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Stephens SB, Shalhub S, Dodd N, Li J, Huang M, Oda S, Kancherla K, Doan TT, Prakash SK, Weigand JD, Asch FM, Beecroft T, Cecchi A, Shittu T, Preiss L, LeMaire SA, Devereux RB, Pyeritz RE, Holmes KW, Roman MJ, Lacro RV, Shohet RV, Krishnamurthy R, Eagle K, Byers P, Milewicz DM, Morris SA. Vertebral Tortuosity Is Associated With Increased Rate of Cardiovascular Events in Vascular Ehlers-Danlos Syndrome. J Am Heart Assoc 2023; 12:e029518. [PMID: 37776192 PMCID: PMC10727246 DOI: 10.1161/jaha.123.029518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 07/26/2023] [Indexed: 10/02/2023]
Abstract
Background Arterial tortuosity is associated with adverse events in Marfan and Loeys-Dietz syndromes but remains understudied in Vascular Ehlers-Danlos syndrome. Methods and Results Subjects with a pathogenic COL3A1 variant diagnosed at age <50 years were included from 2 institutions and the GenTAC Registry (National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions). Height-adjusted vertebral artery tortuosity index (VTI-h) using magnetic resonance or computed tomography angiography was calculated. Associations between VTI-h and outcomes of (1) cardiovascular events (arterial dissection/rupture, aneurysm requiring intervention, stroke), or (2) hollow organ collapse/rupture at age <50 years were evaluated using receiver operator curve analysis (using outcome by age 30 years) and mixed-effects Poisson regression for incidence rate ratios. Of 65 subjects (54% male), median VTI-h was 12 (interquartile range, 8-16). Variants were missense in 46%, splice site in 31%, and null/gene deletion in 14%. Thirty-two subjects (49%) had 59 events, including 28 dissections, 5 arterial ruptures, 4 aneurysms requiring intervention, 4 strokes, 11 hollow organ ruptures, and 7 pneumothoraces. Receiver operator curve analysis suggested optimal discrimination at VTI-h ≥15.5 for cardiovascular events (sensitivity 70%, specificity 76%) and no association with noncardiovascular events (area under the curve, 0.49 [95% CI, 0.22-0.78]). By multivariable analysis, older age was associated with increased cardiovascular event rate while VTI-h ≥15.5 was not (incidence rate ratios, 1.79 [95% CI, 0.76-4.24], P=0.185). However, VTI-h ≥15.5 was associated with events among those with high-risk variants <40 years (incidence rate ratios, 4.14 [95% CI, 1.13-15.10], P=0.032), suggesting effect modification by genotype and age. Conclusions Increased arterial tortuosity is associated with a higher incidence rate of cardiovascular events in Vascular Ehlers-Danlos syndrome. Vertebral tortuosity index may be a useful biomarker for prognosis when evaluated in conjunction with genotype and age.
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Affiliation(s)
- Sara B. Stephens
- Division of Cardiology, Department of Pediatrics, Baylor College of MedicineTexas Children’s HospitalHoustonTXUSA
- Department of Epidemiology, Human Genetics & Environmental Sciences, School of Public HealthThe University of Texas Health Science Center at HoustonHoustonTXUSA
| | - Sherene Shalhub
- Division of Vascular and Endovascular Surgery, Department of SurgeryOregon Health & Science UniversityPortlandORUSA
| | - Nicholas Dodd
- Memorial Health University Medical CenterSavannahGAUSA
| | - Jesse Li
- Division of Medical Genetics, Department of Internal MedicineThe University of Texas Health Science CenterHoustonTXUSA
| | - Michael Huang
- Division of Medical Genetics, Department of Internal MedicineThe University of Texas Health Science CenterHoustonTXUSA
| | - Seitaro Oda
- Department of Diagnostic Radiology, Faculty of Life SciencesKumamoto UniversityKumamotoJapan
- National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions (GenTAC)
| | - Kalyan Kancherla
- National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions (GenTAC)
- MedStar Heart and Vascular InstituteWashingtonDCUSA
- CHI St. VincentLittle RockARUSA
| | - Tam T. Doan
- Division of Cardiology, Department of Pediatrics, Baylor College of MedicineTexas Children’s HospitalHoustonTXUSA
| | - Siddharth K. Prakash
- Division of Medical Genetics, Department of Internal MedicineThe University of Texas Health Science CenterHoustonTXUSA
| | - Justin D. Weigand
- Division of Cardiology, Department of Pediatrics, Baylor College of MedicineTexas Children’s HospitalHoustonTXUSA
| | - Federico M. Asch
- National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions (GenTAC)
- MedStar Heart and Vascular InstituteWashingtonDCUSA
| | - Taylor Beecroft
- Division of Cardiology, Department of Pediatrics, Baylor College of MedicineTexas Children’s HospitalHoustonTXUSA
| | - Alana Cecchi
- Division of Medical Genetics, Department of Internal MedicineThe University of Texas Health Science CenterHoustonTXUSA
| | - Teniola Shittu
- Division of Cardiology, Department of Pediatrics, Baylor College of MedicineTexas Children’s HospitalHoustonTXUSA
| | | | - Scott A. LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of SurgeryBaylor College of MedicineHoustonTXUSA
| | | | - Reed E. Pyeritz
- Division of Translational Medicine and Human GeneticsPerelman School of Medicine at the University of PennsylvaniaPAUSA
| | - Kathryn W. Holmes
- Section of Cardiology, Department of PediatricsOregon Health & Science University and OHSU Doernbecher Children’s HospitalPortlandORUSA
| | - Mary J. Roman
- Department of MedicineWeill Cornell MedicineNew YorkNY
| | - Ronald V. Lacro
- Department of CardiologyBoston Children’s HospitalBostonMAUSA
| | | | | | - Kim Eagle
- National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions (GenTAC)
- Division of Cardiovascular Medicine, Frankel Cardiovascular Center, Department of Internal Medicine, Michigan MedicineUniversity of MichiganAnn ArborMIUSA
| | - Peter Byers
- Department of Laboratory Medicine and Pathology, Department of Medicine (Medical Genetics)University of WashingtonSeattleWAUSA
| | - Dianna M. Milewicz
- Division of Medical Genetics, Department of Internal MedicineThe University of Texas Health Science CenterHoustonTXUSA
| | - Shaine A. Morris
- Division of Cardiology, Department of Pediatrics, Baylor College of MedicineTexas Children’s HospitalHoustonTXUSA
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Baleilevuka-Hart ME, Holmes KW, Khader A, De Alba CEG, Huang JH. Competitive Sports Participation is Associated with Decreased Risk of Obesity in Children with Bicuspid Aortic Valve. Pediatr Cardiol 2023:10.1007/s00246-023-03237-3. [PMID: 37515600 DOI: 10.1007/s00246-023-03237-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 07/09/2023] [Indexed: 07/31/2023]
Abstract
Individuals with bicuspid aortic valve (BAV) have historically been advised to avoid contact sports and isometric exercise for risk of increasing aortic dilation and valve disease. There is mounting evidence that current sports participation guidelines qualify children for a high rate of sports exclusion, and that this population is at increased risk of obesity. The primary aim of this study was to evaluate relationship between sports participation and aortic dilation in children with bicuspid aortic valve and secondarily the relationship between competitive sports participation and obesity. We performed a review of children between the ages of 8 and 17 years with isolated BAV followed at Oregon Health & Science University. We excluded those with other congenital heart diseases, genetic conditions, prior cardiac intervention, and inability to ambulate independently. Parents completed a phone survey detailing their child's level of daily activity and participation in competitive sports. Demographic information and most recent echo findings were collected from the electronic medical record. We found no difference between the aortic diameters of athletes vs non-athletes. We also found that sports participation and daily activity were both associated with a decreased likelihood of obesity (OR 0.24, 95% CI 0.078-0.73 and OR 0.24, 95% CI 0.081-0.71 respectively). In summary, in our sample population, competitive sports participation was associated with a decreased risk of obesity. Competitive sports participation does not appear to be associated with an increased risk of aortic dilation in our population.
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Affiliation(s)
| | - Kathryn W Holmes
- Department of Pediatric Cardiology, Oregon Health and Science University, Portland, USA
| | - Ayesha Khader
- Oregon Health and Science University School of Medicine, Portland, USA
| | | | - Jennifer H Huang
- Department of Pediatric Cardiology, Oregon Health and Science University, Portland, USA
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3
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Warner D, Holmes KW, Afifi R, Russo ML, Shalhub S. Emergency vascular surgical care in populations with unique physiologic characteristics: Pediatric, pregnant, and frail populations. Semin Vasc Surg 2023; 36:340-354. [PMID: 37330246 DOI: 10.1053/j.semvascsurg.2023.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/23/2023] [Accepted: 04/25/2023] [Indexed: 06/19/2023]
Abstract
Vascular surgical emergencies are common in vascular surgical care and require complex decision making and multidisciplinary care. They are especially challenging when they occur in patients with unique physiological characteristics, such as pediatric, pregnant, and frail patients. Among the pediatric and pregnant population, vascular emergencies are rare. This rarity challenges accurate and timely diagnosis of the vascular emergency. This landscape review summarizes these three unique populations' epidemiology and emergency vascular considerations. Understanding the epidemiology is the foundation for accurate diagnosis and subsequent management. Considering each population's unique characteristics is crucial to the emergent vascular surgical interventions decision making. Collaborative and multidisciplinary care is vital in gaining expertise in managing these special populations and achieving optimal patient outcomes.
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Affiliation(s)
- David Warner
- Division of Vascular and Endovascular Surgery, Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code OP11, Portland, OR 97239
| | - Kathryn W Holmes
- Division of Cardiology, Department of Pediatrics, Oregon Health and Science University, Portland, OR
| | - Rana Afifi
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX
| | - Melissa L Russo
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Women and Infants Hospital, Providence, RI; Warren Alpert Medical School of Brown University, Providence, RI
| | - Sherene Shalhub
- Division of Vascular and Endovascular Surgery, Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code OP11, Portland, OR 97239.
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Holmes KW, Huang JH, Gutshall K, Kim A, Ronai C, Madriago EJ. Fetal counseling for congenital heart disease: is communication effective? J Matern Fetal Neonatal Med 2021; 35:5049-5053. [PMID: 33879024 DOI: 10.1080/14767058.2021.1874909] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE To assess the accuracy of maternal understanding of fetal cardiac defects following initial fetal counseling. METHODS Pregnant women with a fetal diagnosis of congenital heart disease (CHD) were surveyed regarding understanding of their fetus's heart defect. The survey asked: (1) for a description of the heart condition; (2) how confident they were in the diagnosis; (3) whether their fetus would require heart surgery. Two fetal cardiologists evaluated the maternal qualitative description. Partners were excluded from the study. RESULTS Fifty-one participants consented and 39 completed the survey. Mean age was 31 years, 60% had some college level or post-graduate education, 48% had Medicaid insurance, and 81% were Caucasian. More than three-quarters of participants, stated they had either "quite a bit" or "very much" understanding of their fetus's diagnosis. Maternal assessment matched the physician's assessment of accuracy with 77% (N = 30) demonstrating either "quite a bit" or a "very accurate" description of the diagnosis. All women correctly understood if their fetus would require heart surgery. Highest level of maternal education positively correlated with the accuracy of diagnosis (regression coefficient 0.48, p < .002). However, confidence in the diagnosis was independent of both education (0.30, p = .167) and maternal age (-0.03, p = .234). CONCLUSIONS Fetal counseling is effective in conveying anatomy and the need for surgery; however, accuracy amongst women with lower levels of education and maternal confidence in understanding can be improved.
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Affiliation(s)
- Kathryn W Holmes
- Division of Pediatric Cardiology, Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
| | - Jennifer H Huang
- Division of Pediatric Cardiology, Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
| | - Kristine Gutshall
- Division of Pediatric Cardiology, Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
| | - Amanda Kim
- Division of Pediatric Cardiology, Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA.,Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
| | - Christina Ronai
- Division of Pediatric Cardiology, Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
| | - Erin J Madriago
- Division of Pediatric Cardiology, Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
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Stephens S, Shalhub S, Dodd N, Oda S, Kancheria K, Doan T, Weigand J, Zachariah JP, Asch FM, Beecroft T, Cecchi A, Shittu T, Preiss L, Lemaire SA, Devereux RB, Pyeritz RE, Holmes KW, Roman MJ, Lacro RV, Shohet R, Krishnamurthy R, Eagle K, Byers PH, Milewicz DM, Morris SA. VERTEBRAL ARTERY TORTUOSITY IS A BIOMARKER FOR ARTERIAL EVENTS IN CHILDREN AND YOUNG ADULTS WITH VASCULAR EHLERS-DANLOS SYNDROME. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)32248-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Kelly P, Hua N, Madriago EJ, Holmes KW, Shaughnessy R, Ronai C. The Utility of Echocardiography in Pediatric Patients with Structurally Normal Hearts and Suspected Endocarditis. Pediatr Cardiol 2020; 41:62-68. [PMID: 31673735 DOI: 10.1007/s00246-019-02222-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 10/15/2019] [Indexed: 12/19/2022]
Abstract
The objective of this study was to evaluate the utility of transthoracic echocardiography (TTE) in children with structurally normal hearts suspected of having infective endocarditis (IE). We hypothesized that the diagnostic yield of TTE is minimal in low-risk patients with normal hearts. We performed a retrospective chart review of TTEs performed for concern for endocarditis at a pediatric tertiary care referral center in Portland, Oregon. Three hundred patients met inclusion criteria (< 21 years old, completed TTE for IE from 2005 to 2015, no history of congenital heart disease or endocarditis). We recorded findings that met the modified Duke criteria (MDC) including fever, positive blood culture, and vascular/immunologic findings; presence of a central line; whether or not patients were diagnosed with IE clinically; and if any changes to antibiotic regimens were made based on TTE. Ten patients (3%) had echocardiograms consistent with IE. When compared to the clinical diagnosis of IE, the positive predictive value (PPV) of one positive blood culture without other major/minor MDC was 0. Similarly, the PPV of two positive blood cultures without other major/minor criteria was 0.071. Patients should be evaluated using the MDC to assess the clinical probability of IE prior to performing a TTE. Patients with a low probability for IE should not undergo TTE as it has a low diagnostic yield and patients are unlikely to be diagnosed with disease.
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Affiliation(s)
- Patrick Kelly
- Oregon Health & Science University, Portland, OR, USA
| | - Nancy Hua
- Oregon Health & Science University, Portland, OR, USA.,Division of Cardiology, Department of Pediatrics, Doernbecher Children's Hospital, 707 SW Gaines St., CDRC-P, Portland, OR, 97239, USA
| | - Erin J Madriago
- Oregon Health & Science University, Portland, OR, USA.,Division of Cardiology, Department of Pediatrics, Doernbecher Children's Hospital, 707 SW Gaines St., CDRC-P, Portland, OR, 97239, USA
| | - Kathryn W Holmes
- Oregon Health & Science University, Portland, OR, USA.,Division of Cardiology, Department of Pediatrics, Doernbecher Children's Hospital, 707 SW Gaines St., CDRC-P, Portland, OR, 97239, USA
| | - Robin Shaughnessy
- Oregon Health & Science University, Portland, OR, USA.,Division of Cardiology, Department of Pediatrics, Doernbecher Children's Hospital, 707 SW Gaines St., CDRC-P, Portland, OR, 97239, USA
| | - Christina Ronai
- Oregon Health & Science University, Portland, OR, USA. .,Division of Cardiology, Department of Pediatrics, Doernbecher Children's Hospital, 707 SW Gaines St., CDRC-P, Portland, OR, 97239, USA.
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7
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Arndt AL, Madriago E, Huang J, Ronai C, Silberbach M, Broberg CS, Holmes KW. Determination of right ventricular function with adjusted systolic to diastolic duration ratio after transannular patch repair of tetralogy of Fallot. Echocardiography 2019; 36:1706-1712. [PMID: 31490578 DOI: 10.1111/echo.14465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 07/29/2019] [Accepted: 08/08/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Early detection of right ventricular dysfunction after transannular patch for tetralogy of Fallot (TOF-TAP) is essential for management. OBJECTIVES To evaluate echocardiographic metrics of ventricular function correlate with functional MRI measurements, in patients with TOF-TAP. METHODS A retrospective review of patients with TOF-TAP between 2007 and 2017 who had an echocardiogram and MRI within six months were analyzed. Systolic to diastolic ratio (SD ratio) was measured from the tricuspid regurgitation and adjusted for heart rate. Tricuspid Annular Plane Systolic Excursion (TAPSE), Fractional Area Change (FAC), and shortening fraction (SF) were additionally measured. Echocardiographic measurements were correlated with MRI assessment of right ventricular ejection fraction (RVEF), left ventricular ejection fraction (LVEF), right ventricular end-diastolic volume index (RVEDi), and right to left ventricle volume ratio (RV/LV). RESULTS Of the 53 patients (mean age 12.8 years) that met inclusion criteria, 45 (85%) had available TR jets for SD ratio analysis. The HR adjusted SD ratio negatively correlated with RVEF (r = -.359, P = .016), LVEF (r = -.317, P = .038) and positively with RV/LV EDV ratio (r = .347, P = .024). TAPSE, FAC, and SF measurements did not show significant correlation. CONCLUSION In patients with TOF-TAP, there is a moderate negative correlation between heart rate adjusted SD ratio and MRI metrics of ventricular function, suggesting that decreased filling time is a marker for reduced right ventricular function. The SD ratio may be a useful echocardiographic tool for serial evaluation of in this population.
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Affiliation(s)
- Andrew L Arndt
- School of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Erin Madriago
- Pediatrics, Division of Cardiology, Oregon Health and Science University, Portland, OR, USA
| | - Jennifer Huang
- Pediatrics, Division of Cardiology, Oregon Health and Science University, Portland, OR, USA
| | - Christina Ronai
- Pediatrics, Division of Cardiology, Oregon Health and Science University, Portland, OR, USA
| | - Michael Silberbach
- Pediatrics, Division of Cardiology, Oregon Health and Science University, Portland, OR, USA
| | - Craig S Broberg
- Medicine, Division of Cardiovascular Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Kathryn W Holmes
- Pediatrics, Division of Cardiology, Oregon Health and Science University, Portland, OR, USA
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Gern BH, Mehta A, McCammond AN, Holmes KW, Guzman-Cottrill JA. Case 1: Vomiting and Ventricular Arrhythmia in a 2-year-old Girl. Pediatr Rev 2018; 39:91-92. [PMID: 29437128 DOI: 10.1542/pir.2016-0133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Benjamin H Gern
- Department of Pediatrics, Oregon Health and Science University, Portland, OR
| | - Amit Mehta
- Department of Pediatrics, Oregon Health and Science University, Portland, OR
| | - Amy N McCammond
- Department of Pediatrics, Oregon Health and Science University, Portland, OR
| | - Kathryn W Holmes
- Department of Pediatrics, Oregon Health and Science University, Portland, OR
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Roman MJ, Devereux RB, Preiss LR, Asch FM, Eagle KA, Holmes KW, LeMaire SA, Maslen CL, Milewicz DM, Morris SA, Prakash SK, Pyeritz RE, Ravekes WJ, Shohet RV, Song HK, Weinsaft JW. Associations of Age and Sex With Marfan Phenotype: The National Heart, Lung, and Blood Institute GenTAC (Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions) Registry. ACTA ACUST UNITED AC 2018; 10:CIRCGENETICS.116.001647. [PMID: 28600386 DOI: 10.1161/circgenetics.116.001647] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 04/06/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND The associations of age and sex with phenotypic features of Marfan syndrome have not been systematically examined in a large cohort of both children and adults. METHODS AND RESULTS We evaluated 789 Marfan patients enrolled in the National Heart, Lung, and Blood Institute GenTAC (Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions) Registry (53% male; mean age 31 [range: 1-86 years]). Females aged ≥15 and males aged ≥16 years were considered adults based on average age of skeletal maturity. Adults (n=606) were more likely than children (n=183) likely to have spontaneous pneumothorax, scoliosis, and striae but were comparable in revised Ghent systemic score, ectopia lentis, and most phenotypic features, including prevalence of aortic root dilatation. Prophylactic aortic root replacement and mitral valve surgery were rare during childhood versus adulthood (2% versus 35% and 1% versus 9%, respectively, both P<0.0001). Adult males were more likely than females to have aortic root dilatation (92% versus 84%), aortic regurgitation (55% versus 36%), and to have undergone prophylactic aortic root replacement (47% versus 24%), all P<0.001. Prevalence of previous aortic dissection tended to be higher in males than females (25% versus 18%, P=0.06); 44% of dissections were type B. Type B dissection was strongly associated with previous prophylactic aortic root replacement. CONCLUSIONS Pulmonary, skeletal, and aortic complications, but not other phenotypic features, are more prevalent in adults than children in Marfan syndrome. Aortic aneurysms and prophylactic aortic surgery are more common in men. Aortic dissection, commonly type B, occurs in an appreciable proportion of Marfan patients, especially in men and after previous prophylactic aortic root replacement.
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Affiliation(s)
- Mary J Roman
- From the Division of Cardiology, Weill Cornell Medicine, New York, NY (M.J.R., R.B.D., J.W.W.); Biostatistics and Epidemiology Division, RTI International, Rockville, MD (L.R.P.); MedStar Cardiovascular Research Network, Washington, DC (F.M.A.); Division of Cardiology, University of Michigan Health System, Ann Arbor (K.A.E.); Department of Pediatrics (K.W.H.), Division of Cardiothoracic Surgery (H.K.S.), and Knight Cardiovascular Institute (C.L.M.), Oregon Health & Science University, Portland; Division of Cardiothoracic Surgery (S.A.L.) and Division of Pediatric Cardiology, Department of Pediatrics (S.A.M.), Baylor College of Medicine, Houston, TX; Department of Cardiovascular Surgery, Texas Heart Institute, Houston (S.A.L.); Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, San Antonio (D.M.M., S.K.P.); Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.E.P.); Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (W.J.R.); and Department of Medicine, John A. Burns School of Medicine, Honolulu, HI (R.V.S.).
| | - Richard B Devereux
- From the Division of Cardiology, Weill Cornell Medicine, New York, NY (M.J.R., R.B.D., J.W.W.); Biostatistics and Epidemiology Division, RTI International, Rockville, MD (L.R.P.); MedStar Cardiovascular Research Network, Washington, DC (F.M.A.); Division of Cardiology, University of Michigan Health System, Ann Arbor (K.A.E.); Department of Pediatrics (K.W.H.), Division of Cardiothoracic Surgery (H.K.S.), and Knight Cardiovascular Institute (C.L.M.), Oregon Health & Science University, Portland; Division of Cardiothoracic Surgery (S.A.L.) and Division of Pediatric Cardiology, Department of Pediatrics (S.A.M.), Baylor College of Medicine, Houston, TX; Department of Cardiovascular Surgery, Texas Heart Institute, Houston (S.A.L.); Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, San Antonio (D.M.M., S.K.P.); Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.E.P.); Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (W.J.R.); and Department of Medicine, John A. Burns School of Medicine, Honolulu, HI (R.V.S.)
| | - Liliana R Preiss
- From the Division of Cardiology, Weill Cornell Medicine, New York, NY (M.J.R., R.B.D., J.W.W.); Biostatistics and Epidemiology Division, RTI International, Rockville, MD (L.R.P.); MedStar Cardiovascular Research Network, Washington, DC (F.M.A.); Division of Cardiology, University of Michigan Health System, Ann Arbor (K.A.E.); Department of Pediatrics (K.W.H.), Division of Cardiothoracic Surgery (H.K.S.), and Knight Cardiovascular Institute (C.L.M.), Oregon Health & Science University, Portland; Division of Cardiothoracic Surgery (S.A.L.) and Division of Pediatric Cardiology, Department of Pediatrics (S.A.M.), Baylor College of Medicine, Houston, TX; Department of Cardiovascular Surgery, Texas Heart Institute, Houston (S.A.L.); Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, San Antonio (D.M.M., S.K.P.); Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.E.P.); Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (W.J.R.); and Department of Medicine, John A. Burns School of Medicine, Honolulu, HI (R.V.S.)
| | - Federico M Asch
- From the Division of Cardiology, Weill Cornell Medicine, New York, NY (M.J.R., R.B.D., J.W.W.); Biostatistics and Epidemiology Division, RTI International, Rockville, MD (L.R.P.); MedStar Cardiovascular Research Network, Washington, DC (F.M.A.); Division of Cardiology, University of Michigan Health System, Ann Arbor (K.A.E.); Department of Pediatrics (K.W.H.), Division of Cardiothoracic Surgery (H.K.S.), and Knight Cardiovascular Institute (C.L.M.), Oregon Health & Science University, Portland; Division of Cardiothoracic Surgery (S.A.L.) and Division of Pediatric Cardiology, Department of Pediatrics (S.A.M.), Baylor College of Medicine, Houston, TX; Department of Cardiovascular Surgery, Texas Heart Institute, Houston (S.A.L.); Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, San Antonio (D.M.M., S.K.P.); Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.E.P.); Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (W.J.R.); and Department of Medicine, John A. Burns School of Medicine, Honolulu, HI (R.V.S.)
| | - Kim A Eagle
- From the Division of Cardiology, Weill Cornell Medicine, New York, NY (M.J.R., R.B.D., J.W.W.); Biostatistics and Epidemiology Division, RTI International, Rockville, MD (L.R.P.); MedStar Cardiovascular Research Network, Washington, DC (F.M.A.); Division of Cardiology, University of Michigan Health System, Ann Arbor (K.A.E.); Department of Pediatrics (K.W.H.), Division of Cardiothoracic Surgery (H.K.S.), and Knight Cardiovascular Institute (C.L.M.), Oregon Health & Science University, Portland; Division of Cardiothoracic Surgery (S.A.L.) and Division of Pediatric Cardiology, Department of Pediatrics (S.A.M.), Baylor College of Medicine, Houston, TX; Department of Cardiovascular Surgery, Texas Heart Institute, Houston (S.A.L.); Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, San Antonio (D.M.M., S.K.P.); Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.E.P.); Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (W.J.R.); and Department of Medicine, John A. Burns School of Medicine, Honolulu, HI (R.V.S.)
| | - Kathryn W Holmes
- From the Division of Cardiology, Weill Cornell Medicine, New York, NY (M.J.R., R.B.D., J.W.W.); Biostatistics and Epidemiology Division, RTI International, Rockville, MD (L.R.P.); MedStar Cardiovascular Research Network, Washington, DC (F.M.A.); Division of Cardiology, University of Michigan Health System, Ann Arbor (K.A.E.); Department of Pediatrics (K.W.H.), Division of Cardiothoracic Surgery (H.K.S.), and Knight Cardiovascular Institute (C.L.M.), Oregon Health & Science University, Portland; Division of Cardiothoracic Surgery (S.A.L.) and Division of Pediatric Cardiology, Department of Pediatrics (S.A.M.), Baylor College of Medicine, Houston, TX; Department of Cardiovascular Surgery, Texas Heart Institute, Houston (S.A.L.); Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, San Antonio (D.M.M., S.K.P.); Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.E.P.); Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (W.J.R.); and Department of Medicine, John A. Burns School of Medicine, Honolulu, HI (R.V.S.)
| | - Scott A LeMaire
- From the Division of Cardiology, Weill Cornell Medicine, New York, NY (M.J.R., R.B.D., J.W.W.); Biostatistics and Epidemiology Division, RTI International, Rockville, MD (L.R.P.); MedStar Cardiovascular Research Network, Washington, DC (F.M.A.); Division of Cardiology, University of Michigan Health System, Ann Arbor (K.A.E.); Department of Pediatrics (K.W.H.), Division of Cardiothoracic Surgery (H.K.S.), and Knight Cardiovascular Institute (C.L.M.), Oregon Health & Science University, Portland; Division of Cardiothoracic Surgery (S.A.L.) and Division of Pediatric Cardiology, Department of Pediatrics (S.A.M.), Baylor College of Medicine, Houston, TX; Department of Cardiovascular Surgery, Texas Heart Institute, Houston (S.A.L.); Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, San Antonio (D.M.M., S.K.P.); Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.E.P.); Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (W.J.R.); and Department of Medicine, John A. Burns School of Medicine, Honolulu, HI (R.V.S.)
| | - Cheryl L Maslen
- From the Division of Cardiology, Weill Cornell Medicine, New York, NY (M.J.R., R.B.D., J.W.W.); Biostatistics and Epidemiology Division, RTI International, Rockville, MD (L.R.P.); MedStar Cardiovascular Research Network, Washington, DC (F.M.A.); Division of Cardiology, University of Michigan Health System, Ann Arbor (K.A.E.); Department of Pediatrics (K.W.H.), Division of Cardiothoracic Surgery (H.K.S.), and Knight Cardiovascular Institute (C.L.M.), Oregon Health & Science University, Portland; Division of Cardiothoracic Surgery (S.A.L.) and Division of Pediatric Cardiology, Department of Pediatrics (S.A.M.), Baylor College of Medicine, Houston, TX; Department of Cardiovascular Surgery, Texas Heart Institute, Houston (S.A.L.); Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, San Antonio (D.M.M., S.K.P.); Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.E.P.); Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (W.J.R.); and Department of Medicine, John A. Burns School of Medicine, Honolulu, HI (R.V.S.)
| | - Dianna M Milewicz
- From the Division of Cardiology, Weill Cornell Medicine, New York, NY (M.J.R., R.B.D., J.W.W.); Biostatistics and Epidemiology Division, RTI International, Rockville, MD (L.R.P.); MedStar Cardiovascular Research Network, Washington, DC (F.M.A.); Division of Cardiology, University of Michigan Health System, Ann Arbor (K.A.E.); Department of Pediatrics (K.W.H.), Division of Cardiothoracic Surgery (H.K.S.), and Knight Cardiovascular Institute (C.L.M.), Oregon Health & Science University, Portland; Division of Cardiothoracic Surgery (S.A.L.) and Division of Pediatric Cardiology, Department of Pediatrics (S.A.M.), Baylor College of Medicine, Houston, TX; Department of Cardiovascular Surgery, Texas Heart Institute, Houston (S.A.L.); Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, San Antonio (D.M.M., S.K.P.); Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.E.P.); Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (W.J.R.); and Department of Medicine, John A. Burns School of Medicine, Honolulu, HI (R.V.S.)
| | - Shaine A Morris
- From the Division of Cardiology, Weill Cornell Medicine, New York, NY (M.J.R., R.B.D., J.W.W.); Biostatistics and Epidemiology Division, RTI International, Rockville, MD (L.R.P.); MedStar Cardiovascular Research Network, Washington, DC (F.M.A.); Division of Cardiology, University of Michigan Health System, Ann Arbor (K.A.E.); Department of Pediatrics (K.W.H.), Division of Cardiothoracic Surgery (H.K.S.), and Knight Cardiovascular Institute (C.L.M.), Oregon Health & Science University, Portland; Division of Cardiothoracic Surgery (S.A.L.) and Division of Pediatric Cardiology, Department of Pediatrics (S.A.M.), Baylor College of Medicine, Houston, TX; Department of Cardiovascular Surgery, Texas Heart Institute, Houston (S.A.L.); Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, San Antonio (D.M.M., S.K.P.); Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.E.P.); Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (W.J.R.); and Department of Medicine, John A. Burns School of Medicine, Honolulu, HI (R.V.S.)
| | - Siddharth K Prakash
- From the Division of Cardiology, Weill Cornell Medicine, New York, NY (M.J.R., R.B.D., J.W.W.); Biostatistics and Epidemiology Division, RTI International, Rockville, MD (L.R.P.); MedStar Cardiovascular Research Network, Washington, DC (F.M.A.); Division of Cardiology, University of Michigan Health System, Ann Arbor (K.A.E.); Department of Pediatrics (K.W.H.), Division of Cardiothoracic Surgery (H.K.S.), and Knight Cardiovascular Institute (C.L.M.), Oregon Health & Science University, Portland; Division of Cardiothoracic Surgery (S.A.L.) and Division of Pediatric Cardiology, Department of Pediatrics (S.A.M.), Baylor College of Medicine, Houston, TX; Department of Cardiovascular Surgery, Texas Heart Institute, Houston (S.A.L.); Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, San Antonio (D.M.M., S.K.P.); Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.E.P.); Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (W.J.R.); and Department of Medicine, John A. Burns School of Medicine, Honolulu, HI (R.V.S.)
| | - Reed E Pyeritz
- From the Division of Cardiology, Weill Cornell Medicine, New York, NY (M.J.R., R.B.D., J.W.W.); Biostatistics and Epidemiology Division, RTI International, Rockville, MD (L.R.P.); MedStar Cardiovascular Research Network, Washington, DC (F.M.A.); Division of Cardiology, University of Michigan Health System, Ann Arbor (K.A.E.); Department of Pediatrics (K.W.H.), Division of Cardiothoracic Surgery (H.K.S.), and Knight Cardiovascular Institute (C.L.M.), Oregon Health & Science University, Portland; Division of Cardiothoracic Surgery (S.A.L.) and Division of Pediatric Cardiology, Department of Pediatrics (S.A.M.), Baylor College of Medicine, Houston, TX; Department of Cardiovascular Surgery, Texas Heart Institute, Houston (S.A.L.); Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, San Antonio (D.M.M., S.K.P.); Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.E.P.); Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (W.J.R.); and Department of Medicine, John A. Burns School of Medicine, Honolulu, HI (R.V.S.)
| | - William J Ravekes
- From the Division of Cardiology, Weill Cornell Medicine, New York, NY (M.J.R., R.B.D., J.W.W.); Biostatistics and Epidemiology Division, RTI International, Rockville, MD (L.R.P.); MedStar Cardiovascular Research Network, Washington, DC (F.M.A.); Division of Cardiology, University of Michigan Health System, Ann Arbor (K.A.E.); Department of Pediatrics (K.W.H.), Division of Cardiothoracic Surgery (H.K.S.), and Knight Cardiovascular Institute (C.L.M.), Oregon Health & Science University, Portland; Division of Cardiothoracic Surgery (S.A.L.) and Division of Pediatric Cardiology, Department of Pediatrics (S.A.M.), Baylor College of Medicine, Houston, TX; Department of Cardiovascular Surgery, Texas Heart Institute, Houston (S.A.L.); Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, San Antonio (D.M.M., S.K.P.); Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.E.P.); Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (W.J.R.); and Department of Medicine, John A. Burns School of Medicine, Honolulu, HI (R.V.S.)
| | - Ralph V Shohet
- From the Division of Cardiology, Weill Cornell Medicine, New York, NY (M.J.R., R.B.D., J.W.W.); Biostatistics and Epidemiology Division, RTI International, Rockville, MD (L.R.P.); MedStar Cardiovascular Research Network, Washington, DC (F.M.A.); Division of Cardiology, University of Michigan Health System, Ann Arbor (K.A.E.); Department of Pediatrics (K.W.H.), Division of Cardiothoracic Surgery (H.K.S.), and Knight Cardiovascular Institute (C.L.M.), Oregon Health & Science University, Portland; Division of Cardiothoracic Surgery (S.A.L.) and Division of Pediatric Cardiology, Department of Pediatrics (S.A.M.), Baylor College of Medicine, Houston, TX; Department of Cardiovascular Surgery, Texas Heart Institute, Houston (S.A.L.); Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, San Antonio (D.M.M., S.K.P.); Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.E.P.); Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (W.J.R.); and Department of Medicine, John A. Burns School of Medicine, Honolulu, HI (R.V.S.)
| | - Howard K Song
- From the Division of Cardiology, Weill Cornell Medicine, New York, NY (M.J.R., R.B.D., J.W.W.); Biostatistics and Epidemiology Division, RTI International, Rockville, MD (L.R.P.); MedStar Cardiovascular Research Network, Washington, DC (F.M.A.); Division of Cardiology, University of Michigan Health System, Ann Arbor (K.A.E.); Department of Pediatrics (K.W.H.), Division of Cardiothoracic Surgery (H.K.S.), and Knight Cardiovascular Institute (C.L.M.), Oregon Health & Science University, Portland; Division of Cardiothoracic Surgery (S.A.L.) and Division of Pediatric Cardiology, Department of Pediatrics (S.A.M.), Baylor College of Medicine, Houston, TX; Department of Cardiovascular Surgery, Texas Heart Institute, Houston (S.A.L.); Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, San Antonio (D.M.M., S.K.P.); Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.E.P.); Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (W.J.R.); and Department of Medicine, John A. Burns School of Medicine, Honolulu, HI (R.V.S.)
| | - Jonathan W Weinsaft
- From the Division of Cardiology, Weill Cornell Medicine, New York, NY (M.J.R., R.B.D., J.W.W.); Biostatistics and Epidemiology Division, RTI International, Rockville, MD (L.R.P.); MedStar Cardiovascular Research Network, Washington, DC (F.M.A.); Division of Cardiology, University of Michigan Health System, Ann Arbor (K.A.E.); Department of Pediatrics (K.W.H.), Division of Cardiothoracic Surgery (H.K.S.), and Knight Cardiovascular Institute (C.L.M.), Oregon Health & Science University, Portland; Division of Cardiothoracic Surgery (S.A.L.) and Division of Pediatric Cardiology, Department of Pediatrics (S.A.M.), Baylor College of Medicine, Houston, TX; Department of Cardiovascular Surgery, Texas Heart Institute, Houston (S.A.L.); Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, San Antonio (D.M.M., S.K.P.); Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.E.P.); Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (W.J.R.); and Department of Medicine, John A. Burns School of Medicine, Honolulu, HI (R.V.S.)
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10
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Regalado ES, Mellor-Crummey L, De Backer J, Braverman AC, Ades L, Benedict S, Bradley TJ, Brickner ME, Chatfield KC, Child A, Feist C, Holmes KW, Iannucci G, Lorenz B, Mark P, Morisaki T, Morisaki H, Morris SA, Mitchell AL, Ostergaard JR, Richer J, Sallee D, Shalhub S, Tekin M, Estrera A, Musolino P, Yetman A, Pyeritz R, Milewicz DM. Clinical history and management recommendations of the smooth muscle dysfunction syndrome due to ACTA2 arginine 179 alterations. Genet Med 2018; 20:1206-1215. [PMID: 29300374 PMCID: PMC6034999 DOI: 10.1038/gim.2017.245] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 11/16/2017] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Smooth muscle dysfunction syndrome (SMDS) due to heterozygous ACTA2 arginine 179 alterations is characterized by patent ductus arteriosus, vasculopathy (aneurysm and occlusive lesions), pulmonary arterial hypertension, and other complications in smooth muscle-dependent organs. We sought to define the clinical history of SMDS to develop recommendations for evaluation and management. METHODS Medical records of 33 patients with SMDS (median age 12 years) were abstracted and analyzed. RESULTS All patients had congenital mydriasis and related pupillary abnormalities at birth and presented in infancy with a patent ductus arteriosus or aortopulmonary window. Patients had cerebrovascular disease characterized by small vessel disease (hyperintense periventricular white matter lesions; 95%), intracranial artery stenosis (77%), ischemic strokes (27%), and seizures (18%). Twelve (36%) patients had thoracic aortic aneurysm repair or dissection at median age of 14 years and aortic disease was fully penetrant by the age of 25 years. Three (9%) patients had axillary artery aneurysms complicated by thromboembolic episodes. Nine patients died between the ages of 0.5 and 32 years due to aortic, pulmonary, or stroke complications, or unknown causes. CONCLUSION Based on these data, recommendations are provided for the surveillance and management of SMDS to help prevent early-onset life-threatening complications.
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Affiliation(s)
- Ellen S Regalado
- Department of Internal Medicine, University of Texas Health Science Center at Houston McGovern Medical School, Houston, USA, Texas
| | - Lauren Mellor-Crummey
- Department of Internal Medicine, University of Texas Health Science Center at Houston McGovern Medical School, Houston, USA, Texas
| | - Julie De Backer
- Center for Medical Genetics, University Hospital Ghent, Ghent, Belgium
| | - Alan C Braverman
- Cardiovascular Division, Washington University School of Medicine, St. Louis, USA, Missouri
| | - Lesley Ades
- Division of Pediatrics and Child Health, University of Sydney, Sydney, Australia, New South Wales
| | - Susan Benedict
- Department of Pediatrics, The University of Utah School of Medicine, Salt Lake City, USA, Utah
| | - Timothy J Bradley
- Division of Cardiology, Department of Pediatrics, University of Saskatchewan, Saskatoon, Canada, Saskatchewan
| | - M Elizabeth Brickner
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, USA, Texas
| | - Kathryn C Chatfield
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, USA, Colorado
| | - Anne Child
- Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK
| | - Cori Feist
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, USA, Oregon
| | - Kathryn W Holmes
- Department of Pediatrics, Oregon Health and Science University, Portland, USA, Oregon
| | - Glen Iannucci
- Department of Pediatrics, Emory University School of Medicine, Atlanta, USA, Georgia
| | - Birgit Lorenz
- Department of Ophthalmology, Justus-Liebig-University Giessen, Giessen, Germany
| | - Paul Mark
- Department of Medical Genetics, Spectrum Health, Grand Rapids, USA, Michigan
| | - Takayuki Morisaki
- Tokyo University of Technology School of Health Sciences, Tokyo, Japan
| | - Hiroko Morisaki
- Department of Medical Genetics, Sakakibara Heart Institute, Tokyo, Japan
| | - Shaine A Morris
- Texas Children's Hospital, Baylor College of Medicine, Houston, USA, Texas
| | - Anna L Mitchell
- Department of Genetics and Genome Sciences, Case Western Reserve University, Cleveland, USA, Ohio
| | - John R Ostergaard
- Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
| | - Julie Richer
- Department of Medical Genetics, Children's Hospital of Eastern Ontario, Ottawa, Canada, Ontario
| | - Denver Sallee
- Department of Pediatrics, Emory University School of Medicine, Atlanta, USA, Georgia
| | - Sherene Shalhub
- Department of Surgery, University of Washington, Seattle, USA, Washington
| | - Mustafa Tekin
- John P. Hussman Institute for Human Genomics and Dr. John T. Macdonald Foundation Department of Human Genetics, University of Miami Miller School of Medicine, Miami, USA, Florida
| | | | - Anthony Estrera
- Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston McGovern Medical School, Houston, USA, Texas
| | - Patricia Musolino
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA, Massachusetts
| | - Anji Yetman
- Department of Pediatrics, Children's Hospital & Medical Center, University of Nebraska, Omaha, USA, Nebraska
| | - Reed Pyeritz
- Perelman School of Medicine at the, University of Pennsylvania, Philadelphia, USA, Pennsylvania
| | - Dianna M Milewicz
- Department of Internal Medicine, University of Texas Health Science Center at Houston McGovern Medical School, Houston, USA, Texas.
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11
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Krepp JM, Roman MJ, Devereux RB, Bruce A, Prakash SK, Morris SA, Milewicz DM, Holmes KW, Ravekes W, Shohet RV, Pyeritz RE, Maslen CL, Kroner BL, Eagle KA, Preiss L, Asch FM. Bicuspid and unicuspid aortic valves: Different phenotypes of the same disease? Insight from the GenTAC Registry. CONGENIT HEART DIS 2017; 12:740-745. [PMID: 28805011 DOI: 10.1111/chd.12520] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 06/17/2017] [Accepted: 06/26/2017] [Indexed: 01/26/2023]
Abstract
BACKGROUND Unicuspid aortic valve (UAV) is a rare disorder, often difficult to distinguish from bicuspid aortic valve (BAV). BAV and UAV share valve pathology such as the presence of a raphe, leaflet fusion, aortic stenosis, aortic regurgitation, and/or ascending aortic dilatation, but a comprehensive echocardiographic comparison of patients with UAV and BAV has not been previously performed. METHODS We investigated UAV and BAV patients at an early stage of disease included in GenTAC, a national registry of genetically related aortic aneurysms and associated cardiac conditions. Clinical and echocardiographic data from the GenTAC Registry were compared between 17 patients with UAV and 17 matched-controls with BAV. RESULTS Baseline characteristics including demographics, clinical findings including family history of BAV and aortic aneurysm/coarctation, and echocardiographic variables were similar between BAV and UAV patients; aortic stenosis was more common and more severe in patients with UAV. This was evidenced by higher mean and peak gradient, smaller aortic valve area, and more advanced valvular degeneration (all P < .05). There were no significant differences in aortic dimensions, with a similar pattern of enlargement of the ascending aorta. CONCLUSIONS The similar baseline characteristics with more accelerated aortic valve degeneration and stenosis suggest that UAV represents an extreme in the spectrum of BAV syndromes. Therefore, it is reasonable to consider application of recommendations for the management of patients with BAV to those with the rarer UAV.
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Affiliation(s)
- Joseph M Krepp
- MedStar Health Research Institute, Washington, District of Columbia, USA
| | - Mary J Roman
- Weill Medical College of Cornell University, New York, New York, USA
| | | | - Adrienne Bruce
- MedStar Health Research Institute, Washington, District of Columbia, USA
| | | | | | | | | | | | | | - Reed E Pyeritz
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | - Kim A Eagle
- University of Michigan, Ann Arbor, Michigan, USA
| | - Liliana Preiss
- RTI International, Research Triangle Park, North Carolina, USA
| | | | - Federico M Asch
- MedStar Health Research Institute, Washington, District of Columbia, USA
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12
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Asch FM, Yuriditsky E, Prakash SK, Roman MJ, Weinsaft JW, Weissman G, Weigold WG, Morris SA, Ravekes WJ, Holmes KW, Silberbach M, Milewski RK, Kroner BL, Whitworth R, Eagle KA, Devereux RB, Weissman NJ. The Need for Standardized Methods for Measuring the Aorta: Multimodality Core Lab Experience From the GenTAC Registry. JACC Cardiovasc Imaging 2016; 9:219-26. [PMID: 26897684 DOI: 10.1016/j.jcmg.2015.06.023] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 05/19/2015] [Accepted: 06/11/2015] [Indexed: 12/25/2022]
Abstract
OBJECTIVES This study sought to evaluate variability in aortic measurements with multiple imaging modalities in clinical centers by comparing with a standardized measuring protocol implemented in a core laboratory. BACKGROUND In patients with aortic disease, imaging of thoracic aorta plays a major role in risk stratifying individuals for life-threatening complications and in determining timing of surgical intervention. However, standardization of the procedures for performance of aortic measurements is lacking. METHODS To characterize the diversity of methods used in clinical practice, we compared aortic measurements performed by echocardiography, computed tomography (CT), and magnetic resonance imaging (MRI) at the 6 GenTAC (National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions) clinical centers to those performed at the imaging core laboratory in 965 studies. Each center acquired and analyzed their images according to local protocols. The same images were subsequently analyzed blindly by the core laboratory, on the basis of a standardized protocol for all imaging modalities. Paired measurements from clinical centers and core laboratory were compared by mean of differences and intraclass correlation coefficient (ICC). RESULTS For all segments of the ascending aorta, echocardiography showed a higher ICC (0.84 to 0.93) than CT (0.84) and MRI (0.82 to 0.90), with smaller mean of differences. MRI showed higher ICC for the arch and descending aorta (0.91 and 0.93). In a mixed adjusted model, the different imaging modalities and clinical centers were identified as sources of variability between clinical and core laboratory measurements, whereas age groups or diagnosis at enrollment were not. CONCLUSIONS By comparing core laboratory with measurements from clinical centers, our study identified important sources of variability in aortic measurements. Furthermore, our findings with regard to CT and MRI suggest a need for imaging societies to work toward the development of unifying acquisition protocols and common measuring methods.
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Affiliation(s)
- Federico M Asch
- MedStar Health Research Institute at MedStar Washington Hospital Center, Washington, DC.
| | - Eugene Yuriditsky
- MedStar Health Research Institute at MedStar Washington Hospital Center, Washington, DC
| | | | - Mary J Roman
- Weill Cornell Medical College, New York, New York
| | | | - Gaby Weissman
- MedStar Health Research Institute at MedStar Washington Hospital Center, Washington, DC
| | - Wm Guy Weigold
- MedStar Health Research Institute at MedStar Washington Hospital Center, Washington, DC
| | | | | | | | | | - Rita K Milewski
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | | | | | | | | | - Neil J Weissman
- MedStar Health Research Institute at MedStar Washington Hospital Center, Washington, DC
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13
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Brady TM, Appel LJ, Holmes KW, Fivush B, Miller ER. Association Between Adiposity and Left Ventricular Mass in Children With Hypertension. J Clin Hypertens (Greenwich) 2015; 18:625-33. [PMID: 26530452 DOI: 10.1111/jch.12717] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 08/13/2015] [Accepted: 08/16/2015] [Indexed: 01/19/2023]
Abstract
Left ventricular hypertrophy (LVH) is prevalent among hypertensive children; however, blood pressure (BP) does not predict its presence. The authors conducted a 1-year prospective cohort study to examine the hypothesis that obesity-related risk factors are associated with left ventricular mass index (LVMI) in hypertensive children, and the association between adiposity and LVMI is mediated by BP-dependent and -independent pathways. A total of 49 hypertensive children were enrolled: 51% were overweight/obese and 41% had LVH at baseline. Children overweight/obese at baseline and follow-up had a greater LVMI increase than those of healthy weight at each visit: mean change of 6.4 g/m(2.7) vs 0.95 g/m(2.7) . Baseline body mass index z score was independently associated with LVMI change (β=4.08, 1.54-6.61; P=.002). Only pulse pressure and serum aldosterone partially mediated this relationship. Hypertensive youth manifest multiple cardiovascular disease risk factors that worsen over time despite treatment. Of these, adiposity is most associated with LVH and increasing LVMI.
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Affiliation(s)
- Tammy M Brady
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Lawrence J Appel
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD
| | - Kathryn W Holmes
- Division of Pediatric Cardiology, Oregon Health and Science University, Portland, OR
| | - Barbara Fivush
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Edgar R Miller
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD
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14
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Song HK, Preiss LR, Maslen CL, Kroner B, Devereux RB, Roman MJ, Holmes KW, Tolunay HE, Desvigne-Nickens P, Asch FM, Milewski RK, Bavaria J, LeMaire SA. Valve-sparing aortic root replacement in patients with Marfan syndrome enrolled in the National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions. J Heart Valve Dis 2014; 23:292-298. [PMID: 25296451 PMCID: PMC4995179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND AND AIM OF THE STUDY The long-term outcomes of aortic valve-sparing (AVS) root replacement in Marfan syndrome (MFS) patients remain uncertain. The study aim was to determine the utilization and outcomes of AVS root replacement in MFS patients enrolled in the Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions (GenTAC). METHODS At the time of this analysis, 788 patients with MFS were enrolled in the GenTAC Registry, of whom 288 had undergone aortic root replacement. Patients who had undergone AVS procedures were compared to those who had undergone aortic valve replacement (AVR). RESULTS AVS root replacement was performed in 43.5% of MFS patients, and the frequency of AVS was increased over the past five years. AVS patients were younger at the time of surgery (31.0 versus 36.3 years, p = 0.006) and more likely to have had elective rather than emergency surgery compared to AVR patients, in whom aortic valve dysfunction and aortic dissection was the more likely primary indication for surgery. After a mean follow up of 6.2 +/- 3.6 years, none of the 87 AVS patients had required reoperation; in contrast, after a mean follow up of 10.5 +/- 7.6 years, 11.5% of AVR patients required aortic root reoperation. Aortic valve function has been durable, with 95.8% of AVS patients having aortic insufficiency that was graded as mild or less. CONCLUSION AVS root replacement is performed commonly among the MFS population, and the durability of the aortic repair and aortic valve function have been excellent to date. These results justify a continued use of the procedure in an elective setting. The GenTAC Registry will be a useful resource to assess the long-term durability of AVS root replacement in the future.
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Abstract
A prenatal diagnosis of ductal-dependent, complex congenital heart disease was made in a fetus with trisomy 18. The parents requested that the genetic diagnosis be excluded from all medical and surgical decision-making and that all life-prolonging therapies be made available to their infant. There was conflict among the medical team about what threshold of neonatal benefit could outweigh maternal and neonatal treatment burdens. A prenatal ethics consultation was requested.
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Affiliation(s)
- Renee D Boss
- Department of Pediatrics, Johns Hopkins University School of Medicine, Johns Hopkins University School of Nursing, Baltimore, MD, USA.
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Holmes KW, Maslen CL, Kindem M, Kroner BL, Song HK, Ravekes W, Dietz HC, Weinsaft JW, Roman MJ, Devereux RB, Pyeritz RE, Bavaria J, Milewski K, Milewicz D, LeMaire SA, Hendershot T, Eagle KA, Tolunay HE, Desvigne-Nickens P, Silberbach M. GenTAC registry report: gender differences among individuals with genetically triggered thoracic aortic aneurysm and dissection. Am J Med Genet A 2013; 161A:779-86. [PMID: 23444191 DOI: 10.1002/ajmg.a.35836] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Accepted: 12/06/2012] [Indexed: 01/15/2023]
Abstract
Previous data suggest women are at increased risk of death from aortic dissection. Therefore, we analyzed data from the GenTAC registry, the NIH-sponsored program that collects information about individuals with genetically triggered thoracic aortic aneurysms and cardiovascular conditions. We performed cross-sectional analyses in adults with Marfan syndrome (MFS), familial thoracic aortic aneurysm or dissection (FTAAD), bicuspid aortic valve (BAV) with thoracic aortic aneurysm or dissection, and subjects under 50 years of age with thoracic aortic aneurysm or dissection (TAAD <50 years). Women comprised 32% of 1,449 subjects and were 21% of subjects with BAV, 34% with FTAAD, 22% with TAAD <50 years, and 47% with MFS. Thoracic aortic dissections occurred with equal gender frequency yet women with BAV had more extensive dissections. Aortic size was smaller in women but was similar after controlling for BSA. Age at operation for aortic valve dysfunction, aneurysm or dissection did not differ by gender. Multivariate analysis (adjusting for age, BSA, hypertension, study site, diabetes, and subgroup diagnoses) showed that women had fewer total aortic surgeries (OR = 0.65, P < 0.01) and were less likely to receive angiotensin converting enzyme inhibitors (ACEi; OR = 0.68, P < 0.05). As in BAV, other genetically triggered aortic diseases such as FTAAD and TAAD <50 are more common in males. In women, decreased prevalence of aortic operations and less treatment with ACEi may be due to their smaller absolute aortic diameters. Longitudinal studies are needed to determine if women are at higher risk for adverse events.
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Holmes KW. Timing of pulmonary valve replacement in tetralogy of fallot using cardiac magnetic resonance imaging: an evolving process. J Am Coll Cardiol 2012; 60:1015-7. [PMID: 22921970 DOI: 10.1016/j.jacc.2012.05.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Accepted: 05/08/2012] [Indexed: 01/12/2023]
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Song HK, Kindem M, Bavaria JE, Dietz HC, Milewicz DM, Devereux RB, Eagle KA, Maslen CL, Kroner BL, Pyeritz RE, Holmes KW, Weinsaft JW, Menashe V, Ravekes W, LeMaire SA. Long-term implications of emergency versus elective proximal aortic surgery in patients with Marfan syndrome in the Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions Consortium Registry. J Thorac Cardiovasc Surg 2011; 143:282-6. [PMID: 22104675 DOI: 10.1016/j.jtcvs.2011.10.024] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Revised: 09/08/2011] [Accepted: 10/20/2011] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Patients with Marfan syndrome with aortic root aneurysms undergo elective aortic root replacement to avoid the life-threatening outcomes of aortic dissection and emergency repair. The long-term implications of failed aortic surveillance leading to acute dissection and emergency repair are poorly defined. We compared the long-term clinical courses of patients with Marfan syndrome who survive emergency versus elective proximal aortic surgery. METHODS The Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions Registry is a National Institutes of Health-funded multicenter database and biorepository that enrolls patients with genetically triggered thoracic aortic aneurysms. Of the 635 patients with Marfan syndrome enrolled as of March 2011, 194 had undergone proximal aortic replacement. Patients were grouped according to emergency (n = 47) or elective (n = 147) status at the time of surgery. RESULTS Patients in the emergency group were more likely to have incomplete proximal aortic resection; 83% of emergency procedures included aortic root replacement, compared with 95% of elective procedures. At long-term follow-up (mean, >6 years), the emergency group had a higher incidence of chronic dissection of the distal aorta and significantly larger diameters in distal aortic segments than elective patients. Patients in the emergency group had undergone more operations (1.31 vs 1.11 procedures/patient; P = .01) and had lower activity scores on a health-related quality of life survey. CONCLUSIONS For patients with Marfan syndrome, failed aortic surveillance and consequent emergency dissection repair have important long-term implications with regard to the status of the distal aorta, need for multiple procedures, and quality of life. These findings emphasize the importance of aortic surveillance and timely elective aortic root aneurysm repair for patients with Marfan syndrome.
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Affiliation(s)
- Howard K Song
- Division of Cardiothoracic Surgery, Oregon Health & Science University, Portland, OR 97239, USA.
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Kroner BL, Tolunay HE, Basson CT, Pyeritz RE, Holmes KW, Maslen CL, Milewicz DM, LeMaire SA, Hendershot T, Desvigne-Nickens P, Devereux RB, Dietz HC, Song HK, Ringer D, Mitchell M, Weinsaft JW, Ravekes W, Menashe V, Eagle KA. The National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions (GenTAC): results from phase I and scientific opportunities in phase II. Am Heart J 2011; 162:627-632.e1. [PMID: 21982653 DOI: 10.1016/j.ahj.2011.07.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Accepted: 07/12/2011] [Indexed: 11/27/2022]
Abstract
BACKGROUND Genetically triggered thoracic aortic conditions (GenTACs) represent an important problem for patients and their families. Accordingly, the National Heart, Lung, and Blood Institute established the first phase of its national GenTAC Registry in 2006. ENROLLMENT AND DIAGNOSES Between 2007 and 2010, 6 enrolling centers established the GenTAC I Registry consisting of 2,046 patients (Marfan syndrome 576 [28.2%], bicuspid aortic valve disease 504 [24.6%], aneurysm or dissection age <50 years 369 [18%], and others). Biologic samples for DNA analyses (white blood cells or saliva) are available in 97%, and stored plasma is available in 60% of enrollees. RESULTS Initial scientific inquiry using the GenTAC Registry has included validation studies of genetic causes for aortic syndromes, potential usefulness of transforming growth factor beta (TGFB) blood levels in Marfan subjects, and current surgical approaches to ascending aortic conditions. FUTURE OPPORTUNITY The second phase of GenTAC will allow biannual follow-up of GenTAC I enrollees for up to 9 years, enrollment of an additional 1,500 subjects, further integration of imaging findings with clinical and genetic data through utilization of an imaging core laboratory, important validation of phenotype-genotype correlations through a phenotyping core laboratory, and integration of a scientific advisory committee to help define the full range and depth of the Registry's scientific capabilities. The registry resources are available to the external scientific community through an application process accessible at https://gentac.rti.org.
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LeMaire SA, McDonald MLN, Guo DC, Russell L, Miller CC, Johnson RJ, Bekheirnia MR, Franco LM, Nguyen M, Pyeritz RE, Bavaria JE, Devereux R, Maslen C, Holmes KW, Eagle K, Body SC, Seidman C, Seidman JG, Isselbacher EM, Bray M, Coselli JS, Estrera AL, Safi HJ, Belmont JW, Leal SM, Milewicz DM. Genome-wide association study identifies a susceptibility locus for thoracic aortic aneurysms and aortic dissections spanning FBN1 at 15q21.1. Nat Genet 2011; 43:996-1000. [PMID: 21909107 DOI: 10.1038/ng.934] [Citation(s) in RCA: 150] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 08/09/2011] [Indexed: 12/18/2022]
Abstract
Although thoracic aortic aneurysms and dissections (TAAD) can be inherited as a single-gene disorder, the genetic predisposition in the majority of affected people is poorly understood. In a multistage genome-wide association study (GWAS), we compared 765 individuals who had sporadic TAAD (STAAD) with 874 controls and identified common SNPs at a 15q21.1 locus that were associated with STAAD, with odds ratios of 1.6-1.8 that achieved genome-wide significance. We followed up 107 SNPs associated with STAAD with P < 1 × 10(-5) in the region, in two separate STAAD cohorts. The associated SNPs fall into a large region of linkage disequilibrium encompassing FBN1, which encodes fibrillin-1. FBN1 mutations cause Marfan syndrome, whose major cardiovascular complication is TAAD. This study shows that common genetic variants at 15q21.1 that probably act via FBN1 are associated with STAAD, suggesting a common pathogenesis of aortic disease in Marfan syndrome and STAAD.
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Affiliation(s)
- Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
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21
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Song HK, Bavaria JE, Kindem MW, Holmes KW, Milewicz DM, Maslen CL, Pyeritz RE, Basson CT, Eagle K, Tolunay HE, Kroner BL, Dietz H, Menashe V, Devereux RB, Desvigne-Nickens P, Ravekes W, Weinsaft JW, Brambilla D, Stylianou MP, Hendershot T, Mitchell MS, LeMaire SA. Surgical treatment of patients enrolled in the national registry of genetically triggered thoracic aortic conditions. Ann Thorac Surg 2009; 88:781-7; discussion 787-8. [PMID: 19699898 DOI: 10.1016/j.athoracsur.2009.04.034] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2009] [Revised: 04/06/2009] [Accepted: 04/08/2009] [Indexed: 01/15/2023]
Abstract
BACKGROUND Genetic disorders are an important cause of thoracic aortic aneurysms (TAAs) in young patients. Despite advances in the treatment of genetically triggered TAAs, the optimal syndrome-specific treatment approach remains undefined. We used data from the National Institutes of Health-funded, multicenter National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions (GenTAC) to characterize the contemporary surgical treatment of patients with genetically triggered TAAs. METHODS GenTAC's aim is to collect longitudinal clinical data and banked biospecimens from 2800 patients with genetically triggered TAAs. We analyzed data from the 606 patients (mean age, 37.5 years) enrolled in GenTAC to date whose clinical data were available. RESULTS The patients' primary diagnoses included Marfan syndrome (35.8%), bicuspid aortic valve with aneurysm (29.2%), and familial TAAs and dissections (10.7%). Of these, 56.4% had undergone at least one operation; the most common indications were aneurysm (85.7%), valve dysfunction (65.8%), and dissection (25.4%). Surgical procedures included replacement of the aortic root (50.6%), ascending aorta (64.8%), aortic arch (27.9%), and descending or thoracoabdominal aorta (12.4%). Syndrome-specific differences in age, indications for operation, and procedure type were identified. CONCLUSIONS Patients with genetically transmitted TAAs evaluated in tertiary care centers frequently undergo surgical repair. Aneurysm repairs most commonly involve the aortic root and ascending aorta; distal repairs are less common. Like TAAs themselves, complications of TAAs, including dissection and aortic valve dysfunction, are important indications for intervention. Future studies will focus on syndrome- and gene-specific phenotypes, biomarkers, treatments, and outcomes to improve the treatment of patients with TAAs.
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Affiliation(s)
- Howard K Song
- Song, Division of Cardiothoracic Surgery, Oregon Health and Science University, Portland, Oregon 97239, USA.
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Frazier A, Judge DP, Schulman SP, Johnson N, Holmes KW, Murphy AM. Familial hypertrophic cardiomyopathy associated with cardiac beta-myosin heavy chain and troponin I mutations. Pediatr Cardiol 2008; 29:846-50. [PMID: 18175163 DOI: 10.1007/s00246-007-9177-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2007] [Revised: 11/01/2007] [Accepted: 11/21/2007] [Indexed: 11/29/2022]
Abstract
We report an African American family with hypertrophic cardiomyopathy in which an individual with severe disease has alterations in two sarcomeric protein genes, cardiac beta-myosin heavy chain (MYH7) and troponin I (TNNI3). Each of her children has only one of these mutations. Although novel, the MYH7 mutation disrupts a conserved amino acid, and other missense substitutions at this position are known to cause disease. The TNNI3 alteration, replacing proline with serine (Pro82Ser), has been previously implicated in elderly-onset hypertrophic cardiomyopathy, although its pathogenicity is not clear. Proline in this position is conserved in all species, and its alteration to a serine is likely to result in a dramatic change in protein structure. We analyzed DNA from a panel of 100 healthy African Americans and found 3% carry the heterozygous TNNI3 missense allele that was identified in this family. Based on these findings, we propose that the TNNI3 Pro82Ser alteration is likely a disease-modifying mutation in a severely affected individual, and, furthermore, carriers of this alteration (3% of African Americans) might be at increased risk of late-onset cardiac hypertrophy.
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Affiliation(s)
- Aisha Frazier
- Department of Pediatrics, Cardiology Division, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA
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Holmes KW, Lehmann CU, Dalal D, Nasir K, Dietz HC, Ravekes WJ, Thompson WR, Spevak PJ. Progressive dilation of the ascending aorta in children with isolated bicuspid aortic valve. Am J Cardiol 2007; 99:978-83. [PMID: 17398196 DOI: 10.1016/j.amjcard.2006.10.065] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2006] [Revised: 10/30/2006] [Accepted: 10/30/2006] [Indexed: 11/20/2022]
Abstract
Although patients with bicuspid aortic valves (BAVs) are predisposed to ascending aortic (AA) dilation, stenosis, and dissection, the development of aortic disease in children with BAVs is poorly described. The purposes of this study were to determine the rate of change of AA diameter in children with BAVs and to identify risk factors for the development of aortic dilation. The echocardiograms of 276 children aged<19 years (mean 8.5+/-5.3) with isolated BAVs were reviewed. Aortic measurements were normalized to z scores on the basis of body surface area. In a subset of 112 patients with serial examinations, aortic growth rates were calculated and risk factors for more rapid aortic growth determined. At presentation, 33 patients (12%) demonstrated marked AA dilation (z>4), and 70 (25%) were moderately abnormal (z between 2 and 4). The mean+/-SD AA diameter increased more than expected, at a rate of 0.18+/-0.30 z score per year (p<0.0001). In 61 patients with normal AA diameters on initial study, 22 (36%) had abnormal diameters, with z scores>2, at follow-up. Univariate analysis demonstrated right-noncoronary commissural fusion (p<0.02) and aortic valve gradient on initial examination (p<0.02) as significant predictors of AA growth. In multivariate analysis, however, the significance of gradient and valve morphology was diminished (p = 0.06 for both). In conclusion, the progression of AA diameter in patients with normal z scores on initial examination suggests that serial echocardiograms are required to screen for the development of significant aortic dilation.
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Affiliation(s)
- Kathryn W Holmes
- Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland, USA.
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Holmes KW, Bluemke DA, Vricella LA, Ravekes WJ, Kling KM, Spevak PJ. Magnetic resonance imaging of a distorted left subclavian artery course: an important clue to an unusual type of double aortic arch. Pediatr Cardiol 2006; 27:316-20. [PMID: 16565909 DOI: 10.1007/s00246-005-1118-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The objective of this study was to determine if distortion of the left subclavian artery course distinguishes double aortic arch with atretic left dorsal aorta from right aortic arch with mirror image branching. We performed a retrospective case series at a tertiary care center. Twenty-six patients undergoing magnetic resonance imaging for suspicion of a vascular ring were identified, 6 of whom had an atretic left dorsal aorta confirmed by surgical inspection. Six patients with the diagnosis of right aortic arch with mirror image branching were identified for comparison. The course of the left subclavian artery was assessed using surface-rendered magnetic resonance angiography (MRA) and axial fast spin echo images. All patients with double aortic arch had clinical symptoms suggestive of esophageal or tracheal compression. Six patients had double aortic arch, 3 of whom had an atretic left dorsal aorta. In these 3 patients, the branching patterns on MRA mimicked right aortic arch mirror image branching except for the distortion of the initial course of the left subclavian artery. Surgical observation confirmed the presence of an atretic left dorsal aorta that resulted in tension on the left subclavian artery pulling it posteriorly and inferiorly and completing the vascular ring. Patients with right aortic arch mirror image branching demonstrated no such subclavian artery distortion, and these patients did not have clinical symptoms suggestive of a vascular ring. Our results demonstrate that left subclavian artery distortion due to traction by an atretic left arch is an important diagnostic finding in the evaluation 6 patients with suspected vascular rings.
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Affiliation(s)
- K W Holmes
- Division of Pediatric Cardiology, Johns Hopkins Hospital, 600 N. Wolfe Street, Brady 501, Baltimore, MD 21287, USA.
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Vricella LA, Williams JA, Ravekes WJ, Holmes KW, Dietz HC, Gott VL, Cameron DE. Early Experience With Valve-Sparing Aortic Root Replacement in Children. Ann Thorac Surg 2005; 80:1622-6; discussion 1626-7. [PMID: 16242427 DOI: 10.1016/j.athoracsur.2005.04.062] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2005] [Revised: 04/24/2005] [Accepted: 04/26/2005] [Indexed: 11/18/2022]
Abstract
BACKGROUND Aortic valve-sparing root replacement has become an established treatment for adults with aneurysms of the ascending aorta, but there is limited experience in children, for whom the advantages of avoiding valve prostheses are particularly attractive. METHODS A retrospective clinical study was undertaken to examine results of aortic valve-sparing operations in pediatric patients at a single institution. Clinical and echocardiographic data were obtained from chart review and outpatient follow-up examination. RESULTS Between 1997 and 2004, 19 children underwent aortic valve-sparing root replacement. Mean age was 12.2 +/- 4.4 years, and mean weight was 51.5 +/- 22.9 kg. Median length of clinical follow-up was 58 months (range, 5 to 91). Fifteen of 19 patients (78.9%) had Marfan syndrome and 1 had aortic root dilation late after the arterial switch operation. Mean preoperative root diameter was 4.7 +/- 0.6 cm, with an average Z score of 7.7 +/- 1.9. Fourteen patients (73.7%) underwent root remodeling, whereas 5 (26.3%) had a reimplantation procedure. One patient required concomitant mitral valve repair. There was no operative mortality and only 1 reoperation for bleeding (5.3%). Median length of hospital stay was 5 days (range, 3 to 12). At latest follow-up, 3 of 19 patients (15.8%) have required late aortic valve replacement. Fifteen patients have no or mild aortic valve insufficiency, and 1 has moderate but stable valve regurgitation. No patient with a reimplantation procedure has had a reoperation or more than mild insufficiency, and no patient has suffered endocarditis or thromboembolism. CONCLUSIONS Valve-sparing aortic root replacement is a viable alternative to root replacement with mechanical or biological prostheses in children, and can be accomplished with minimal morbidity and mortality. Reimplantation procedures appear to have more durable results than root remodeling techniques, and should be strongly considered for pediatric patients with aortic root enlargement secondary to connective tissue disorders and other forms of congenital heart disease.
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Affiliation(s)
- Luca A Vricella
- Division of Pediatric Cardiac Surgery, The Johns Hopkins University Hospital, Baltimore, Maryland, USA.
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26
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Affiliation(s)
- Kathryn W Holmes
- Division of Pediatric Cardiology, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21287, USA.
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Clauss SB, Holmes KW, Hopkins P, Stein E, Cho M, Tate A, Johnson-Levonas AO, Kwiterovich PO. Efficacy and safety of lovastatin therapy in adolescent girls with heterozygous familial hypercholesterolemia. Pediatrics 2005; 116:682-8. [PMID: 16140708 DOI: 10.1542/peds.2004-2090] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The present study was designed to evaluate the lipid-altering efficacy, safety, and tolerability of lovastatin treatment in adolescent girls with heterozygous familial hypercholesterolemia. METHODS A total of 54 postmenarchal girls, aged 10 to 17 years, were enrolled in a 24-week, double-blind, randomized, placebo-controlled study. After a 4-week diet/placebo run-in period, patients were randomized to 1 of 2 groups: (1) treatment with diet plus lovastatin 20 mg/day for 4 weeks, followed by diet plus lovastatin 40 mg/day for 20 weeks, or (2) diet plus placebo for 24 weeks. RESULTS Baseline values of lipids, lipoproteins, and apolipoproteins (apo) were comparable between treatment groups. Lovastatin treatment was efficacious at reducing low-density lipoprotein cholesterol by 23% to 27%, total cholesterol by 17% to 22%, and apo B by 20% to 23% at weeks 4 and 24, respectively. Between-treatment group differences were not statistically significant for triglycerides, very-low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, or apo A-I. Lovastatin was generally safe and well tolerated. There were no clinically significant alterations in vital signs (blood pressure and pulse rate), anthropomorphic measurements (height, weight, and BMI), hormone levels (luteinizing hormone, follicle-stimulating hormone, dehydroepiandrosterone sulfate, estradiol, and cortisol), menstrual cycle length, or tests of liver and muscle function. CONCLUSIONS Lovastatin offers an efficacious and well-tolerated treatment option for improving lipid profiles in adolescent girls with familial hypercholesterolemia.
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Affiliation(s)
- Sarah B Clauss
- The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
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Holmes KW, Hales R, Chu S, Maxwell MJ, Mogayzel PJ, Zeitlin PL. Modulation of Sp1 and Sp3 in lung epithelial cells regulates ClC-2 chloride channel expression. Am J Respir Cell Mol Biol 2003; 29:499-505. [PMID: 12714379 DOI: 10.1165/rcmb.2003-0030oc] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
ClC-2 is a pH- and voltage-activated chloride channel, which is highly expressed in fetal airways and downregulated at birth. The ClC-2 promoter contains consensus binding sites within the first 237 bp, which bind transcription factors Sp1 and Sp3(1). This study directly links Sp1 and Sp3 with ClC-2 protein expression by demonstrating: (i) induction of ClC-2 protein by transient overexpression of each transcription factor in adult rat Type II cells, which have low levels of ClC-2; and (ii) reduction of ClC-2 expression by incubation with a competitive inhibitor of Sp1 and Sp3 in fetal rat Type II cells, which have high levels of endogenous ClC-2. Endogenous fetal lung Sp1 is differentially expressed as two major species of 105 kD and 95 kD. Although low-level expression of Sp1 in adult cells is almost exclusively the 105-kD species, overexpression of Sp1 results in increased expression of the 95-kD band. These experiments suggest that the mechanism for postnatal reduction of ClC-2 expression in lung epithelia is based on decreased interaction of Sp1 and Sp3 with the ClC-2 promoter.
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Affiliation(s)
- Kathryn W Holmes
- Eudowood Division of Pediatric Respiratory Sciences, The Johns Hopkins Medical Institutions, 600 N Wolfe St. Park 316, Baltimore, MD 21287-2533, USA
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Saiman L, Jakob K, Holmes KW, Whittier S, Garzon MC, Rago JV, Schlievert PM, Della-Latta P. Molecular epidemiology of staphylococcal scalded skin syndrome in premature infants. Pediatr Infect Dis J 1998; 17:329-34. [PMID: 9576389 DOI: 10.1097/00006454-199804000-00012] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Outbreaks of nosocomial staphylococcal scalded skin syndrome (SSSS) in infants have been well-described associated with the well baby nursery or delivery room. We describe two cases of SSSS in very low birth weight infants in a neonatal intensive care unit (NICU) and the success of infection control strategies used to prevent an outbreak. METHODS Staphylococcal scalded skin syndrome was diagnosed in two infants in the NICU: Case I (a 47-day-old, formerly 530-g female); and Case II diagnosed 48 h later (a 41-day old, formerly 706-g female). Multiple infection control measures were implemented: (1) isolation and intravenous antibiotic treatment of cases; (2) placement of exposed infants into a cohort; (3) prophylactic mupirocin treatment of the anterior nares of all infants in the NICU and staff colonized with Staphylococcus aureus; and (4) personnel hand washing with hexachlorophene. Detection of exfoliative toxin A and studies to determine the genetic relatedness of S. aureus strains isolated from patients and staff were performed. RESULTS In addition to the two SSSS cases, S. aureus was isolated from 2 of 12 (17%) exposed asymptomatic infants, 2 of 20 (10%) ancillary staff, 8 of 30 (27%) nurses and 6 of 24 (25%) physicians. Exfoliative toxin A-producing strains were isolated from both cases and one asymptomatic infant. No toxin was expressed by strains isolated from staff. Pulse field gel electrophoresis demonstrated genetically identical strains of S. aureus from the two SSSS cases and the asymptomatic infant, whereas three staff members harbored strains genetically related to the case strain. Unexpectedly two additional unique clusters of genetically related S. aureus strains were identified from the surveillance cultures. CONCLUSIONS This report documents the rare occurrence of nosocomial SSSS attributed to transmission in the NICU among extremely low birth weight infants. Multiple infection control strategies were effective in limiting the outbreak. Molecular epidemiology investigation supported a unique S. aureus strain responsible for this event and the presence of bidirectional spread between staff and patients of non-toxin-producing strains.
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Affiliation(s)
- L Saiman
- Department of Pediatrics, Columbia University and Columbia-Presbyterian Medical Center, New York, NY 10032, USA.
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