm
- From the Department of Pediatrics, Nordsjællands Hospital, Copenhagen University Hospital, Hillerød, Denmark (S.B., L.C., K.H., G.S.)
| | - Gitte Salskov
- From the Department of Pediatrics, Nordsjællands Hospital, Copenhagen University Hospital, Hillerød, Denmark (S.B., L.C., K.H., G.S.)
| | - Mogens Erlandsen
- Section for Biostatistics, Department of Public Health, Aarhus University, Denmark (M.E.)
| | - Agnethe Berglund
- Department of Endocrinology and Internal Medicine and the Medical Research Laboratories (S.B., A.B., C.H.G.), Aarhus University Hospital, Denmark
- Department of Molecular Medicine (A.B., C.H.G.), Aarhus University Hospital, Denmark
| | - Niels H. Andersen
- Department of Cardiology, Aalborg University Hospital, Denmark (N.H.A.)
| | - Claus H. Gravholt
- Department of Endocrinology and Internal Medicine and the Medical Research Laboratories (S.B., A.B., C.H.G.), Aarhus University Hospital, Denmark
- Department of Molecular Medicine (A.B., C.H.G.), Aarhus University Hospital, Denmark
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Krikščiūnienė R, Navickaitė I, Ereminienė E, Lukoševičius S, Žilaitienė B, Verkauskienė R. Relationship between Echocardiographic and Magnetic Resonance-Derived Measurements of the Thoracic Aorta in Turner Syndrome Patients. Int J Endocrinol 2019; 2019:9258726. [PMID: 31531017 PMCID: PMC6721444 DOI: 10.1155/2019/9258726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 07/16/2019] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Turner syndrome (TS) is assigned to the rare diseases group. Morbidity and mortality of TS patients are high, particularly due to the cardiovascular disorders, so monitoring for cardiovascular complications must be ensured. The data demonstrate a strong correlation between 2-dimensional echocardiographic (2Decho) evaluation and magnetic resonance imaging (MRI); still, according to recent guidelines, MRI remains a gold standard. In this study, we aimed to compare aortic dimensions on MRI and 2Decho in TS patients. METHODS 50 TS patients (≥18 years) were enrolled into the cross-sectional study. 2Decho and MRI were performed. The measurements of the aorta were assessed in five standard positions on 2Decho and in 9 standard positions on MRI; ASI (aortic size index) of the ascending aorta was calculated since reduced adult height is observed in TS patients. RESULTS ASI on echocardiography strongly correlated with ASI on MRI in all positions of the ascending aorta, but significantly larger medians of ASI were found on 2Decho in all positions of the ascending aorta and arch when compared with MRI measurements. Still, the prevalence of aortic sinus dilation was significantly and more frequently (52% vs. 38%, p < 0.001) observed on MRI when compared with 2Decho. CONCLUSION The relation of aortic size was significant in all positions when comparing the MRI and 2Decho methods; still, the dilatation of the sinus of aorta was more frequently found on MRI compared with echocardiography.
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Affiliation(s)
- Rūta Krikščiūnienė
- Lithuanian University of Health Sciences, Department of Endocrinology, Medical Academy, Kaunas, Lithuania
| | | | - Eglė Ereminienė
- Lithuanian University of Health Sciences, Department of Cardiology, Medical Academy, Kaunas, Lithuania
| | - Saulius Lukoševičius
- Lithuanian University of Health Sciences, Department of Radiology, Medical Academy, Kaunas, Lithuania
| | - Birutė Žilaitienė
- Lithuanian University of Health Sciences, Department of Endocrinology, Medical Academy, Kaunas, Lithuania
| | - Rasa Verkauskienė
- Lithuanian University of Health Sciences, Department of Endocrinology, Medical Academy, Kaunas, Lithuania
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Silberbach M, Roos-Hesselink JW, Andersen NH, Braverman AC, Brown N, Collins RT, De Backer J, Eagle KA, Hiratzka LF, Johnson WH, Kadian-Dodov D, Lopez L, Mortensen KH, Prakash SK, Ratchford EV, Saidi A, van Hagen I, Young LT. Cardiovascular Health in Turner Syndrome: A Scientific Statement From the American Heart Association. CIRCULATION-GENOMIC AND PRECISION MEDICINE 2018; 11:e000048. [DOI: 10.1161/hcg.0000000000000048] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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32
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Mosaic Turner syndrome shows reduced penetrance in an adult population study. Genet Med 2018; 21:877-886. [PMID: 30181606 PMCID: PMC6752315 DOI: 10.1038/s41436-018-0271-6] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 08/03/2018] [Indexed: 12/21/2022] Open
Abstract
Purpose Many women with X chromosome aneuploidy undergo lifetime clinical monitoring for possible complications. However, ascertainment of cases in the clinic may mean that the penetrance has been overestimated. Methods We characterized the prevalence and phenotypic consequences of X chromosome aneuploidy in a population of 244,848 women over 40 years of age from UK Biobank, using single-nucleotide polymorphism (SNP) array data. Results We detected 30 women with 45,X; 186 with mosaic 45,X/46,XX; and 110 with 47,XXX. The prevalence of nonmosaic 45,X (12/100,000) and 47,XXX (45/100,000) was lower than expected, but was higher for mosaic 45,X/46,XX (76/100,000). The characteristics of women with 45,X were consistent with the characteristics of a clinically recognized Turner syndrome phenotype, including short stature and primary amenorrhea. In contrast, women with mosaic 45,X/46,XX were less short, had a normal reproductive lifespan and birth rate, and no reported cardiovascular complications. The phenotype of women with 47,XXX included taller stature (5.3 cm; SD = 5.52 cm; P = 5.8 × 10−20) and earlier menopause age (5.12 years; SD = 5.1 years; P = 1.2 × 10−14). Conclusion Our results suggest that the clinical management of women with 45,X/46,XX mosaicism should be minimal, particularly those identified incidentally.
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Kosteria I, Kanaka-Gantenbein C. Turner Syndrome: transition from childhood to adolescence. Metabolism 2018; 86:145-153. [PMID: 29309748 DOI: 10.1016/j.metabol.2017.12.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 12/29/2017] [Accepted: 12/31/2017] [Indexed: 01/15/2023]
Abstract
Transition from pediatric to adult care for young women with Turner Syndrome (TS) is characterized by high drop-out rates and inadequate follow-up, leading to increased morbidity and mortality. The complexity of the health issues young women with TS face or new problems that may arise warrants a well-structured and efficiently coordinated gradual transition plan, which is adapted to the individual needs of the emerging young adult and is based on interdisciplinary communication between physicians. In order to achieve a high level of care, it is important for the patient to be sincerely informed about her condition but also supported throughout this critical period of rising responsibility and autonomy by an experienced, multidisciplinary team. In this review, we present the basic concepts that should characterize transition and the major health issues that should be thoroughly addressed, including growth, Hormone Replacement Treatment and fertility options, cardiovascular disease, bone health, gastrointestinal disorders, autoimmunity, orthopaedic and ENT issues, as well as the overall psychological well-being of the young adult with TS.
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Affiliation(s)
- Ioanna Kosteria
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, Medical School, National and Kapodistrian University of Athens, "Agia Sophia" Children's Hospital, Athens, Greece.
| | - Christina Kanaka-Gantenbein
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, Medical School, National and Kapodistrian University of Athens, "Agia Sophia" Children's Hospital, Athens, Greece
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34
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Clinical and Echocardiographic Prevalence and Detection of Congenital and Acquired Cardiac Abnormalities in Girls and Women with the Turner Syndrome. Am J Cardiol 2018; 122:327-330. [PMID: 29731120 DOI: 10.1016/j.amjcard.2018.03.357] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 03/16/2018] [Accepted: 03/27/2018] [Indexed: 01/15/2023]
Abstract
The prevalence of congenital and acquired heart disease in patients with the Turner syndrome (TS) is based on historic cohorts who underwent imaging before the advent of modern day echocardiography. Recent small studies suggest a higher prevalence of cardiac defects. We reviewed clinical and echocardiographic data on 564 girls and women with TS to assess the prevalence of cardiac defects. Echocardiographic review on a subset of this population was performed to assess for diagnostic limitations of echocardiography in assessing for congenital and acquired defects in this patient cohort. Bicuspid aortic valve was present in 39%, aortic coarctation in 21%, and some forms of structural cardiac anomaly in 56%. Failure to perform a complete congenital echocardiogram with suprasternal and high right or left parasternal windows was associated with failure to identify congenital and acquired cardiac defects. In conclusion, major cardiac defects are present in the majority of patients with TS. Echocardiographic technique can be optimized to avoid missing cardiac lesions of potential hemodynamic significance.
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Pees C, Heno JA, Häusler G, Ertl DA, Gulesserian T, Michel-Behnke I. Aortic elasticity deterioration proves intrinsic abnormality of the ascending aorta in pediatric Turner syndrome unrelated to the aortic valve morphology. Heart Vessels 2018; 33:1350-1357. [PMID: 29777298 PMCID: PMC6208677 DOI: 10.1007/s00380-018-1187-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 05/11/2018] [Indexed: 01/15/2023]
Abstract
Turner syndrome (TS) is a common genetic disorder in females with high incidence of ascending aortic dilatation and even dissection occurring as early as in the second decade. Known risk factors (RF) are bicuspid aortic valves (BAV), coarctation of the aorta (CoA), and arterial hypertension. Since 10% of dissections occur in patients without RF, an intrinsic aortic wall abnormality has been postulated. This study aimed to investigate the elasticity of the ascending aorta as a surrogate marker of aortic wall texture. Forty-six pediatric patients with genetically proven TS were prospectively examined for the morphology of their aortic valve, and size and elasticity indices of the adjacent aorta. Cohorts of 46 female subjects with tricuspid aortic valves (TAV) and ten non-syndromic females with BAV were investigated as separate control groups. Comparison of healthy controls with TS patients revealed significantly deteriorated elasticity indices in those with TS. Furthermore, normalized aortic dimensions were greater in TS patients, but dilatations of the ascending aorta with z-score levels above two were restricted to those with BAV (14/46). Deteriorated elasticity indices were measured in TS patients, independent of aortic dilatation, BAV, and CoA, and were comparable to those of patients with isolated, non-syndromic BAVs. By measuring elasticity levels as a surrogate for aortic wall texture, we were able to gather evidence that TS presents with an intrinsic abnormality of the ascending aorta even in patients without concomitant BAV, CoA or dilatations as early as in childhood.
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Affiliation(s)
- Christiane Pees
- Pediatric Heart Center Vienna/Division of Pediatric Cardiology, University Children's Hospital Vienna, Medical University Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | - Julian A Heno
- Pediatric Heart Center Vienna/Division of Pediatric Cardiology, University Children's Hospital Vienna, Medical University Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Gabriele Häusler
- Division of Pediatric Pulmonology, University Children's Hospital Vienna, Vienna, Austria
| | - Diana-Alexandra Ertl
- Division of Pediatric Pulmonology, University Children's Hospital Vienna, Vienna, Austria
| | - Talin Gulesserian
- Pediatric Heart Center Vienna/Division of Pediatric Cardiology, University Children's Hospital Vienna, Medical University Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Ina Michel-Behnke
- Pediatric Heart Center Vienna/Division of Pediatric Cardiology, University Children's Hospital Vienna, Medical University Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
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36
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Aortic root remodeling in a patient with Turner syndrome using the reference curves of aortic diameters in children. Gen Thorac Cardiovasc Surg 2018; 66:667-670. [PMID: 29372397 DOI: 10.1007/s11748-018-0889-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 01/13/2018] [Indexed: 01/15/2023]
Abstract
We report the successful surgical treatment of aortic regurgitation in a 27-year-old woman with Turner syndrome (TS) who was admitted with exacerbation of dyspnea on exertion. Echocardiography showed a bicuspid aortic valve with severe aortic regurgitation and computed tomography showed dilatation of the ascending aorta and aortic root. Due to the patient's low body surface area (due to TS), standard determination of aortic size was not possible; therefore, we used the reference curves of aortic diameters in children. Because of the possibility of fatal ascending aortic dissection and rupture, we performed concomitant aortic root remodeling and aortic valve repair.
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Corbitt H, Maslen C, Prakash S, Morris SA, Silberbach M. Allometric considerations when assessing aortic aneurysms in Turner syndrome: Implications for activity recommendations and medical decision-making. Am J Med Genet A 2017; 176:277-282. [PMID: 29243875 DOI: 10.1002/ajmg.a.38584] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 11/06/2017] [Accepted: 11/26/2017] [Indexed: 01/15/2023]
Abstract
In Turner syndrome, the potential to form thoracic aortic aneurysms requires routine patient monitoring. However, the short stature that typically occurs complicates the assessment of severity and risk because the relationship of body size to aortic dimensions is different in Turner syndrome compared to the general population. Three allometric formula have been proposed to adjust aortic dimensions, all employing body surface area: aortic size index, Turner syndrome-specific Z-scores, and Z-scores based on a general pediatric and young adult population. In order to understand the differences between these formula we evaluated the relationship between age and aortic size index and compared Turner syndrome-specific Z-scores and pediatric/young adult based Z-scores in a group of girls and women with Turner syndrome. Our results suggest that the aortic size index is highly age-dependent for those under 15 years; and that Turner-specific Z-scores are significantly lower than Z-scores referenced to the general population. Higher Z-scores derived from the general reference population could result in stigmatization, inappropriate restriction from sports, and increasing the risk of unneeded medical or operative treatments. We propose that when estimating aortic dissection risk clinicians use Turner syndrome-specific Z-score for those under fifteen years of age.
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Affiliation(s)
- Holly Corbitt
- Knight Cardiovascular Institute, Department of Molecular and Medical Genetics, Oregon Health & Science University, Portland, Oregon
| | - Cheryl Maslen
- Knight Cardiovascular Institute, Department of Molecular and Medical Genetics, Oregon Health & Science University, Portland, Oregon
| | - Siddharth Prakash
- Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, Houston, Texas
| | - Shaine A Morris
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Michael Silberbach
- Department of Pediatrics, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
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38
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Koenig SN, LaHaye S, Feller JD, Rowland P, Hor KN, Trask AJ, Janssen PM, Radtke F, Lilly B, Garg V. Notch1 haploinsufficiency causes ascending aortic aneurysms in mice. JCI Insight 2017; 2:91353. [PMID: 29093270 DOI: 10.1172/jci.insight.91353] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 09/29/2017] [Indexed: 12/20/2022] Open
Abstract
An ascending aortic aneurysm (AscAA) is a life-threatening disease whose molecular basis is poorly understood. Mutations in NOTCH1 have been linked to bicuspid aortic valve (BAV), which is associated with AscAA. Here, we describe a potentially novel role for Notch1 in AscAA. We found that Notch1 haploinsufficiency exacerbated the aneurysmal aortic root dilation seen in the Marfan syndrome mouse model and that heterozygous deletion of Notch1 in the second heart field (SHF) lineage recapitulated this exacerbated phenotype. Additionally, Notch1+/- mice in a predominantly 129S6 background develop aortic root dilation, indicating that loss of Notch1 is sufficient to cause AscAA. RNA sequencing analysis of the Notch1.129S6+/- aortic root demonstrated gene expression changes consistent with AscAA. These findings are the first to our knowledge to demonstrate an SHF lineage-specific role for Notch1 in AscAA and suggest that genes linked to the development of BAV may also contribute to the associated aortopathy.
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Affiliation(s)
- Sara N Koenig
- Center for Cardiovascular Research and.,The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA.,Dorothy M. Davis Heart and Lung Research Institute
| | - Stephanie LaHaye
- Center for Cardiovascular Research and.,The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Molecular Genetics
| | - James D Feller
- Center for Cardiovascular Research and.,The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Patrick Rowland
- Center for Cardiovascular Research and.,The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Kan N Hor
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Pediatrics, and
| | - Aaron J Trask
- Center for Cardiovascular Research and.,The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Pediatrics, and
| | - Paul Ml Janssen
- Department of Physiology and Cell Biology, The Ohio State University, Columbus, Ohio, USA
| | - Freddy Radtke
- Ecole Polytechnique Fédérale de Lausanne, Swiss Institute for Experimental Cancer Research, Lausanne, Switzerland
| | - Brenda Lilly
- Center for Cardiovascular Research and.,The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Molecular Genetics
| | - Vidu Garg
- Center for Cardiovascular Research and.,The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA.,Dorothy M. Davis Heart and Lung Research Institute.,Department of Molecular Genetics.,Department of Pediatrics, and
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Gravholt CH, Andersen NH, Conway GS, Dekkers OM, Geffner ME, Klein KO, Lin AE, Mauras N, Quigley CA, Rubin K, Sandberg DE, Sas TCJ, Silberbach M, Söderström-Anttila V, Stochholm K, van Alfen-van derVelden JA, Woelfle J, Backeljauw PF. Clinical practice guidelines for the care of girls and women with Turner syndrome: proceedings from the 2016 Cincinnati International Turner Syndrome Meeting. Eur J Endocrinol 2017; 177:G1-G70. [PMID: 28705803 DOI: 10.1530/eje-17-0430] [Citation(s) in RCA: 602] [Impact Index Per Article: 86.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 06/07/2017] [Indexed: 12/14/2022]
Abstract
Turner syndrome affects 25-50 per 100,000 females and can involve multiple organs through all stages of life, necessitating multidisciplinary approach to care. Previous guidelines have highlighted this, but numerous important advances have been noted recently. These advances cover all specialty fields involved in the care of girls and women with TS. This paper is based on an international effort that started with exploratory meetings in 2014 in both Europe and the USA, and culminated with a Consensus Meeting held in Cincinnati, Ohio, USA in July 2016. Prior to this meeting, five groups each addressed important areas in TS care: 1) diagnostic and genetic issues, 2) growth and development during childhood and adolescence, 3) congenital and acquired cardiovascular disease, 4) transition and adult care, and 5) other comorbidities and neurocognitive issues. These groups produced proposals for the present guidelines. Additionally, four pertinent questions were submitted for formal GRADE (Grading of Recommendations, Assessment, Development and Evaluation) evaluation with a separate systematic review of the literature. These four questions related to the efficacy and most optimal treatment of short stature, infertility, hypertension, and hormonal replacement therapy. The guidelines project was initiated by the European Society for Endocrinology and the Pediatric Endocrine Society, in collaboration with The European Society for Pediatric Endocrinology, The Endocrine Society, European Society of Human Reproduction and Embryology, The American Heart Association, The Society for Endocrinology, and the European Society of Cardiology. The guideline has been formally endorsed by the European Society for Endocrinology, the Pediatric Endocrine Society, the European Society for Pediatric Endocrinology, the European Society of Human Reproduction and Embryology and the Endocrine Society. Advocacy groups appointed representatives who participated in pre-meeting discussions and in the consensus meeting.
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Affiliation(s)
- Claus H Gravholt
- Departments of Endocrinology and Internal Medicine
- Departments of Molecular Medicine
| | - Niels H Andersen
- Departments of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Gerard S Conway
- Department of Women's Health, University College London, London, UK
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Mitchell E Geffner
- The Saban Research Institute, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Karen O Klein
- Rady Children's Hospital, University of California, San Diego, California, USA
| | - Angela E Lin
- Department of Pediatrics, Medical Genetics Unit, Mass General Hospital for Children, Boston, Massachusetts, USA
| | - Nelly Mauras
- Division of Endocrinology, Nemours Children's Health System, Jacksonville, Florida, USA
| | | | - Karen Rubin
- Connecticut Children's Medical Center, Hartford, Connecticut, USA
| | - David E Sandberg
- Division of Psychology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Theo C J Sas
- Department of Pediatric Endocrinology, Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Pediatrics, Dordrecht, The Netherlands
| | - Michael Silberbach
- Department of Pediatrics, Doernbecher Children's Hospital, Portland, Oregon, USA
| | | | - Kirstine Stochholm
- Departments of Endocrinology and Internal Medicine
- Center for Rare Diseases, Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
| | | | - Joachim Woelfle
- Department of Pediatric Endocrinology, Children's Hospital, University of Bonn, Bonn, Germany
| | - Philippe F Backeljauw
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Amedro P, Tahhan N, Bertet H, Jeandel C, Guillaumont S, Mura T, Picot MC. Health-related quality of life among children with Turner syndrome: controlled cross-sectional study. J Pediatr Endocrinol Metab 2017; 30:863-868. [PMID: 28753541 DOI: 10.1515/jpem-2017-0026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 06/03/2017] [Indexed: 01/15/2023]
Abstract
BACKGROUND The aim of the study was to assess health-related quality of life (HR-QoL) in children with Turner syndrome in comparison with controls. METHODS We prospectively recruited 16 female girls with Turner syndrome (mean age 15.2±2.6 years) and 78 female controls (mean age 12.7±2.8 years) in randomly selected schools. We used the PedsQL, a generic HR-QoL questionnaire (self and parents' versions). RESULTS Global HR-QoL scores in Turner syndrome were lower than controls for self-reports (respectively, 74.3±3.0 vs. 82.8±1.3, p=0.01) and parents' reports (62.7±3.8 vs. 80.1±1.7, p<0.0001). In Turner syndrome, self-reported HR-QoL was impaired in school functioning (70.6±4.0 vs. 80.71±1.7, p=0.02), social functioning (78.2±4.0 vs. 90.4±1.8, p<0.01) and physical functioning (78.5±3.2 vs. 87.1±1.4, p=0.02), but not in emotional functioning. Parents' reported HR-QoL was impaired in all four dimensions. CONCLUSIONS HR-QoL was impaired in this cohort of young females with Turner syndrome, as in previously reported adult studies. In addition to medical treatment and routine clinical follow-up, female girls and teenagers with Turner syndrome should also be supported psychologically by social, educational and psychotherapeutic interventions that aim to address their self-esteem and emotional difficulties.
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Abstract
Thoracic aortic aneurysm is a potentially life-threatening condition in that it places patients at risk for aortic dissection or rupture. However, our modern understanding of the pathogenesis of thoracic aortic aneurysm is quite limited. A genetic predisposition to thoracic aortic aneurysm has been established, and gene discovery in affected families has identified several major categories of gene alterations. The first involves mutations in genes encoding various components of the transforming growth factor beta (TGF-β) signaling cascade (FBN1, TGFBR1, TGFBR2, TGFB2, TGFB3, SMAD2, SMAD3 and SKI), and these conditions are known collectively as the TGF-β vasculopathies. The second set of genes encode components of the smooth muscle contractile apparatus (ACTA2, MYH11, MYLK, and PRKG1), a group called the smooth muscle contraction vasculopathies. Mechanistic hypotheses based on these discoveries have shaped rational therapies, some of which are under clinical evaluation. This review discusses published data on genes involved in thoracic aortic aneurysm and attempts to explain divergent hypotheses of aneurysm origin.
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Affiliation(s)
- Eric M Isselbacher
- From Thoracic Aortic Center (E.M.I., C.L.L.C., M.E.L.), Cardiovascular Genetics Program (M.E.L.), Cardiovascular Research Center (C.L.L.C., M.E.L.), and Cardiology Division (E.M.I., C.L.L.C., M.E.L.), Department of Medicine, and Pediatric Cardiology Division, Department of Pediatrics (M.E.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Christian Lacks Lino Cardenas
- From Thoracic Aortic Center (E.M.I., C.L.L.C., M.E.L.), Cardiovascular Genetics Program (M.E.L.), Cardiovascular Research Center (C.L.L.C., M.E.L.), and Cardiology Division (E.M.I., C.L.L.C., M.E.L.), Department of Medicine, and Pediatric Cardiology Division, Department of Pediatrics (M.E.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Mark E Lindsay
- From Thoracic Aortic Center (E.M.I., C.L.L.C., M.E.L.), Cardiovascular Genetics Program (M.E.L.), Cardiovascular Research Center (C.L.L.C., M.E.L.), and Cardiology Division (E.M.I., C.L.L.C., M.E.L.), Department of Medicine, and Pediatric Cardiology Division, Department of Pediatrics (M.E.L.), Massachusetts General Hospital, Harvard Medical School, Boston.
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Increased aortic stiffness in prepubertal girls with Turner syndrome. J Cardiol 2017; 69:201-207. [DOI: 10.1016/j.jjcc.2016.03.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 02/24/2016] [Accepted: 03/01/2016] [Indexed: 01/15/2023]
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An HS, Baek JS, Kim GB, Lee YA, Song MK, Kwon BS, Bae EJ, Noh CI. Impaired Vascular Function of the Aorta in Adolescents with Turner Syndrome. Pediatr Cardiol 2017; 38:20-26. [PMID: 27628435 DOI: 10.1007/s00246-016-1478-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 09/07/2016] [Indexed: 01/15/2023]
Abstract
To investigate intrinsic vascular abnormalities of the ascending aorta before adulthood in Turner syndrome patients (TS), we compared 25 adolescent TS patients (mean age 14.6 ± 3.4 years) and 16 healthy controls from a university hospital. Blood pressure and other vascular indices were evaluated using echocardiography such as aortic strain, stiffness index, distensibility, and pulse wave velocity. Aortic strain (0.1237 vs. 0.1865, respectively; P = 0.003) and aortic distensibility (0.0049 vs. 0.0081, P = 0.002) were significantly lower in the TS group than in the controls. The fractional area change on velocity vector imaging was also lower in TS patients (29.05 vs. 36.19, P = 0.002). These findings were still observed after adjustment for age, body mass index, and systolic blood pressure. The aortic stiffness index was greater in the TS patients than in the control group (6.79 vs. 3.34, P = 0.02). The pulse wave velocity and ascending aorta diameter did not significantly differ between the TS and control groups. Blood pressures were significantly higher in the TS patients than in the controls (systolic, 120.4 vs. 108.4 mmHg, P = 0.001; diastolic 71.5 vs. 61.7 mmHg, P < 0.001). Although the dimensional changes in the aorta were not clearly observed in adolescents with TS, the elastic properties of the aorta were significantly decreased in TS patients as compared to control subjects.
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Affiliation(s)
- Hyo Soon An
- Department of Pediatrics, Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, South Korea.,Department of Pediatrics, SMG-SNU Boramae Medical Center, Seoul, South Korea
| | - Jae Suk Baek
- Department of Pediatrics, Asan Medical Center, Seoul, South Korea
| | - Gi Beom Kim
- Department of Pediatrics, Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, South Korea.
| | - Young Ah Lee
- Department of Pediatrics, Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, South Korea
| | - Mi Kyoung Song
- Department of Pediatrics, Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, South Korea
| | - Bo Sang Kwon
- Department of Pediatrics, Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, South Korea
| | - Eun Jung Bae
- Department of Pediatrics, Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, South Korea
| | - Chung Il Noh
- Department of Pediatrics, Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, South Korea
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Somerville S, Rosolowsky E, Suntratonpipat S, Girgis R, Goot BH, Tham EB. Cardiac Magnetic Resonance Imaging in Pediatric Turner Syndrome. J Pediatr 2016; 175:111-115.e1. [PMID: 27233524 DOI: 10.1016/j.jpeds.2016.04.080] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 03/17/2016] [Accepted: 04/22/2016] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To compare the detection of cardiac lesions with the use of cardiac magnetic resonance imaging (CMR) and conventional echocardiography in children with Turner syndrome. STUDY DESIGN Twenty-four girls with Turner syndrome, 8-18 years of age, were recruited through the Pediatric Endocrinology Program. Participants underwent CMR and echocardiography within a 2-year period, and discrepancies between the results of each modality were identified. RESULTS Fifteen of 24 (63%) girls had a cardiac lesion identified on CMR or echocardiography. Both modalities identified the same lesion in 10 of 15 (67%); however, 6 of 15 (40%) participants had a lesion identified on CMR but not echocardiography. Participants with a missed lesion had a trend towards greater body mass index. Aortic dilation and bicuspid aortic valve were the most commonly missed lesions by echocardiography. CONCLUSIONS CMR identifies significant cardiac lesions missed by echocardiography in pediatric patients with Turner syndrome, particularly along the aorta. These findings support the current guidelines that recommend screening CMR in addition to echocardiogram. Early identification of cardiac abnormalities in patients with Turner syndrome will allow for a greater understanding of the natural history in these patients and potentially identify candidates for earlier intervention.
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Affiliation(s)
- Scott Somerville
- Pediatric Endocrinology, University of Alberta, Edmonton, Alberta, Canada
| | | | - Somjate Suntratonpipat
- Pediatric Cardiology, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Rose Girgis
- Pediatric Endocrinology, University of Alberta, Edmonton, Alberta, Canada
| | - Benjamin H Goot
- Pediatric Cardiology, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Edythe B Tham
- Pediatric Cardiology, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada.
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Arterial hypertension in Turner syndrome: a review of the literature and a practical approach for diagnosis and treatment. J Hypertens 2016; 33:1342-51. [PMID: 26039527 DOI: 10.1097/hjh.0000000000000599] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Turner syndrome is a rare chromosomal disorder with complete or partial absence of one X chromosome that only occurs in women. Clinical presentation is variable, but congenital and acquired cardiovascular diseases are frequently associated diseases that add significantly to the increased morbidity and mortality in Turner syndrome patients. Arterial hypertension is reported in 13-58% of adult Turner syndrome patients and confers an increased risk for stroke and aortic dissection. Hypertension can be present from childhood on and is reported in one-quarter of the paediatric Turner syndrome patients. This article reviews the prevalence and cause of arterial hypertension in Turner syndrome and describes the relationship between blood pressure, aortic dilation and increased cardiovascular risk. We compare current treatment strategies and also propose an integrated practical approach for the diagnosis and treatment of hypertension in Turner syndrome applicable in daily practice.
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Abstract
INTRODUCTION Dilatation of the ascending aorta is described in Turner's syndrome with variable prevalence (6.8-32%). Reported series typically include patients with associated cardiac anomalies. OBJECTIVE To characterise the prevalence, age of onset, and the progress of dilatation of the ascending aorta in Turner's syndrome patients free of structural cardiac anomalies. Potential risk factors such as karyotype and growth hormone therapy were analysed for correlation with aortic dilatation. METHODS We carried out a retrospective study with data collected from medical records and echocardiography studies. Patients with Tuner's syndrome followed-up between 1992 and 2010 with at least two echocardiography studies were eligible. Patients with previous cardiac surgery or under anti-hypertensive medication were excluded. Ascending aorta diameter measurements were adjusted for body surface area, and dilatation was defined as Z-score>2. RESULTS The study population consisted of 44 patients, aged 11.9±7.4 years at the first echocardiogram and 17.9±7.3 years at the last follow-up, with a follow-up duration of 6.0±3.7 years. A total of 13 (29.5%) patients exhibited aortic dilatation during follow-up, suggesting an actuarial estimate of the freedom from aortic dilatation dropping from 86 to 70% and then to 37% at 10, 20, and 30 years of age, respectively. There was no statistically significant impact of karyotype or growth hormone therapy on aortic Z-score progression. CONCLUSION The prevalence of dilatation of the ascending aorta in Turner's syndrome patients free of structural aortic anomalies is comparable with published data with associated lesions. Growth hormone therapy and karyotype had no significant impact; however, longitudinal follow-up is warranted.
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Zarate YA, Sellars E, Lepard T, Carlo WF, Tang X, Collins RT. Aortic dilation in pediatric patients. Eur J Pediatr 2015; 174:1585-92. [PMID: 26070999 DOI: 10.1007/s00431-015-2575-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 05/21/2015] [Accepted: 05/28/2015] [Indexed: 01/15/2023]
Abstract
UNLABELLED Aortic dilation at the level of the aortic root can be caused by a variety of congenital or acquired conditions that lead to weakening of the aortic wall. In this retrospective study, we sought to determine the frequency of different associated diagnoses from children with aortic dilation seen at a single institution. A total of 377 children (68 % male) met study inclusion criteria. Patients were classified based on the suspected or confirmed associated diagnosis in one of the following categories: congenital heart disease (241/377, 64 %), chromosomal (34/377, 9 %), Marfan syndrome (26/377, 7 %), other genetic and non-genetic (22/377, 6 %), Loeys-Dietz syndrome (6/377, 2 %), and unknown (48/377, 13 %). Bicuspid aortic valve was by far the most prevalent congenital heart defect (206/241, 85 %), while Turner syndrome was the most frequent chromosomal abnormality (12/34, 35 %). Patients with Marfan syndrome were more likely to have severe dilation of the ascending aorta (p = 0.002) and to require aortic root replacement surgery (p < 0.001) compared to those in other diagnosis categories. CONCLUSION The differential diagnosis of aortic dilation is broad and requires a careful assessment of cardiac anatomy. Evaluation by a clinical geneticist in this setting should be strongly considered given the high frequency of associated genetic conditions. WHAT IS KNOWN • Aortic dilation is frequent in bicuspid aortic valve and other congenital heart defects. • Aortic dilation can be seen in several connective tissue disorders. Limited information is available in regard to the differential diagnosis of aortic dilation in children. WHAT IS NEW • In patients with aortic dilation concurrent congenital heart disease is frequently diagnosed. • Almost 18 % of cases in the present study had a defined presumptive or confirmed genetic diagnosis. We suggest considering a genetics evaluation in the setting of aortic dilation.
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Affiliation(s)
- Yuri A Zarate
- Section of Genetics and Metabolism, Department of Pediatrics, The University of Arkansas for Medical Sciences, Little Rock, AR, USA. .,Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, 1 Children's Way; Slot 512-22, Little Rock, AR, 72202, USA.
| | - Elizabeth Sellars
- Section of Genetics and Metabolism, Department of Pediatrics, The University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - Tiffany Lepard
- Section of Genetics and Metabolism, Department of Pediatrics, The University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - Waldemar F Carlo
- Division of Pediatric Cardiology, The University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Xinyu Tang
- Biostatics Program, Department of Pediatrics, The University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - R Thomas Collins
- Divisions of Cardiology, Department of Pediatrics, The University of Arkansas for Medical Sciences, Little Rock, AR, USA. .,Department of Internal Medicine, The University of Arkansas for Medical Sciences, Little Rock, AR, USA.
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Aortic dilation, genetic testing, and associated diagnoses. Genet Med 2015; 18:356-63. [PMID: 26133393 DOI: 10.1038/gim.2015.88] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 05/19/2015] [Indexed: 01/15/2023] Open
Abstract
PURPOSE The aims of this study were to determine the genetic diagnoses most frequently associated with aortic dilation in a large population and to describe the results of genetic testing in the same. METHODS A retrospective review of records from patients with known aortic dilation identified through an echocardiogram database was performed. During the study period, different chromosomal microarray platforms and molecular diagnostic techniques were used. RESULTS A total of 715 patients (mean age, 9.7 years; 67% male) met study inclusion criteria. The overall frequency of underlying presumptive or confirmed genetic diagnoses was 17% (125/715). Molecular evaluation for possible underlying aortopathy-related disorders was performed in 9% of patients (66/715). Next-generation sequencing panels were performed in 16 patients, and pathogenic abnormalities were detected in 4 (25%). Microarrays were conducted in 10% of patients (72/715), with a total of 23 pathogenic copy-number variants identified in 19 patients (26%). Marfan syndrome was the most frequently recognized genetic disorder associated with aortic dilation, but other cytogenetic abnormalities and associated diagnoses also were identified. CONCLUSION The differential diagnosis in patients with aortic dilation is broad and includes many conditions outside the common connective tissue disorder spectrum. A genetics evaluation should be considered to assist in the diagnostic evaluation.Genet Med 18 4, 356-363.
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Turtle EJ, Sule AA, Webb DJ, Bath LE. Aortic dissection in children and adolescents with Turner syndrome: risk factors and management recommendations. Arch Dis Child 2015; 100:662-6. [PMID: 25573747 DOI: 10.1136/archdischild-2014-307080] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 12/10/2014] [Indexed: 01/15/2023]
Abstract
There is a general lack of awareness of the risk of aortic dissection in Turner syndrome (TS) from both patients with TS and their physicians. Patients often ignore symptoms for up to 24 h before seeking medical advice, significantly increasing their risk of death. A clinical profile of those at risk of dissection is emerging and includes the presence of congenital heart defects, aortic dilatation and hypertension. MRI has revolutionised the visualisation of cardiovascular anatomy in TS but remains underutilised, especially in children and adolescents, and there is currently little guidance on blood pressure (BP) assessment or hypertension management. Children and adolescents with TS at risk of dissection could be easily identified by timely imaging and BP assessment. This would allow medical management or surgical intervention to be put in place to reduce the risk of this major, and often fatal, complication. Since guidance is lacking, we have reviewed the literature on the risk factors for dissection in TS during childhood and adolescence, and make recommendations on the assessment and management of these patients.
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Affiliation(s)
- E J Turtle
- Edinburgh Centre for Endocrinology, Western General Hospital, Edinburgh, UK
| | - A A Sule
- Tan Tock Seng Hospital, Singapore, Singapore
| | - D J Webb
- Queen's Medical Research Institute, University of Edinburgh/BHF Centre for Cardiovascular Science, Edinburgh, UK
| | - L E Bath
- Edinburgh Centre for Endocrinology, Royal Hospital for Sick Children, Edinburgh, UK
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Quezada E, Lapidus J, Shaughnessy R, Chen Z, Silberbach M. Aortic dimensions in Turner syndrome. Am J Med Genet A 2015; 167A:2527-32. [PMID: 26118429 DOI: 10.1002/ajmg.a.37208] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 06/03/2015] [Indexed: 12/15/2022]
Abstract
In Turner syndrome, linear growth is less than the general population. Consequently, to assess stature in Turner syndrome, condition-specific comparators have been employed. Similar reference curves for cardiac structures in Turner syndrome are currently unavailable. Accurate assessment of the aorta is particularly critical in Turner syndrome because aortic dissection and rupture occur more frequently than in the general population. Furthermore, comparisons to references calculated from the taller general population with the shorter Turner syndrome population can lead to over-estimation of aortic size causing stigmatization, medicalization, and potentially over-treatment. We used echocardiography to measure aortic diameters at eight levels of the thoracic aorta in 481 healthy girls and women with Turner syndrome who ranged in age from two to seventy years. Univariate and multivariate linear regression analyses were performed to assess the influence of karyotype, age, body mass index, bicuspid aortic valve, blood pressure, history of renal disease, thyroid disease, or growth hormone therapy. Because only bicuspid aortic valve was found to independently affect aortic size, subjects with bicuspid aortic valve were excluded from the analysis. Regression equations for aortic diameters were calculated and Z-scores corresponding to 1, 2, and 3 standard deviations from the mean were plotted against body surface area. The information presented here will allow clinicians and other caregivers to calculate aortic Z-scores using a Turner-based reference population. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Emilio Quezada
- Department of Pediatrics, Division of Pediatric Cardiology, Oregon Health & Sciences University, Portland, Oregon
| | - Jodi Lapidus
- Department of Public Health & Preventive Medicine, Oregon Health & Sciences University, Portland, Oregon
| | - Robin Shaughnessy
- Department of Pediatrics, Division of Pediatric Cardiology, Oregon Health & Sciences University, Portland, Oregon
| | - Zunqiu Chen
- Department of Public Health & Preventive Medicine, Oregon Health & Sciences University, Portland, Oregon
| | - Michael Silberbach
- Department of Pediatrics, Division of Pediatric Cardiology, Oregon Health & Sciences University, Portland, Oregon
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