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Rahimzadeh M, Tennstedt S, Aherrahrou Z. Nexilin in cardiomyopathy: unveiling its diverse roles with special focus on endocardial fibroelastosis. Heart Fail Rev 2024; 29:1025-1037. [PMID: 38985384 DOI: 10.1007/s10741-024-10416-8] [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] [Accepted: 07/01/2024] [Indexed: 07/11/2024]
Abstract
Cardiac disorders exhibit considerable heterogeneity, and understanding their genetic foundations is crucial for their diagnosis and treatment. Recent genetic analyses involving a growing number of participants have uncovered novel mutations within both coding and non-coding regions of DNA, contributing to the onset of cardiac conditions. The NEXN gene, encoding the Nexilin protein, an actin filament-binding protein, is integral to normal cardiac function. Mutations in this gene have been linked to cardiomyopathies, cardiovascular disorders, and sudden deaths. Heterozygous or homozygous variants of the NEXN gene are associated with the development of endocardial fibroelastosis (EFE), a rare cardiac condition characterized by excessive collagen and elastin deposition in the left ventricular endocardium predominantly affecting infants and young children. EFE occurs both primary and secondary to other conditions and often leads to unfavorable prognoses and outcomes. This review explores the role of NEXN genetic variants in cardiovascular disorders, particularly EFE, revealing that functional mutations are not clustered in a specific domain of Nexilin based on the cardiac disorder phenotype. Our review underscores the importance of understanding genetic mutations for the diagnosis and treatment of cardiac conditions.
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Affiliation(s)
- Mahsa Rahimzadeh
- Cardiovascular Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
- Molecular Medicine Research Center, Hormozgan Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
- Department of Biochemistry, Faculty of Medicine, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Stephanie Tennstedt
- Institute for Cardiogenetics, University of Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany
- DZHK (German Research Centre for Cardiovascular Research), Partner Site Hamburg/Lübeck/Kiel, 23562, Germany
- University Heart Center Lübeck, Lübeck, 23562, Germany
| | - Zouhair Aherrahrou
- Institute for Cardiogenetics, University of Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany.
- DZHK (German Research Centre for Cardiovascular Research), Partner Site Hamburg/Lübeck/Kiel, 23562, Germany.
- University Heart Center Lübeck, Lübeck, 23562, Germany.
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Mîndru DE, Țarcă E, Braha EE, Curpăn AȘ, Roșu ST, Anton-Păduraru DT, Adumitrăchioaiei H, Bernic V, Pădureț IA, Luca AC. Congenital Heart Malformations Masked by Infantile Gangliosidosis-Case Report and Growing Evidence for Metabolic Disease-Associated Aortopathies. Diagnostics (Basel) 2024; 14:491. [PMID: 38472963 DOI: 10.3390/diagnostics14050491] [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: 01/14/2024] [Revised: 02/15/2024] [Accepted: 02/22/2024] [Indexed: 03/14/2024] Open
Abstract
Gangliosidosis (ORPHA: 79255) is an autosomal recessive lysosomal storage disease (LSD) with a variable phenotype and an incidence of 1:200000 live births. The underlying genotype is comprised GLB1 mutations that lead to β-galactosidase deficiency and subsequently to the accumulation of monosialotetrahexosylganglioside (GM1) in the brain and other organs. In total, two diseases have been linked to this gene mutation: Morquio type B and Gangliosidosis. The most frequent clinical manifestations include dysmorphic facial features, nervous and skeletal systems abnormalities, hepatosplenomegaly, and cardiomyopathies. The correct diagnosis of GM1 is a challenge due to the overlapping clinical manifestation between this disease and others, especially in infants. Therefore, in the current study we present the case of a 3-month-old male infant, admitted with signs and symptoms of respiratory distress alongside rapid progressive heart failure, with minimal neurologic and skeletal abnormalities, but with cardiovascular structural malformations. The atypical clinical presentation raised great difficulties for our diagnostic team. Unfortunately, the diagnostic of GM1 was made postmortem based on the DBS test and we were able to correlate the genotype with the unusual phenotypic findings.
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Affiliation(s)
- Dana Elena Mîndru
- Department of Mother and Child Medicine, University of Medicine and Pharmacy "Gr. T. Popa", 700115 Iasi, Romania
| | - Elena Țarcă
- Department of Surgery II-Pediatric Surgery, University of Medicine and Pharmacy "Gr. T. Popa", 700115 Iasi, Romania
| | - Elena Emanuela Braha
- Department of Genetics Endocrinology, National Institute of Endocrinology CI Parhon, 011863 Bucureşti, Romania
| | | | - Solange Tamara Roșu
- Department of Nursing, University of Medicine and Pharmacy "Gr. T. Popa", 700115 Iasi, Romania
| | - Dana-Teodora Anton-Păduraru
- Department of Mother and Child Medicine, University of Medicine and Pharmacy "Gr. T. Popa", 700115 Iasi, Romania
| | - Heidrun Adumitrăchioaiei
- Department of Mother and Child Medicine, University of Medicine and Pharmacy "Gr. T. Popa", 700115 Iasi, Romania
| | - Valentin Bernic
- Department of Surgery II, "Saint Spiridon" Hospital, 700115 Iasi, Romania
| | | | - Alina Costina Luca
- Department of Mother and Child Medicine, University of Medicine and Pharmacy "Gr. T. Popa", 700115 Iasi, Romania
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Xin XX, Se YY. Caution in the use of sedation and endomyocardial biopsy for the management of pediatric acute heart failure caused by endocardial fibroelastosis. World J Clin Cases 2023; 11:5412-5415. [PMID: 37621580 PMCID: PMC10445076 DOI: 10.12998/wjcc.v11.i22.5412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 07/04/2023] [Accepted: 07/17/2023] [Indexed: 08/04/2023] Open
Abstract
Endocardial fibroelastosis (EFE) is commonly considered to be an inflammatory reactive lesion of hyperplasia and deposition of tissue fibers and collagen in the endocardium and/or subendocardium, which is strongly associated with endocardial sclerosis, ventricular remodeling and acute and chronic heart failure, and is one of the important causes for pediatric heart transplantation. Early diagnosis and treatment are the key factors in determining the prognosis of the children. In this paper, we would like to highlight the potential unintended consequences of the use of sedation and biopsy for pediatric acute heart failure caused by EFE and the comprehensive considerations prior to clinical diagnosis.
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Affiliation(s)
- Xiao-Xuan Xin
- School of Hulunbuir Clinical Medicine, Inner Mongolia Minzu University, Hulunbuir 021000, Inner Mongolia Autonomous Region, China
| | - Yo-Yeng Se
- Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong 999077, China
- Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Hong Kong 999077, China
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Xin XX, Se YY. Caution in the use of sedation and endomyocardial biopsy for the management of pediatric acute heart failure caused by endocardial fibroelastosis. World J Clin Cases 2023; 11:5406-5409. [DOI: 10.12998/wjcc.v11.i22.5406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 07/04/2023] [Accepted: 07/17/2023] [Indexed: 08/03/2023] Open
Abstract
Endocardial fibroelastosis (EFE) is commonly considered to be an inflammatory reactive lesion of hyperplasia and deposition of tissue fibers and collagen in the endocardium and/or subendocardium, which is strongly associated with endocardial sclerosis, ventricular remodeling and acute and chronic heart failure, and is one of the important causes for pediatric heart transplantation. Early diagnosis and treatment are the key factors in determining the prognosis of the children. In this paper, we would like to highlight the potential unintended consequences of the use of sedation and biopsy for pediatric acute heart failure caused by EFE and the comprehensive considerations prior to clinical diagnosis.
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Affiliation(s)
- Xiao-Xuan Xin
- School of Hulunbuir Clinical Medicine, Inner Mongolia Minzu University, Hulunbuir 021000, Inner Mongolia Autonomous Region, China
| | - Yo-Yeng Se
- Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong 999077, China
- Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Hong Kong 999077, China
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Xie YY, Li QL, Li XL, Yang F. Pediatric acute heart failure caused by endocardial fibroelastosis mimicking dilated cardiomyopathy: A case report. World J Clin Cases 2023; 11:1771-1781. [PMID: 36970005 PMCID: PMC10037286 DOI: 10.12998/wjcc.v11.i8.1771] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 10/26/2022] [Accepted: 01/09/2023] [Indexed: 03/07/2023] Open
Abstract
BACKGROUND Endocardial fibroelastosis (EFE) is a diffuse endocardial collagen and elastin hyperplasia disease of unknown etiology, which may be accompanied by myocardial degenerative changes leading to acute or chronic heart failure. However, acute heart failure (AHF) without obvious associated triggers is rare. Prior to the report of endomyocardial biopsy, the diagnosis and treatment of EFE are highly susceptible to being confounded with other primary cardiomyopathies. Here, we report a case of pediatric AHF caused by EFE mimicking dilated cardiomyopathy (DCM), with the aim of providing a valuable reference for clinicians to early identify and diagnose EFE-induced AHF.
CASE SUMMARY A 13-mo-old female child was admitted to hospital with retching. Chest X-ray demonstrated enhanced texture in both lungs and an enlarged heart shadow. Color doppler echocardiography showed an enlarged left heart with ventricular wall hypokinesis and decreased left heart function. Abdominal color ultrasonography revealed a markedly enlarged liver. Pending the result of the endomyocardial biopsy report, the child was treated with a variety of resuscitative measures including nasal cannula for oxygen, intramuscular sedation with chlorpromazine and promethazine, cedilanid for cardiac contractility enhancement, and diuretic treatment with furosemide. Subsequently, the child’s endomyocardial biopsy report result was confirmed as EFE. After the above early interventions, the child’s condition gradually stabilized and improved. One week later, the child was discharged. During a 9-mo follow-up period, the child took intermittent low-dose oral digoxin with no signs of recurrence or exacerbation of the heart failure.
CONCLUSION Our report suggests that EFE-induced pediatric AHF may present in children over 1 year of age without any apparent precipitants, and that the associated clinical presentations are grossly similar to that of pediatric DCM. Nonetheless, it is still possible to be diagnosed effectively on the basis of the comprehensive analysis of auxiliary inspection findings before the result of the endomyocardial biopsy is reported.
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Affiliation(s)
- Yao-Ying Xie
- College of Clinical Medicine, Inner Mongolia Minzu University, Tongliao 028000, Inner Mongolia Autonomous Region, China
- Department of Pediatric Medical Center, Soochow University, Affiliated Hulunbuir Hospital, Hulunbuir 021000, Inner Mongolia Autonomous Region, China
| | - Qiu-Li Li
- College of Medicine, Shantou University, Shantou 515063, Guangdong Province, China
| | - Xin-Le Li
- College of Clinical Medicine, Inner Mongolia Minzu University, Tongliao 028000, Inner Mongolia Autonomous Region, China
| | - Fan Yang
- Department of Pediatric Medical Center, Soochow University, Affiliated Hulunbuir Hospital, Hulunbuir 021000, Inner Mongolia Autonomous Region, China
- School of Medicine, Shihezi University, Shihezi 832000, Xinjiang Uygur Autonomous Region, China
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Xie YY, Li QL, Li XL, Yang F. Pediatric acute heart failure caused by endocardial fibroelastosis mimicking dilated cardiomyopathy: A case report. World J Clin Cases 2023; 11:1771-1781. [DOI: 10.12998/wjcc.v11.i8.1771 xie yy] [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: 09/30/2023] Open
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Xiao W, Wang Y, Cheng W, Zhang Y. The value of cardiac magnetic resonance imaging in endocardial fibroelastosis. Front Pediatr 2022; 10:874597. [PMID: 36389343 PMCID: PMC9663488 DOI: 10.3389/fped.2022.874597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 10/05/2022] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Endocardial fibroelastosis (EFE), an uncommon congenital heart disorder often occurring in infants, has a poor prognosis. It is of great significance to perform early diagnosis and accurately analyze cardiac function to enable further clinical treatment and prognosis decisions. This study aimed to explore the findings of cardiac magnetic resonance (CMR) in patients with EFE, including morphological changes and cardiac function analyses. Additionally, we compared the difference in the evaluation of the cardiac function between CMR and echocardiography (Echo). METHODS Eleven patients with EFE (nine females and two males, aged between 0.3 and 1.9 years), treated in our hospital, were analyzed retrospectively. Left ventricular posterior wall thickness (LVPW), anterior wall thickness (LVAW), fractional shortening (FS), ejection fraction (EF), end-systolic diameter (ESD), end-diastolic diameter (EDD), end-systolic volume (ESV), and end-diastolic volume (EDV) were assessed using both Echo and CMR. The Original Ross classification and the New York Heart Association functional classification were used to grade the patients' cardiac function. The correlations between clinical cardiac function classification and MRI- and Echo-derived imaging data were determined. RESULTS All patients showed a thickened endocardium and left ventricle globular dilatation on CMR. We observed significant systolic dysfunction and whole or segmental abnormal ventricular movement. Compared with those measured by Echo, the EF, FS, and EDV values were significantly lower when measured using CMR. Compared with Echo measurements, the ESV, ESD, LVAW, and LVPW values were significantly higher when measured using CMR. CMR-measured EF and FS correlated better with the clinical cardiac functional score than those derived from Echo (EF, r = 0.646 > 0.224; FS, r = 0.627 > 0.245, respectively). CONCLUSION In patients with EFE, the characteristic morphological changes of the heart could be displayed accurately using CMR. The parameters measured by CMR were more accurate than those of Echo and correlated well with clinical cardiac function scores, mainly because it does not make invalid geometrical assumptions.
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Affiliation(s)
- Wenjiao Xiao
- Department of Radiology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yuanlin Wang
- Department of Radiology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Weiqin Cheng
- Department of Radiology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yuting Zhang
- Department of Radiology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China
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Pan B, Hu D, Sun H, Lv T, Xu W, Tian J. Pediatric Diastolic Heart Failure: Clinical Features Description of 421 Cases. Front Pediatr 2022; 10:846408. [PMID: 35586825 PMCID: PMC9108191 DOI: 10.3389/fped.2022.846408] [Citation(s) in RCA: 2] [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: 12/31/2021] [Accepted: 04/11/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND AND AIM Heart failure in children differs substantially from the adult population. Clinical characteristics of pediatric diastolic heart failure has rarely been reported. In this study, we aimed to summary the causes, clinical features, lab tests, and treatment effect of pediatric diastolic heart failure. METHODS This study was a single center, retrospective study conducted in Children's Hospital of Chongqing Medical University. Children who were diagnosed with diastolic heart failure (DHF) without systolic heart failure (SHF) between 2006 and 2014 were included. Meanwhile, SHF (without DHF) cases were also collected from 2013 to 2014. RESULTS A total of 421 DHF and 42 SHF cases were included. The average age of pediatric DHF was 1.89 ± 3.29 years old, significant younger than that of SHF (4.65 ± 4.90). The top three cardiovascular causes of DHF were complex congenital heart malformations (53.4%), simple congenital heart defect (15.7%), and cardiomyopathy (7.4%). Alternatively, number of cardiomyopathy cases (57.1%) ranked first in SHF group. Simple congenital heart diseases (CHDs) rarely caused SHF. The most common symptom and sign were tachypnea and hepatomegaly in pediatric HF. Symptoms like cyanosis, feeding difficulty, be fidgety, pale, fatigue, and edema were valuable in differential diagnosis of DHF and SHF in children. B-type natriuretic peptide (BNP) increase was found in 36.9% of DHF children, and 60% in SHF patients. Sensitivity of BNP greater than 100 pg/ml in diagnosis of DHF was 0.37, and specificity of it was 0.86. Diastolic function indicators, such as E/A (early wave/late wave) ratio, IVRT (isovolumic relaxation time) were significant recovered after treatment in DHF patients. Less therapeutic benefits were achieved in children with cardiomyopathy induced DHF, in compared with non-cardiomyopathy patients. CONCLUSION Pediatric DHF and SHF were largely different in primary causes, clinical symptoms and signs and short-term prognosis. There was a limit diagnostic value of BNP with 100 pg/ml as cut-off value in pediatric DHF. Larger, multicenter studies of pediatric DHF are required in the future.
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Affiliation(s)
- Bo Pan
- Department of Cardiology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Di Hu
- Department of Otorhinolaryngology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Huichao Sun
- Department of Cardiology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Tiewei Lv
- Department of Cardiology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Wangguo Xu
- Department of Cardiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Jie Tian
- Department of Cardiology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
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Ţarcă E, Roșu ST, Cojocaru E, Trandafir L, Luca AC, Lupu VV, Moisă ȘM, Munteanu V, Butnariu LI, Ţarcă V. Statistical Analysis of the Main Risk Factors of an Unfavorable Evolution in Gastroschisis. J Pers Med 2021; 11:jpm11111168. [PMID: 34834520 PMCID: PMC8619615 DOI: 10.3390/jpm11111168] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/05/2021] [Accepted: 11/08/2021] [Indexed: 12/14/2022] Open
Abstract
Gastroschisis is a congenital abdominal wall defect that presents an increasing occurrence at great cost for the health system. The aim of the study is to detect the main factors of an unfavorable evolution in the case of gastroschisis and to find the best predictors of death. METHODS we conducted a retrospective cohort study of neonates with gastroschisis treated in a tertiary pediatric center during the last 30 years; 159 patients were eligible for the study. Logistic regression was used to determine the risk of death, estimated based on independent variables previously validated by the chi-square test. RESULTS if the birth weight is below normal, then we find an increased risk (4.908 times) of evolution to death. Similarly, the risk of death is 7.782 times higher in the case of developing abdominal compartment syndrome, about 3 times in the case of sepsis and 7.883 times in the case of bronchopneumonia. All four independent variables contributed 47.6% to the risk of death. CONCLUSION although in the past 30 years in our country we have seen transformational improvements in outcome of gastroschisis, survival rates increasing from 26% to 52%, some factors may still be ameliorated for a better outcome.
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Affiliation(s)
- Elena Ţarcă
- Department of Surgery II—Pediatric Surgery, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaşi, Romania;
| | - Solange Tamara Roșu
- Department of Nursing, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaşi, Romania;
| | - Elena Cojocaru
- Department of Morphofunctional Sciences I—Pathology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaşi, Romania;
| | - Laura Trandafir
- Department of Mother and Child Medicine—Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaşi, Romania; (A.C.L.); (Ș.M.M.)
- Correspondence: (L.T.); (V.V.L.)
| | - Alina Costina Luca
- Department of Mother and Child Medicine—Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaşi, Romania; (A.C.L.); (Ș.M.M.)
| | - Valeriu Vasile Lupu
- Department of Mother and Child Medicine—Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaşi, Romania; (A.C.L.); (Ș.M.M.)
- Correspondence: (L.T.); (V.V.L.)
| | - Ștefana Maria Moisă
- Department of Mother and Child Medicine—Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaşi, Romania; (A.C.L.); (Ș.M.M.)
| | - Valentin Munteanu
- Department of Biomedical Sciences, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaşi, Romania;
| | - Lăcrămioara Ionela Butnariu
- Department of Mother and Child Medicine—Genetics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaşi, Romania;
| | - Viorel Ţarcă
- County Statistics Department, 700115 Iaşi, Romania;
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