Bear bile: dilemma of traditional medicinal use and animal protection

Bear bile has been used in Traditional Chinese Medicine (TCM) for thousands of years. Modern investigations showed that it has a wide range of pharmacological actions with little toxicological side effect and the pure compounds have been used for curing hepatic and biliary disorders for decades. However, extensive consumption of bear bile made bears endangered species. In the 1980's, bear farming was established in China to extract bear bile from living bears with "Free-dripping Fistula Technique". Bear farming is extremely inhumane and many bears died of illness such as chronic infections and liver cancer. Efforts are now given by non-governmental organizations, mass media and Chinese government to end bear farming ultimately. At the same time, systematic research has to be done to find an alternative for bear bile. In this review, we focused on the literature, laboratory and clinical results related to bear bile and its substitutes or alternative in English and Chinese databases. We examined the substitutes or alternative of bear bile from three aspects: pure compounds derived from bear bile, biles from other animals and herbs from TCM. We then discussed the strategy for stopping the trading of bear bile and issues of bear bile related to potential alternative candidates, existing problems in alternative research and work to be done in the future.

Hepatoprotective effect and its possible mechanism of Coptidis rhizoma aqueous extract on carbon tetrachloride-induced chronic liver hepatotoxicity in rats

ETHNOPHARMACOLOGICAL RELEVANCE

Coptidis rhizoma is traditionally used for heat-clearing and toxic-scavenging and it belongs to liver meridian in Chinese medicine practice. Clinically, Coptidis rhizoma can be used for hepatic and biliary disorders, yet details in the therapies of liver diseases and underlying mechanism(s) remain unclear. Our previous study demonstrated that Coptidis rhizoma aqueous extract (CRAE) against CCl(4)-induced acute liver damage was related to antioxidant property. In the present study, the protection of CRAE on chronic liver damage induced by carbon tetrachloride (CCl(4)) in rats and its related mechanism were explored.

MATERIALS AND METHODS

The CCl(4)-induced chronic liver damage model was established, and CRAE's protective effect was examined. Serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) activity, serum and liver superoxide dismutase (SOD) activity were then measured. The histological changes were observed under microscopy and then computed in numerical score. The normal or damaged cells were isolated and related signaling pathway was evaluated.

RESULT

Serum AST and ALT activities were significantly decreased in rats treated with different doses of CRAE, indicating its protective effect against CCl(4)-induced chronic liver damage. Observation on serum SOD activity revealed that CRAE might act as an anti-oxidant agent against CCl(4)-induced chronic oxide stress. Histological study supported these observations. Erk1/2 inhibition may take part into CRAE's effect on preventing hepatocyte from apoptosis when exposed to oxidative stress.

CONCLUSION

CRAE showed protective effect against CCl(4)-induced chronic liver damage in rats and its potential as an agent in the treatment of chronic liver diseases by protecting hepatocyte from injury.

Acteoside, a component of Stachys sieboldii MIQ, may be a promising antinephritic agent (2): Effect of acteoside on leukocyte accumulation in the glomeruli of nephritic rats

We investigated the effect of acteoside in comparison with that of cyclosporin A on leukocyte accumulation in the glomeruli of rats with crescentic-type anti-glomerular basement membrane (GBM) nephritis. Acteoside given p.o. at a dose of 30 mg/kg once a day for 15 consecutive days after treatment with anti-GBM serum markedly suppressed the urinary protein as well as glomerular histological changes. Acteoside given p.o. for 5 or 15 consecutive days markedly suppressed the accumulation of total leukocytes, ED-1-positive cells (monocytes/macrophages), CD4-positive cells, CD8-positive cells, interleukin-2-receptor-positive cells (activated T cells) and Ia-positive cells in the glomeruli. These effects of cyclosporin A (20 mg/kg/day, p.o.) were also as potent as those of acteoside (30 mg/kg/day, p.o.). Cyclosporin A also strongly suppressed the elevation of plasma antibody level against rabbit gamma-globulin. However, in this dose, acteoside did not significantly suppress the antibody formation. It can be concluded from these results that acetoside may exert its antinephritic action by suppressing the accumulation of leukocytes in the glomeruli.

Isomerizations akin to the Dimroth rearrangement. III. The conversion of simple s-Triazolo[4,3-a]pyrimidines into their [1,5-a] Isomers

The treatment of 2-hydrazinopyrimidines (1) with acylating agents under appropriate conditions is used to prepare s-triazolo[4,3-a]pyrimidine (6a) and its derivatives bearing alkyl or aryl groups at the 3-, 5-, 6- , or 7-position. These compounds rearrange in acid or alkali to give the corresponding s-triazolo[1,5-a]pyrimidines (7). Rates for such isomerizations in alkali increase steeply in the range pH 10-12.5; in acid, they reach maxima at pH values corresponding approximately to the pKa of each substance (in the range pH 1.5-2.5) and fall off on both sides. Rearrangement of the parent heterocycle (6a) is slowed significantly by each added 3-, 6-, and 7-alkyl group and slowed profoundly by a 5-alkyl group: for example, 3,5,7-trimethyltriazolo[4,3-a]pyrimidine rearranges 2500 times more slowly than the unsubstituted heterocycle at pH 11.3. The isomeric systems (6) and (7) are distinguished easily by their tabulated u.v. and N.M.R. spectra.

Inhibition of eukaryotic elongation factor-2 confers to tumor suppression by a herbal formulation Huanglian-Jiedu decoction in human hepatocellular carcinoma

ETHNOPHARMACOLOGICAL RELEVANCE

An oriental medicinal formulation, Huanglian Jiedu Decoction (HLJDD), has been well documented in few Traditional Chinese Medicine Classics 1300 years ago for treatment of heat and dampness-related diseases. Its effect is well accepted in Asian community, including China, Japan and Korea. Recent studies have postulated HLJDD as a regimen for cancer treatment, especially liver cancer, but the underlying mechanism is unknown. The aim of this study was to examine the suppressive effect of HLJDD on the growth of hepatocellular carcinoma (HCC) and its possible underlying mechanism.

METHODS

Chemical composition of HLJDD was analyzed by high performance liquid chromatography. The tumor suppressive effect of HLJDD was determined on both HCC cells and xenograft model. Nascent protein synthesis was detected with Click-IT protein labeling technology; protein expression was determined by immunoblotting and imunnohistochemical analysis.

RESULTS

Quality analysis revealed that HLJDD of different batches is consistent in both chemical composition and bioactivities. HLJDD inhibited HCC cell proliferation at its non-toxic doses, and suppressed growth and angiogenesis in xenografted murine model. HLJDD suppressed the synthesis of nascent protein via inactivation of eEF2 without deregulating the translation initiation factors. The major components in HLJDD, geniposide, berberine and baicalin, additively act on eEF2, and contributed to the responsible activity. HLJDD-activated eEF2 kinase (eEF2K) led to eEF2 inactivation, and activation of AMPK signaling may be responsible for the eEF2K induction. Blocked AMPK activity in HLJDD-treated HCC cells attenuated eEF2K activation as well as the inhibitory effect of the formula. In nutrient deprived HCC cells with inactivated eEF2, the inhibitory effect of HLJDD in tumor cell expansion was interfered.

CONCLUSION

Our results indicate that HLJDD has potential in blocking HCC progression with involvement of eEF2 inhibition.

Acetoside, a component of Stachys sieboldii MIQ, may be a promising antinephritic agent: effect of acteoside on crescentic-type anti-GBM nephritis in rats

Effects of acetoside (ACT) on crescentic-type anti-GBM nephritis in rats were investigated. When rats were treated with ACT from the 1st day after i.v. injection of anti-GBM serum, ACT inhibited the elevation of protein excretion into urine. In the ACT-treated rats, cholesterol and creatinine contents and antibody production against rabbit gamma-globulin in the plasmas were lower than those of the nephritic control rats. Histological observation demonstrated that this agent suppressed hypercellularity and the incidence of crescent formation, adhesion of capillary wall to Bowman's capsule and fibrinoid necrosis in the glomeruli. Furthermore, rat-IgG and C3 deposits on the GBM were significantly less in the ACT-treated group than in the control nephritic group. When the treatment was started from the 20th day after i.v. injection of anti-GBM serum, by which the disease had been established, ACT resulted in a similar effect on the nephritic rats as stated above. These results suggest that ACT may be a useful medicine against rapidly progressive glomerulonephritis, which is characterized by severe glomerular lesions with diffuse crescents.

F-actin reorganization and inactivation of rho signaling pathway involved in the inhibitory effect of Coptidis Rhizoma on hepatoma cell migration

HYPOTHESIS

Hepatocellular carcinoma (HCC) is one of the most malignant human tumors and one of the risk factors is its highly metastatic property. Coptidis Rhizoma aqueous extract (CRAE) is able to suppress the migration and invasion of HCC cells, MHCC97-L, and F-actin reorganization and Rho signaling inhibition is involved.

MAIN METHODS

CRAE was prepared and analyzed by high-performance liquid chromatography combined with mass spectrometry. The cytotoxicity and antimigration action of CRAE on MHCC97-L cells were evaluated; Immunofluorescence and immunoblotting were used to investigate the proposed mechanism of CRAE action.

KEY FINDINGS

Chemical analysis reveals that the active components in CRAE are berberine and berberine-like alkaloids. CRAE exhibits a significant inhibitory effect on MHCC97-L cell migration as indicated by wound-healing and invasion-chamber assays. No significant alteration of matrix metalloproteinases and urokinase-type plasminogen activator (uPA) expression were observed in MHCC97-L cells exposed to CRAE. Reduction of F-actin polymerization and damage to cytoskeleton network in MHCC97-L cells were observed after CRAE treatment. Furthermore, it was found that CRAE significantly downregulated the Rho/ROCK signaling pathway.

SIGNIFICANCE

These results indicate that CRAE may act as a Rho/ROCK signaling inhibitor to suppress MHCC97-L cell migration in vitro and suggested that total alkaloids in Coptidis Rhizoma may be a potential agent for suppressing liver cancer invasion.

Role of nitric oxide in rat nephrotoxic nephritis: comparison between inducible and constitutive nitric oxide synthase

Nitric oxide (NO), generated by inducible NO synthase (iNOS) in migrating macrophages, is increased in glomerulonephritis. This study investigates the effect of NO inhibition on rat nephrotoxic nephritis (NTN) to clarify the role of NO production in glomerular damage. NTN was induced in Sprague Dawley rats by an injection of an anti-glomerular basement membrane (GBM) antibody. Urinary nitrite excretion and nitrite release from kidney slices (5.47 +/- 1.19 versus 2.15 +/- 0.73 nmol/mg protein, NTN versus Control, P < 0.05) were increased in NTN on day 2. Glomerular macrophage infiltration and intercellular adhesion molecule (ICAM)-1 expression increased from day 2. iNOS expression was increased in interstitial macrophages. Glomerular endothelial cell NOS (ecNOS) expression evaluated by counting immunogold particles along GBM was suppressed (0.06 +/- 0.02 versus 0.35 +/- 0.04 gold/micron GBM, P < 0.0001). Glomerular damage developed progressively. NG-nitro-L-arginine methyl ester (L-NAME), which inhibits both iNOS and ecNOS and aminoguanidine (AG), a relatively selective inhibitor for iNOS, equally suppressed nitrite in urine and renal tissue. Glomerular ICAM-1 expression and macrophage infiltration were reduced by L-NAME, but not by AG. Expression of ecNOS was significantly increased by L-NAME (0.91 +/- 0.08, P < 0.0001 versus NTN), but slightly by AG (0.18 +/- 0.04). AG significantly and L-NAME slightly attenuated the glomerular damage at day 4. In conclusion, suppression of iNOS prevents glomerular damage in the early stage of NTN. Treatment by L-NAME reduces macrophage infiltration by suppression of ICAM-1 expression, which may be explained by an increase in ecNOS expression.

Acteoside, a component of Stachys sieboldii MIQ, may be a promising antinephritic agent (3): effect of aceteoside on expression of intercellular adhesion molecule-1 in experimental nephritic glomeruli in rats and cultured endothelial cells

It is known that adhesion molecules play a crucial role in the development of glomerulonephritis. Therefore, we investigated the effects of acteoside on the expression of intercellular adhesion molecule-1 (ICAM-1) in nephritic glomeruli, in vivo, and human umbilical vein endothelial cells (HUVECs) and rat mesangial cells, in vitro. Aceteoside treatment significantly decreased the up-regulation of ICAM-1 expression in nephritic glomeruli. Acteoside prevented the up-regulation of ICAM-1 expression mediated by inflammatory cytokines or phorbol 12-myristate 13-acetate on HUVECs and rat mesangial cells. Adhesion of neutrophils and macrophages to acteoside-treated HUVECs was suppressed to one half of that in untreated HUVECs. These data support the finding that acteoside inhibits the up-regulation of ICAM-1 in the nephritic glomeruli. Additionally, it is suggested that the antinephritic action of acteoside is due to the inhibition of intraglomerular accumulation of leukocytes through the prevention of the up-regulation of ICAM-1. This is the first paper demonstrating that the up-regulation of ICAM-1 in nephritic glomeruli is inhibited by a natural product, acteoside.

Syntheses of 3-substituted 1-methyl-6-phenylpyrimido[5,4-e]-1,2,4-triazine-5,7(1H,6H)-diones (6-phenyl analogs of toxoflavin) and their 4-oxides, and evaluation of antimicrobial activity of toxoflavins and their analogs

6-Phenyl analogs of toxoflavin (1-methyl-6-phenylpyrimido[5,4-e]-1,2,4-triazine-5,7(1H,6H)-diones ) (7a--f) and their 4-oxides (8a-f) were synthesized by nitrosative or nitrative cyclization of the aldehyde hydrazones (6a-f) of 6-(1-methylhydrazino)-3-phenyluracil (5). Both sets of compounds, 7a-f and 8a-f, gave the corresponding 1-demethyl derivatives (10a-f) upon treatment with nucleophiles such as dimethylformamide (DMF) and acetic acid under heating. The activities of toxoflavins (1a-e), toxoflavin 4-oxides (3a-e) and their 6-phenyl analogs (7a-f and 8a-f) against a variety of bacterial and fungal strains were examined. Most of the compounds showed strong inhibitory activities against gram-positive bacteria. Among the compounds, 1c, 1d, 1e, and 3c exhibited the strongest inhibitions of Micrococcus lutea (0.5 micrograms/ml minimal growth-inhibitory concentration) and Staphylococcus aureus 4R (1 microgram/ml), as well as Bacillus subtilis and Staphylococcus aureus (1-2 micrograms/ml). Most of the compounds had strong antifungal activity (2-100 micrograms/ml minimal growth-inhibitory concentration) against Candida albicans and Saccharomyces cerevisiae.

Cancer Stem Cells: The Potential Targets of Chinese Medicines and Their Active Compounds

The pivotal role of cancer stem cells (CSCs) in the initiation and progression of malignancies has been rigorously validated, and the specific methods for identifying and isolating the CSCs from the parental cancer population have also been rapidly developed in recent years. This review aims to provide an overview of recent research progress of Chinese medicines (CMs) and their active compounds in inhibiting tumor progression by targeting CSCs. A great deal of CMs and their active compounds, such as Antrodia camphorate, berberine, resveratrol, and curcumin have been shown to regress CSCs, in terms of reversing drug resistance, inducing cell death and inhibiting cell proliferation as well as metastasis. Furthermore, one of the active compounds in coptis, berbamine may inhibit tumor progression by modulating microRNAs to regulate CSCs. The underlying molecular mechanisms and related signaling pathways involved in these processes were also discussed and concluded in this paper. Overall, the use of CMs and their active compounds may be a promising therapeutic strategy to eradicate cancer by targeting CSCs. However, further studies are needed to clarify the potential of clinical application of CMs and their active compounds as complementary and alternative therapy in this field.

Chinese medicines as a resource for liver fibrosis treatment

Liver fibrosis is a condition of abnormal proliferation of connective tissue due to various types of chronic liver injury often caused by viral infection and chemicals. Effective therapies against liver fibrosis are still limited. In this review, we focus on research on Chinese medicines against liver fibrosis in three categories, namely pure compounds, composite formulae and combination treatment using single compounds with composite formulae or conventional medicines. Action mechanisms of the anti-fibrosis Chinese medicines, clinical application, herbal adverse events and quality control are also reviewed. Evidence indicates that some Chinese medicines are clinically effective on liver fibrosis. Strict quality control such as research to identify and monitor the manufacturing of Chinese medicines enables reliable pharmacological, clinical and in-depth mechanism studies. Further experiments and clinical trials should be carried out on the platforms that conform to international standards.

A Primary Cell Culture System for Human Cytotrophoblasts of Proximal Cytotrophoblast Cell Columns Enabling In Vitro Acquisition of the Extra-villous Phenotype

Cytotrophoblast (CT) differentiation into the extra-villous phenotype is a crucial process in initiating their invasion into the decidua and thereby developing the placenta. However, how CTs differentiate into extra-villous CTs (EVCTs) is not fully elucidated. To address this, a suitable culture model for CTs has been long-sought. But this has been hampered by annoying problems such as; cell aggregation, in vitro syncytialization, low plating efficiency, etc. The aim of this study is to develop a culture system in which CTs differentiate into EVCTs. CTs were isolated from the first trimester placenta using density gradient separation and immuno-depletion using anti-CD9 antibody to remove contaminating fibroblasts and EVCTs. The resultant isolated CTs were found to have the character similar to poorly differentiated CTs comprising proximal cytotrophoblastic cell columns as confirmed by immunocytochemical and flowcytometric analyses. When cultured on type 4 collagen-coated plates in culture media containing low calcium concentration, CTs neither aggregated nor syncytialized, remaining mononuclear and monolayer state. Interestingly, cultured CTs gradually upregulated integrin alpha1, CD9, and human leukocyte antigen (HLA)-G; the known markers specific for EVCTs invading into the decidua diffusely. Hence, the CT culture system provides a sophisticated experimental model in which highly purified CTs acquire the extra-villous phenotype without syncytialization.

Isomerizations akin to the Dimroth rearrangement. IV. Formation of simple s-Triazolo[1,5-c]pyrimidines via their [4,3-c] isomers

Pyrimidin-4-ylhydrazines and simple orthoesters are used in combination (1) to give N-ethoxyalkyl-idene-N'-pyrimidinylhydrazines (2) and thence s-triazolo[4,3-c]pyrimidine (3a) and its 3-, 5-, 7- or 8-alkylated derivatives (3b-s). In glacial acetic acid, these undergo rearrangement into the corresponding s-triazolo[1,5-c]pyrimidines (5) via the acylaminoalkenyltriazoles (4); in aqueous buffers, these reactions stop at the triazoles (4) except in the presence of a 7-methyl group which stimulates completion of the sequence. The ring-fission step, (3) → (4), is retarded markedly by 5- and/or 8-methyl groups but accelerated slightly by 3- and/or 7-alkyl groups; the slower ring-fission of triazolo[1,5-c]-pyrimidines (5) to the same triazoles (4) is retarded by 2-, 5- or 8-alkylation and precluded totally by a 7-methyl group. The recorded u.v. and N.M.R. spectra afford a ready means of distinguishing between the systems (3)-(5).

Purine Analogues as Amplifiers of Phleomycin. V. Thioethers of Several Heterocyclic Systems with One or Two Rings

Thioethers, appropriate for testing as amplifiers of phleomycin against in vitro cultures of Escherichia coli, are prepared via corresponding thiones in the purine, imidazo[4,5-b(and 4,5-c)]pyridine, pyrazolo[3,4-d]pyrimidine, quinazoline, benzothiazole, benzoxazole, pyrimidine, imidazole, thiazoline, 1,2,4-triazole, s-triazolo[4,3-c(and 1,5-c)]pyrimidine, oxazolo[4,5-b]pyridine, quinoline and 1,3,5-triazine series. Structures are confirmed by N.M.R. spectra. Biological activities are tabulated and discussed in terms of structure.

Butein (3,4,2',4'-tetrahydroxychalcone) ameliorates experimental anti-glomerular basement membrane antibody-associated glomerulonephritis (3)

The antinephritic effects of butein (3,4,2',4'-tetrahydroxychalcone) on original-type anti-glomerular basement membrane antibody-associated glomerulonephritis in rats were investigated. Butein was given to anti-glomerular basement membrane antibody-associated glomerulonephritic rats for 15 days after the induction of nephritis. Butein prevented proteinuria and histological alterations. The up-regulation of intercellular adhesion molecule-1 (ICAM-1) expression and increase in leukocyte function-associated antigen-1 (LFA-1) positive cells in nephritic glomeruli significantly declined with butein treatment. In the further investigation to clarify the effects of butein on ICAM-1 expression, human umbilical vein endothelial cells were treated with butein in the presence of tumor necrosis factor-alpha (TNF-alpha) or phorbol 12-myristate 13-acetate (PMA). Butein prevented the up-regulation of ICAM-1 expression mediated by TNF-alpha or PMA on human umbilical vein endothelial cells in a dose-dependent manner. When human umbilical vein endothelial cells or neutrophils were treated with butein, the adhesion of neutrophils to human umbilical vein endothelial cells was suppressed. These data suggest that the antinephritic action of butein is due to inhibition of intraglomerular accumulation of leukocytes through the prevention of the up-regulation of ICAM-1 and the inhibition of a function of adhesion molecules on the surface of leukocytes.

Effect of DP-1904, a thromboxane A2 synthase inhibitor, on passive Heymann nephritis in rats

The antinephritic effect of DP-1904 [6-(1-imidazolylmethyl)-5,6,7,8-tetrahydronaphthalene-2-carboxylic acid hydrochloride], a thromboxane A2 synthase inhibitor, was evaluated using an experimental model of membranous nephropathy, viz. accelerated passive Heymann nephritis in which the glomerular injury is mediated by immune complexes. DP-1904 markedly inhibited the develop-ent of glomerular alteration as well as the elevation of proteinuria and plasma creatinine. When the treatment was started from the 22nd day, at which time proteinuria is fully developed, DP-1904 showed beneficial effects on proteinuria and glomerular histopathological changes. DP-1904 apparently decreased the deposition of both rabbit immunoglobulin G and rat immunoglobulin G on glomerular basement membrane in nephritic rats. A single administration of DP-1904 restored the decreased renal tissue blood flow, inhibited glomerular thromboxane B2 production and increased glomerular prostaglandin E2 and 6-keto prostaglandin F1 alpha production in nephritic rats. These results suggest that DP-1904 may be an effective agent for the treatment of idiopathic membranous nephropathy and that the beneficial effect of this drug may be due to the elimination of glomerular immune deposits and to an increase in renal tissue blood flow related to amelioration of the abnormal metabolism of arachidonic acid.

Isomerizations Akin to the Dimroth Rearrangement. V. Bis-s-triazolo[4,3-α:4',3'-c]pyrimidines and Related Systems

Synthetic routes to the parent compounds and/or simple methylated derivatives of bis-s-triazolo[4,3-a:4',3'-c]pyrimidine (1), bis-s-triazolo[l,S-a:4',3'-clpyrimidine (2) and bis-s-triazolo[4,3-a:1',5-c]- pyrimidine (3) are reported. Structures are confirmed by unambiguous syntheses and/or N.M.R. spectral comparisons with known s-triazolo[4,3-a]pyrimidines and their [1,5-a], [4,3-c] and [1,5-c] isomers. Several ill-based structural assignments in the literature are corrected or confirmed. The systems (1)-(3) are unexpectedly stable towards rearrangement in acid or alkali but system (1) does undergo a thermal Dimroth-like rearrangement into system (2). Attempts to prepare an abnormal bis-s-triazolopyrimidine, e.g. (13), from pyrimidine-4,6-diyldihydrazine (12a) are shown to yield only intermediates for, or a degradation product from, the postulated system.

Peripartum type B aortic dissection in patients with Marfan syndrome who underwent aortic root replacement: a case series study

OBJECTIVE

To investigate pregnancy outcomes, especially the risk of pregnancy-related aortic dissection (AD), in patients with Marfan syndrome (MFS) after prophylactic aortic root replacement (ARR).

DESIGN

Retrospective case series study.

SETTING

Tertiary perinatal care centre at a university hospital.

POPULATION

Pregnant women fulfilling the revised Ghent nosology (2010) criteria for MFS who were managed at our institute.

METHODS

The pregnancy outcomes of all patients with MFS managed at our institute between 1982 and September 2016 were reviewed retrospectively based on medical records.

MAIN OUTCOME MEASURES

Obstetrical management and complication including the incidence of AD throughout the peripartum period.

RESULTS

Among 22 patients (28 pregnancies) who had been managed as potential MFS or related disorders, 14 (17 pregnancies) fulfilled the revised Ghent nosology (2010) criteria for MFS and were enrolled in this study. Five patients (five pregnancies) had received ARR before conception: three (60%) developed type B aortic dissection [AD(B)] during the peripartum period, compared with only one of 10 patients (12 pregnancies) without ARR (P < 0.05, Chi-square test).

CONCLUSIONS

Our study results suggest that MFS patients after prophylactic ARR are still at high risk of AD(B) during the peripartum period. Careful pre-pregnancy counselling and multidisciplinary care throughout the peripartum period are essential for the management of MFS, even after surgical repair of an ascending aortic aneurysm.

TWEETABLE ABSTRACT

MFS patients after prophylactic ARR are still at high risk of type B aortic dissection during the peripartum period.