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John S, Young LT, Lacro RV, Hoskoppal A, Ou Z, Presson AP, Johnson JT, Andrade L, Minich LL, Menon S. Extracardiac Manifestations Fail to Predict the Severity of Cardiac Phenotype in Children and Young Adults with Marfan Syndrome. Pediatr Cardiol 2024:10.1007/s00246-024-03502-z. [PMID: 38727826 DOI: 10.1007/s00246-024-03502-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 04/17/2024] [Indexed: 05/21/2024]
Abstract
We performed a secondary analysis of the Pediatric Heart Network (PHN) Marfan Trial public-use database to evaluate associations between extracardiac features and cardiac and aortic phenotypes in study participants. Aortic aneurysm phenotype was defined as aortic root Z-score ≥4.5, aortic root growth rate ≥75th percentile, aortic dissection, and aortic surgery. Severe cardiac phenotype was defined as aortic dissection, aortic Z-score ≥4.5, aortic valve surgery, at least moderate mitral regurgitation, mitral valve surgery, left ventricular dysfunction, or death. Extracardiac manifestations were characterized by specific organ system involvement and by a novel aggregate extracardiac score (AES) that was created for this study based on the original Ghent nosology. Mixed effects logistic regression analysis compared AES and systems involvement to outcomes. Of 608 participants (60% male), the median age at enrollment was 10.8 years (interquartile range: 6, 15.4). Aortic aneurysm phenotype was observed in 71% of participants and 64% had severe cardiac phenotype. On univariable analysis, skeletal (OR: 1.95, 95% CI: 1.01, 3.72; p = 0.05), skin manifestation (OR: 1.62, 95% CI: 1.13, 2.34; p = 0.01) and AES (OR: 1.17, 95% CI: 1.02, 1.34; p = 0.02) were associated with aortic aneurysm phenotype but were not significant in multivariable analysis. There was no association between extracardiac manifestations and severe cardiac phenotype. Thus, the severity of cardiac manifestations in Marfan syndrome (MFS) was independent of extracardiac phenotype and AES. Severity of extracardiac involvement did not appear to be a useful clinical marker for cardiovascular risk-stratification in this cohort of children and young adults with MFS.
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Affiliation(s)
- Sheba John
- Primary Children's Hospital, University of Utah School of Medicine, Eccles Primary Children's Outpatient Services Building, 81 North Mario Capecchi Drive, Salt Lake City, UT, 84113, USA.
| | - Luciana T Young
- Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Ronald V Lacro
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Arvind Hoskoppal
- Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Zhining Ou
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Angela P Presson
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Joyce T Johnson
- Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | | | - L LuAnn Minich
- Primary Children's Hospital, University of Utah School of Medicine, Eccles Primary Children's Outpatient Services Building, 81 North Mario Capecchi Drive, Salt Lake City, UT, 84113, USA
| | - Shaji Menon
- UPMC Heart and Vascular Institute, Chambersburg, PA, USA
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John S, Young LT, Lacro RV, Hoskoppal A, Ou Z, Presson A, Johnson JT, Andrade L, Minich LL, Menon S. Extracardiac Manifestations Fail to Predict the Severity of Cardiac Phenotype in Children and Young Adults with Marfan Syndrome. RESEARCH SQUARE 2024:rs.3.rs-3994693. [PMID: 38496659 PMCID: PMC10942553 DOI: 10.21203/rs.3.rs-3994693/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
We performed a secondary analysis of the Pediatric Heart Network Marfan Trial public-use database to evaluate associations between extracardiac features and cardiac and aortic phenotypes in study participants. Aortic aneurysm phenotype was defined as aortic root Z-score ≥ 4.5, aortic root growth rate ≥ 75th percentile, aortic dissection, and aortic surgery. Severe cardiac phenotype was defined as aortic dissection, aortic Z-score ≥4.5, aortic valve surgery, at least moderate mitral regurgitation, mitral valve surgery, left ventricular dysfunction, or death. Extracardiac manifestations were characterized by specific organ system involvement and by a novel aggregate extracardiac score that was created for this study based on the original Ghent nosology. Logistic regression analysis compared aggregate extracardiac score and systems involvement to outcomes. Of 608 participants (60% male), the median age at enrollment was 10.8 years (interquartile range: 6, 15.4). Aortic aneurysm phenotype was observed in 71% of participants and 64% had severe cardiac phenotype. On univariate analysis, skeletal (OR: 1.95, 95% CI: 1.01, 3.72; p = 0.05), skin manifestation (OR: 1.62, 95% CI: 1.13, 2.34; p = 0.01) and aggregate extracardiac score (OR: 1.17, 95% CI: 1.02, 1.34; p = 0.02) were associated with aortic aneurysm phenotype but were not significant in multivariate analysis. There was no association between extracardiac manifestations and severe cardiac phenotype. Thus, the severity of cardiac manifestations in Marfan syndrome was independent of extracardiac phenotype and aggregate extracardiac score. Severity of extracardiac involvement did not appear to be a useful clinical marker for cardiovascular risk-stratification in this cohort of children and young adults with Marfan syndrome.
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Pediatric Heart Network Trial of Losartan vs. Atenolol in Children and Young Adults with Marfan Syndrome: Impact on Prescription Practices. Pediatr Cardiol 2023; 44:618-623. [PMID: 35902413 DOI: 10.1007/s00246-022-02976-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 07/11/2022] [Indexed: 10/16/2022]
Abstract
The Pediatric Heart Network (PHN) trial showed similar efficacy of β-blockers (BB) and angiotensin receptor blockers (ARB) for aortic root dilation in Marfan syndrome, but the impact on prescription practices is unknown. We hypothesized BB and ARB prescriptions would increase after the trial results were published (2014). Prescription data (2007-2016) were obtained from outpatient encounters (IBM Marketscan) for Marfan syndrome patients (6 months-25 years old). Excluding 2014 as a washout period, we analyzed two intervals: 2007-2013 and 2015-2016. Medication categories included BB, ARB, angiotensin converting enzyme inhibitors (ACEI), combination (BB/ARB and/or BB/ACEI), and no drug. Interrupted time-series analysis assessed immediate level change after publication and change in slope for the trend pre- and post-publication. Odds ratios (OR) and 95% confidence intervals from logistic regressions and generalized estimating equation methods accounted for correlation of prescriptions within patients. In 1499 patients (age 14.1 ± 6.1 years, 59% female) seen 2007-2013, BB trended lower [OR 0.91 (0.89, 0.93), p < 0.001] and ARB trended higher [OR 1.12 (1.07, 1.18), p < 0.001], while combination, ACEI, and no drug remained stable. This trend persisted, but was not significant, for BB [OR 0.54 (0.27, 1.08), p = 0.37] and ARB [OR 1.91 (0.55, 6.69), p = 0.31] in 2015-2016. Combination, ACEI, and no drug remained similar. In short term follow-up, changes in prescription practices following publication of the PHN trial were not statistically significant. This may be due to a change seen prior to publication with early adoption of ARBs that was maintained after confirmation of their effectiveness.
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Meester JAN, Peeters S, Van Den Heuvel L, Vandeweyer G, Fransen E, Cappella E, Dietz HC, Forbus G, Gelb BD, Goldmuntz E, Hoskoppal A, Landstrom AP, Lee T, Mital S, Morris S, Olson AK, Renard M, Roden DM, Singh MN, Selamet Tierney ES, Tretter JT, Van Driest SL, Willing M, Verstraeten A, Van Laer L, Lacro RV, Loeys BL. Molecular characterization and investigation of the role of genetic variation in phenotypic variability and response to treatment in a large pediatric Marfan syndrome cohort. Genet Med 2022; 24:1045-1053. [PMID: 35058154 PMCID: PMC9680912 DOI: 10.1016/j.gim.2021.12.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/17/2021] [Accepted: 12/20/2021] [Indexed: 12/17/2022] Open
Abstract
PURPOSE In a large cohort of 373 pediatric patients with Marfan syndrome (MFS) with a severe cardiovascular phenotype, we explored the proportion of patients with MFS with a pathogenic FBN1 variant and analyzed whether the type/location of FBN1 variants was associated with specific clinical characteristics and response to treatment. Patients were recruited on the basis of the following criteria: aortic root z-score > 3, age 6 months to 25 years, no prior or planned surgery, and aortic root diameter < 5 cm. METHODS Targeted resequencing and deletion/duplication testing of FBN1 and related genes were performed. RESULTS We identified (likely) pathogenic FBN1 variants in 91% of patients. Ectopia lentis was more frequent in patients with dominant-negative (DN) variants (61%) than in those with haploinsufficient variants (27%). For DN FBN1 variants, the prevalence of ectopia lentis was highest in the N-terminal region (84%) and lowest in the C-terminal region (17%). The association with a more severe cardiovascular phenotype was not restricted to DN variants in the neonatal FBN1 region (exon 25-33) but was also seen in the variants in exons 26 to 49. No difference in the therapeutic response was detected between genotypes. CONCLUSION Important novel genotype-phenotype associations involving both cardiovascular and extra-cardiovascular manifestations were identified, and existing ones were confirmed. These findings have implications for prognostic counseling of families with MFS.
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Affiliation(s)
- Josephina A N Meester
- Center of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Silke Peeters
- Center of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Lotte Van Den Heuvel
- Center of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Geert Vandeweyer
- Center of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Erik Fransen
- Center of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium; StatUa Center for Statistics, University of Antwerp, Antwerp, Belgium
| | | | - Harry C Dietz
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins School of Medicine, The Johns Hopkins University, Baltimore, MD; Howard Hughes Medical Institute, Baltimore, MD
| | - Geoffrey Forbus
- Department of Pediatrics, Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, SC
| | - Bruce D Gelb
- Departments of Pediatrics and Genetics & Genomic Sciences, Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Elizabeth Goldmuntz
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Arvind Hoskoppal
- Departments of Pediatrics and Internal Medicine, University of Utah and Intermountain Healthcare, Salt Lake City, UT
| | - Andrew P Landstrom
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Teresa Lee
- Children's Hospital of New York, New York City, NY
| | - Seema Mital
- Department of Pediatrics, Division of Cardiology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Shaine Morris
- Division of Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Aaron K Olson
- Department of Pediatrics, Seattle Children's Hospital, Seattle, WA
| | - Marjolijn Renard
- Center for Medical Genetics Ghent, Department of Biomolecular Medicine, Ghent University, Ghent, Belgium
| | - Dan M Roden
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Michael N Singh
- Department of Cardiology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA
| | | | - Justin T Tretter
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Sara L Van Driest
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Marcia Willing
- Department of Pediatrics, Division of Genetics and Genomic Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Aline Verstraeten
- Center of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Lut Van Laer
- Center of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Ronald V Lacro
- Department of Cardiology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Bart L Loeys
- Center of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium; Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands.
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Racial and ethnic differences in response to treatment for Marfan syndrome. Cardiol Young 2021; 31:1991-1998. [PMID: 33845931 DOI: 10.1017/s104795112100130x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To determine whether racial/ethnic differences exist for the treatment of Marfan syndrome aortopathy. The 2014 Pediatric Heart Network randomised trial of losartan versus atenolol in Marfan syndrome paediatric and young adult patients showed no treatment differences in the rate of aortic root growth over 3 years; however, they did not examine racial/ethnic differences, and recent data suggest that angiotensin receptor blockers may have different pharmacologic effects in different racial/ethnic populations. METHODS We performed a secondary analysis of public-use data from the Pediatric Heart Network randomised trial comparing the differences by race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic patients) amongst the treatment groups for the primary outcome of rate of aortic root enlargement by z score and secondary outcome of rate of change of absolute diameter of aortic root, z score and absolute diameter of ascending aorta, and blood pressure changes. RESULTS For aortic root enlargement by z score amongst non-Hispanic White patients, patients on losartan exhibited an annual z score change of -0.090 ± 0.016, compared to -0.146 ± 0.015 for those on atenolol (p = 0.01), favouring atenolol. For Hispanic and non-Hispanic Black patients, there was no difference in primary or secondary outcomes between treatment groups. CONCLUSION Non-Hispanic White patients had a small, but statistically significantly greater decrease in aortic root z score favouring atenolol over losartan. There were no significant differences amongst Hispanic or non-Hispanic Black patients, which may be due to relatively small size numbers. These findings may have important implications for medication selection by race/ethnicity in Marfan syndrome patients, which has not previously been evaluated in studies.
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Abstract
Loeys-Dietz syndrome is an autosomal dominant aortic aneurysm syndrome characterized by multisystemic involvement. The most typical clinical triad includes hypertelorism, bifid uvula or cleft palate and aortic aneurysm with tortuosity. Natural history is significant for aortic dissection at smaller aortic diameter and arterial aneurysms throughout the arterial tree. The genetic cause is heterogeneous and includes mutations in genes encoding for components of the transforming growth factor beta (TGFβ) signalling pathway: TGFBR1, TGFBR2, SMAD2, SMAD3, TGFB2 and TGFB3. Despite the loss of function nature of these mutations, the patient-derived aortic tissues show evidence of increased (rather than decreased) TGFβ signalling. These insights offer new options for therapeutic interventions.
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Harris SL, Lindsay ME. Role of Clinical Genetic Testing in the Management of Aortopathies. Curr Cardiol Rep 2021; 23:10. [PMID: 33475873 DOI: 10.1007/s11886-020-01435-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2020] [Indexed: 01/28/2023]
Abstract
PURPOSE OF REVIEW Thoracic aortic aneurysms (TAA) have a strong heritable basis, and identification of a genetic etiology has important implications for patients with TAA and their relatives. This review provides an overview of Mendelian causes of TAA, discusses important considerations for genetic testing, and summarizes the impact a genetic diagnosis may have on a patient's medical care. RECENT FINDINGS Thoracic aortic disease may be non-syndromic or seen as part of a genetic syndrome, such as Marfan syndrome, Loeys-Dietz syndrome, or vascular Ehlers-Danlos syndrome. Expanded access to genetic testing has revealed the wide and overlapping phenotypic spectrum of these conditions, highlighting the need for genetic testing to establish an accurate diagnosis. Important aspects of genetic evaluation include thorough phenotyping through family history and physical examination, selection of an appropriate genetic test driven by the patient's phenotype, and careful interpretation of genetic test results. Improved understanding of the natural history of these conditions has led to tailored management recommendations, including gene-based recommendations for prophylactic surgical repair. Identification of a genetic etiology allows for careful monitoring of disease progression, informs the timing of prophylactic surgical repair, and facilitates the identification of other at-risk relatives through cascade genetic testing.
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Affiliation(s)
- Stephanie L Harris
- Cardiology Division and Cardiovascular Genetics Program, Massachusetts General Hospital, Boston, MA, USA
| | - Mark E Lindsay
- Cardiology Division and Cardiovascular Genetics Program, Massachusetts General Hospital, Boston, MA, USA.
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Perelshtein Brezinov O, Shinfeld A, Arad M, Cahan T, Simchen MJ, Kuperstein R. The Late Effects of Pregnancy on Aortic Dimensions in Patients with Marfan Syndrome. Cardiology 2020; 146:98-105. [PMID: 33238262 DOI: 10.1159/000511127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 08/23/2020] [Indexed: 11/19/2022]
Abstract
While the immediate effects of pregnancy on aortic dimension in patients with Marfan syndrome (MFS) have been evaluated, the late effects of subsequent pregnancies in these patients are less known. For this purpose, we evaluated 2 groups of women with MFS who were under specialized care in our institution. Group A included 23 women with MFS who experienced 55 pregnancies; group B included 12 nulliparous MFS patients. Patients in group A were similar in age (36.13 ± 5.6 years vs. 34.25 ± 6.54 years, p = 0.41) and follow-up time (group A 6.05 ± 3.56 years and group B 4.92 ± 3.37 years, p = 0.37). Baseline aortic root diameters as well as the aortic root diameters at follow-up visits were similar between groups (35.60 ± 4.42 vs. 35.08 ± 3.82 mm, p = 0.73, and 37.57 ± 4.66 vs. 37.33 ± 4.83 mm, p = 0.89, respectively). The aortic root diameter increased by 0.5 (0, 2) mm in group A and 1 (0, 4.5) mm in group B (p = 0.54). The rate of aortic dilation per year of follow-up was similar between the groups (0.34 ± 0.52 mm/year in group A vs. 0.55 ± 0.75 mm/year in group B [p = 0.52]). Chronic medical treatment was similar in both groups. Patients in both groups were treated similarly with β-blockers, angiotensin-converting enzyme inhibitors, and angiotensin II receptor blockers. In summary, subsequent pregnancies in patients with MFS were not associated with an increase in the rate of aortic root dilation in these patients.
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Affiliation(s)
- Olga Perelshtein Brezinov
- Department of Cardiology, Assuta Ashdod Medical Center, Ashdod, Israel.,The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Amihay Shinfeld
- Department of Cardiac Surgery, Chaim Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael Arad
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Leviev Heart Center, Chaim Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel
| | - Tal Cahan
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel
| | - Michal J Simchen
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel
| | - Rafael Kuperstein
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, .,Leviev Heart Center, Chaim Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel,
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Thomas CD, Johnson JA. Pharmacogenetic factors affecting β-blocker metabolism and response. Expert Opin Drug Metab Toxicol 2020; 16:953-964. [PMID: 32726152 DOI: 10.1080/17425255.2020.1803279] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION β-blockers are among the most widely prescribed of all drugs, used for treatment of a large number of cardiovascular diseases. Herein we evaluate literature pertaining to pharmacogenetics of β-blocker therapy, provide insight into the robustness of the genetic associations, and determine the appropriateness for translating these genetic associations into clinical practice. AREAS COVERED A literature search was conducted using PubMed to collate evidence on associations between CYP2D6, ADRB1, ADRB2, and GRK5 genetic variation and drug-response outcomes in the presence of β-blocker exposure. Pharmacokinetic, pharmacodynamic, and clinical outcomes studies were included if genotype data and β-blocker exposure were documented. EXPERT OPINION Substantial data suggest that specific ADRB1 and GRK5 genotypes are associated with improved β-blocker efficacy and have potential for use to guide therapy decisions in the clinical setting. While the data do not justify ordering a CYP2D6 pharmacogenetic test, if CYP2D6 genotype is available in the electronic health record, there may be clinical utility for understanding dosing of β-blockers.
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Affiliation(s)
- Cameron D Thomas
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida , Gainesville, FL, USA
| | - Julie A Johnson
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida , Gainesville, FL, USA
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Lidal IB, Bathen T, Johansen H, Velvin G. A scoping review presenting a wide variety of research on paediatric and adolescent patients with Marfan syndrome. Acta Paediatr 2020; 109:1758-1771. [PMID: 31977115 PMCID: PMC7496935 DOI: 10.1111/apa.15186] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 01/13/2020] [Accepted: 01/20/2020] [Indexed: 12/24/2022]
Abstract
Aim The present study aimed to map and summarise the research on children, aged 0‐18 years, with Marfan syndrome, identify research gaps and point to research agendas. Methods A scoping review was systematically performed by searching multiple databases from January 1996 to April 2019. Primary studies presenting results on at least six individuals aged 0‐18 years with Marfan syndrome, diagnosed according to the Ghent nosology, were selected. Results From 2341 de‐duplicated records, 92 papers were included, mapped and described. Their topics were diagnostics (12%), cardiovascular matters (50%), skeletal matters (22%), ocular matters (9%), other medical aspects (5%) and psychosocial perspectives (2%). Most studies were from Europe and North America and published between 1999 and 2019 in subject‐specific or paediatric journals, while a few were published in genetics journals. All studies had quantitative designs, and very few were multicentre studies. Each study had six to 608 subjects for a total of approximately 5809. Conclusion A wide range of research topics on adolescent and paediatric Marfan syndrome was found, but qualitative studies and a focus on psychosocial matters were lacking. Future investigations addressing noncardiovascular consequences and patient experiences are needed, as well as studies reaffirming or replicating existing intervention study results.
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Affiliation(s)
- Ingeborg Beate Lidal
- TRS Resource Centre for Rare Disorders Sunnaas Rehabilitation Hospital Oslo Norway
| | - Trine Bathen
- TRS Resource Centre for Rare Disorders Sunnaas Rehabilitation Hospital Oslo Norway
| | - Heidi Johansen
- TRS Resource Centre for Rare Disorders Sunnaas Rehabilitation Hospital Oslo Norway
| | - Gry Velvin
- TRS Resource Centre for Rare Disorders Sunnaas Rehabilitation Hospital Oslo Norway
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Hamstra MS, Pemberton VL, Dagincourt N, Hollenbeck-Pringle D, Trachtenberg FL, Cnota JF, Atz AM, Cappella E, De Nobele S, Grima J, King M, Korsin R, Lambert LM, MacNeal MK, Markham LW, MacCarrick G, Sylvester DM, Walter P, Xu M, Lacro RV. Recruitment, retention, and adherence in a clinical trial: The Pediatric Heart Network's Marfan Trial experience. Clin Trials 2020; 17:684-695. [PMID: 32820647 DOI: 10.1177/1740774520945988] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND/AIMS The Pediatric Heart Network Marfan Trial was a randomized trial comparing atenolol versus losartan on aortic root dilation in 608 children and young adults with Marfan syndrome. Barriers to enrollment included a limited pool of eligible participants, restrictive entry criteria, and a diverse age range that required pediatric and adult expertise. Retention was complicated by a 3-year commitment to a complex study and medication regimen. The Network partnered with the Marfan Foundation, bridging the community with the research. The aims of this study are to report protocol and medication adherence and associated predictive factors, and to describe recruitment and retention strategies. METHODS Recruitment, retention, and adherence to protocol activities related to the primary outcome were measured. Retention was measured by percentage of enrolled participants with 3-year outcome data. Protocol adherence was calculated by completion rates of study visits, ambulatory electrocardiography (Holter monitoring), and quarterly calls. Medication adherence was assessed by the number of tablets or the amount of liquid in bottles returned. Centers were ranked according to adherence (high, medium, and low tertiles). Recruitment, retention, and adherence questionnaires were completed by sites. Descriptive statistics summarized recruitment, retention, and adherence, as well as questionnaire results. Regression modeling assessed predictors of adherence. RESULTS Completion rates for visits, Holter monitors, and quarterly calls were 99%, 94%, and 96%, respectively. Primary outcome data at 3 years were obtained for 88% of participants. The mean percentage of medication taken was estimated at 89%. Site and age were associated with all measures of adherence. Young adult and African American participants had lower levels of adherence. Higher adherence sites employed more strategies; had more staffing resources, less key staff turnover, and more collaboration with referring providers; utilized the Foundation's resources; and used a greater number of strategies to recruit, retain, and promote protocol and medication adherence. CONCLUSION Overall adherence was excellent for this trial conducted within a National Institutes of Health-funded clinical trial network. Strategies specifically targeted to young adults and African Americans may have been beneficial. Many strategies employed by higher adherence sites are ones that any site could easily use, such as greeting families at non-study hospital visits, asking for family feedback, providing calendars for tracking schedules, and recommending apps for medication reminders. Additional key learnings include adherence differences by age, race, and site, the value of collaborative learning, and the importance of partnerships with patient advocacy groups. These lessons could shape recruitment, retention, and adherence to improve the quality of future complex trials involving rare conditions.
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Affiliation(s)
- Michelle S Hamstra
- Heart Institute Administration, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | | | | | | | - James F Cnota
- Heart Institute Administration, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Andrew M Atz
- Medical University of South Carolina, Charleston, SC, USA
| | | | | | | | - Martha King
- Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | | | - Linda M Lambert
- Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
| | | | - Larry W Markham
- The Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | | | | | - Patricia Walter
- Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Mingfen Xu
- Duke University School of Medicine, Durham, NC, USA
| | - Ronald V Lacro
- Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
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Van Driest SL, Sleeper LA, Gelb BD, Morris SA, Dietz HC, Forbus GA, Goldmuntz E, Hoskoppal A, James J, Lee TM, Levine JC, Li JS, Loeys BL, Markham LW, Meester JAN, Mital S, Mosley JD, Olson AK, Renard M, Shaffer CM, Sharkey A, Young L, Lacro RV, Roden DM. Variants in ADRB1 and CYP2C9: Association with Response to Atenolol and Losartan in Marfan Syndrome. J Pediatr 2020; 222:213-220.e5. [PMID: 32586526 PMCID: PMC7323908 DOI: 10.1016/j.jpeds.2020.03.064] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 03/03/2020] [Accepted: 03/31/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To test whether variants in ADRB1 and CYP2C9 genes identify subgroups of individuals with differential response to treatment for Marfan syndrome through analysis of data from a large, randomized trial. STUDY DESIGN In a subset of 250 white, non-Hispanic participants with Marfan syndrome in a prior randomized trial of atenolol vs losartan, the common variants rs1801252 and rs1801253 in ADRB1 and rs1799853 and rs1057910 in CYP2C9 were analyzed. The primary outcome was baseline-adjusted annual rate of change in the maximum aortic root diameter z-score over 3 years, assessed using mixed effects models. RESULTS Among 122 atenolol-assigned participants, the 70 with rs1801253 CC genotype had greater rate of improvement in aortic root z-score compared with 52 participants with CG or GG genotypes (Time × Genotype interaction P = .005, mean annual z-score change ± SE -0.20 ± 0.03 vs -0.09 ± 0.03). Among participants with the CC genotype in both treatment arms, those assigned to atenolol had greater rate of improvement compared with the 71 of the 121 assigned to losartan (interaction P = .002; -0.20 ± 0.02 vs -0.07 ± 0.02; P < .001). There were no differences in atenolol response by rs1801252 genotype or in losartan response by CYP2C9 metabolizer status. CONCLUSIONS In this exploratory study, ADRB1-rs1801253 was associated with atenolol response in children and young adults with Marfan syndrome. If these findings are confirmed in future studies, ADRB1 genotyping has the potential to guide therapy by identifying those who are likely to have greater therapeutic response to atenolol than losartan.
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Affiliation(s)
- Sara L. Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA,Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lynn A. Sleeper
- Department of Cardiology, Boston Children’s Hospital; and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Bruce D. Gelb
- Mindich Child Health and Development Institute, Departments of Pediatrics and Genetics & Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shaine A. Morris
- Division of Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX, USA
| | - Harry C. Dietz
- Institute of Genetic Medicine, Johns Hopkins University School of Medicine and Howard Hughes Medical Institute, Baltimore, MD, USA
| | - Geoffrey A. Forbus
- Department of Pediatrics, Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Elizabeth Goldmuntz
- Division of Cardiology, Children’s Hospital of Philadelphia, Department of Pediatrics University of Pennsylvania Perlman School of Medicine, Philadelphia, PA, USA
| | - Arvind Hoskoppal
- Departments of Pediatrics and Internal Medicine, University of Utah and Intermountain Healthcare, Salt Lake City, UT, USA
| | - Jeanne James
- Department of Pediatrics, Section of Cardiology, Medical College of Wisconsin and Children’s Hospital of Wisconsin, Milwaukee, WI, USA
| | - Teresa M. Lee
- Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Jami C. Levine
- Department of Cardiology, Boston Children’s Hospital; and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Jennifer S. Li
- Department of Pediatrics, Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Bart L. Loeys
- Center of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Larry W. Markham
- Department of Pediatrics, Division of Pediatric Cardiology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Josephina A. N. Meester
- Center of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Seema Mital
- Department of Pediatrics, Division of Cardiology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Jonathan D. Mosley
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Aaron K. Olson
- Department of Pediatrics, Seattle Children’s Hospital, Seattle, WA, USA
| | - Marjolijn Renard
- Center for Medical Genetics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Christian M. Shaffer
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Angela Sharkey
- Department of Pediatrics, Washington University, St. Louis, MO, USA
| | - Luciana Young
- Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital, Chicago, IL, USA
| | - Ronald V. Lacro
- Department of Cardiology, Boston Children’s Hospital; and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Dan M. Roden
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA,Departments of Pharmacology and Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
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13
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Emrich F, Penov K, Arakawa M, Dhablania N, Burdon G, Pedroza AJ, Koyano TK, Kim YM, Raaz U, Connolly AJ, Iosef C, Fischbein MP. Anatomically specific reactive oxygen species production participates in Marfan syndrome aneurysm formation. J Cell Mol Med 2019; 23:7000-7009. [PMID: 31402541 PMCID: PMC6787454 DOI: 10.1111/jcmm.14587] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 07/15/2019] [Accepted: 07/17/2019] [Indexed: 12/20/2022] Open
Abstract
Marfan syndrome (MFS) is a connective tissue disorder that results in aortic root aneurysm formation. Reactive oxygen species (ROS) seem to play a role in aortic wall remodelling in MFS, although the mechanism remains unknown. MFS Fbn1C1039G/+ mouse root/ascending (AS) and descending (DES) aortic samples were examined using DHE staining, lucigenin‐enhanced chemiluminescence (LGCL), Verhoeff's elastin‐Van Gieson staining (elastin breakdown) and in situ zymography for protease activity. Fbn1C1039G/+ AS‐ or DES‐derived smooth muscle cells (SMC) were treated with anti‐TGF‐β antibody, angiotensin II (AngII), anti‐TGF‐β antibody + AngII, or isotype control. ROS were detected during early aneurysm formation in the Fbn1C1039G/+ AS aorta, but absent in normal‐sized DES aorta. Fbn1C1039G/+ mice treated with the unspecific NADPH oxidase inhibitor, apocynin reduced AS aneurysm formation, with attenuated elastin fragmentation. In situ zymography revealed apocynin treatment decreased protease activity. In vitro SMC studies showed Fbn1C1039G/+‐derived AS SMC had increased NADPH activity compared to DES‐derived SMC. AS SMC NADPH activity increased with AngII treatment and appeared TGF‐β dependent. In conclusion, ROS play a role in MFS aneurysm development and correspond anatomically with aneurysmal aortic segments. ROS inhibition via apocynin treatment attenuates MFS aneurysm progression. AngII enhances ROS production in MFS AS SMCs and is likely TGF‐β dependent.
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Affiliation(s)
- Fabian Emrich
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California.,Department of Cardiothoracic Surgery, Leipzig University Heart Center, Leipzig, Germany
| | - Kiril Penov
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California.,Department of Cardiothoracic Surgery, Leipzig University Heart Center, Leipzig, Germany
| | - Mamoru Arakawa
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California.,Department of Cardiovascular Surgery, Jichi Medical University, Saitama, Japan
| | - Nathan Dhablania
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Grayson Burdon
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Albert J Pedroza
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Tiffany K Koyano
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Young M Kim
- Department of Cardiovascular Medicine, Stanford University, Stanford, California
| | - Uwe Raaz
- Department of Cardiovascular Medicine, Stanford University, Stanford, California
| | | | - Cristiana Iosef
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
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14
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Hofmann Bowman MA, Eagle KA, Milewicz DM. Update on Clinical Trials of Losartan With and Without β-Blockers to Block Aneurysm Growth in Patients With Marfan Syndrome. JAMA Cardiol 2019; 4:702-707. [DOI: 10.1001/jamacardio.2019.1176] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
| | - Kim A. Eagle
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor
| | - Dianna M. Milewicz
- McGovern Medical School, University of Texas Health Science Center at Houston
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15
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Thomas M, Fronk Z, Gross A, Willmore D, Arango A, Higham C, Nguyen V, Lim H, Kale V, McMillan G, Seegmiller RE. Losartan attenuates progression of osteoarthritis in the synovial temporomandibular and knee joints of a chondrodysplasia mouse model through inhibition of TGF-β1 signaling pathway. Osteoarthritis Cartilage 2019; 27:676-686. [PMID: 30610922 DOI: 10.1016/j.joca.2018.12.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 12/10/2018] [Accepted: 12/24/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Transforming growth factor beta 1 (TGF-β1) is implicated in osteoarthritis (OA). The purpose of this study was to explore the ability of Losartan to inhibit the inflammatory signaling pathway of TGF-β1 observed during osteoarthritic progression in the temporomandibular joint (TMJ) and knee joint using a genetic mouse model. METHODS A murine OA model displaying the heterozygous chondrodysplasia gene (cho/+), a col11a1 mutation, was used to test this hypothesis. Following a 7-month treatment period with Losartan, the synovial joints were analyzed for histopathological improvement comparing two experimental groups. Tissues were fixed in paraformaldehyde, processed to paraffin section, and stained with Safranin O and Fast Green to visualize proteoglycans and collagen proteins in cartilage. Using the Modified Mankin scoring system, the degree of staining and OA progression were evaluated. RESULTS Results show heterozygous animals receiving Losartan having diminished degeneration of TMJ condylar and knee joint articular cartilage. This was confirmed in the TMJ and knee by a statistically significant decrease in the Mankin histopathology score. Decreased expression of HtrA1, a key regulator to the TGF-β1 signaling pathway, was demonstrated in vitro as well as in vivo, via Losartan inhibition. CONCLUSION Using a genetic mouse model of OA, this study demonstrated the utility of Losartan to improve treatment of human OA in the TMJ and knee joint through inhibition of the TGF-β1 signaling cascade. We further demonstrated inhibition of HtrA1, the lowering of Mankin scores to wild type control levels, and the limiting of OA progressive damage with treatment of Losartan.
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Affiliation(s)
- M Thomas
- Roseman University of Health Sciences, College of Dental Medicine, South Jordan, UT 84095, USA
| | - Z Fronk
- Department of Physiology and Developmental Biology, Brigham Young University, Provo, UT 84602, USA
| | - A Gross
- Roseman University of Health Sciences, College of Dental Medicine, South Jordan, UT 84095, USA.
| | - D Willmore
- Department of Physiology and Developmental Biology, Brigham Young University, Provo, UT 84602, USA
| | - A Arango
- Roseman University of Health Sciences, College of Dental Medicine, South Jordan, UT 84095, USA
| | - C Higham
- Roseman University of Health Sciences, College of Dental Medicine, South Jordan, UT 84095, USA
| | - V Nguyen
- Roseman University of Health Sciences, College of Dental Medicine, South Jordan, UT 84095, USA
| | - H Lim
- Roseman University of Health Sciences, College of Dental Medicine, South Jordan, UT 84095, USA
| | - V Kale
- Roseman University of Health Sciences, College of Pharmacy, South Jordan, UT 84095, USA
| | - G McMillan
- Roseman University of Health Sciences, College of Dental Medicine, South Jordan, UT 84095, USA
| | - R E Seegmiller
- Roseman University of Health Sciences, College of Dental Medicine, South Jordan, UT 84095, USA; Department of Physiology and Developmental Biology, Brigham Young University, Provo, UT 84602, USA
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16
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Handisides JC, Hollenbeck-Pringle D, Uzark K, Trachtenberg FL, Pemberton VL, Atz TW, Bradley TJ, Cappella E, De Nobele S, Groh GKT, Hamstra MS, Korsin R, Levine JC, Lindauer B, Liou A, Mac Neal MK, Markham LW, Morrison T, Mussatto KA, Olson AK, Pierpont MEM, Pyeritz RE, Radojewski EA, Roman MJ, Xu M, Lacro RV. Health-Related Quality of Life in Children and Young Adults with Marfan Syndrome. J Pediatr 2019; 204:250-255.e1. [PMID: 30270167 PMCID: PMC6800200 DOI: 10.1016/j.jpeds.2018.08.061] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 07/25/2018] [Accepted: 08/21/2018] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To assess health-related quality of life (HRQOL) in a large multicenter cohort of children and young adults with Marfan syndrome participating in the Pediatric Heart Network Marfan Trial. STUDY DESIGN The Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scales were administered to 321 subjects with Marfan syndrome (5-25 years). PedsQL scores were compared with healthy population norms. The impact of treatment arm (atenolol vs losartan), severity of clinical features, and number of patient-reported symptoms on HRQOL was assessed by general linear models. RESULTS Mean PedsQL scores in children (5-18 years) with Marfan syndrome were lower than healthy population norms for physical (P ≤ .003) and psychosocial (P < .001) domains; mean psychosocial scores for adults (19-25 years) were greater than healthy norms (P < .001). HRQOL across multiple domains correlated inversely with frequency of patient-reported symptoms (r = 0.30-0.38, P < .0001). Those <18 years of age with neurodevelopmental disorders (mainly learning disability, attention-deficit/hyperactivity disorder) had lower mean PedsQL scores (5.5-7.4 lower, P < .04). A multivariable model found age, sex, patient-reported symptoms, and neurodevelopmental disorder to be independent predictors of HRQOL. There were no differences in HRQOL scores by treatment arm, aortic root z score, number of skeletal features, or presence of ectopia lentis. CONCLUSIONS Children and adolescents with Marfan syndrome were at high risk for impaired HRQOL. Patient-reported symptoms and neurodevelopmental disorder, but not treatment arm or severity of Marfan syndrome-related physical findings, were associated with lower HRQOL.
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Affiliation(s)
| | | | - Karen Uzark
- C. S. Mott Children’s Hospital, University of Michigan, Ann Arbor, MI
| | | | | | - Teresa W. Atz
- Medical University of South Carolina, Charleston, SC
| | - Timothy J. Bradley
- The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | | | | | | | | | - Jami C. Levine
- Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Bergen Lindauer
- Primary Children’s Hospital, University of Utah, Salt Lake City, UT
| | | | | | - Larry W. Markham
- The Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN
| | | | | | | | | | - Reed E. Pyeritz
- The Perlman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | | | - Mingfen Xu
- Duke University School of Medicine, Durham, NC
| | - Ronald V. Lacro
- Boston Children’s Hospital, Harvard Medical School, Boston, MA
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17
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Mah DY, Sleeper LA, Crosson JE, Czosek RJ, Love BA, McCrindle BW, Muiño-Mosquera L, Olson AK, Pilcher TA, Tierney ESS, Shah MJ, Wechsler SB, Young LT, Lacro RV. Frequency of Ventricular Arrhythmias and Other Rhythm Abnormalities in Children and Young Adults With the Marfan Syndrome. Am J Cardiol 2018; 122:1429-1436. [PMID: 30115424 DOI: 10.1016/j.amjcard.2018.07.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 07/03/2018] [Accepted: 07/10/2018] [Indexed: 01/14/2023]
Abstract
Patients with the Marfan syndrome (MFS) are at risk for sudden death. The contribution of arrhythmias is unclear. This study examines the prevalence of arrhythmias in children with the MFS and their relation to clinical and/or echocardiographic factors. Data from the Pediatric Heart Network randomized trial of atenolol versus losartan in MFS were analyzed (6 months to 25 years old, aortic root diameter z-score > 3.0, no previous aortic surgery and/or dissection). Baseline 24-hour ambulatory electrocardiographic monitoring was performed. Significant ventricular ectopy (VE) and supraventricular ectopy (SVE) were defined as ≥10 VE or SVE/hour, or the presence of high-grade ectopy. Three-year composite clinical outcome of death, aortic dissection, or aortic root replacement was analyzed. There were 274 analyzable monitors on unique patients from 11 centers. Twenty subjects (7%) had significant VE, 13 (5%) significant SVE; of these, 2 (1%) had both. None had sustained ventricular or supraventricular tachycardia. VE was independently associated with increasing number of major Ghent criteria (odds ratio [OR] = 2.13/each additional criterion, p = 0.03) and greater left ventricular end-diastolic dimension z-score (OR = 1.47/each 1 unit increase in z-score, p = 0.01). SVE was independently associated with greater aortic sinotubular junction diameter z-score (OR = 1.56/each 1 unit increase in z-score, p = 0.03). The composite clinical outcome (14 events) was not related to VE or SVE (p ≥ 0.3), but was independently related to heart rate variability (higher triangular index). In conclusion, in this cohort, VE and SVE were rare. VE was related to larger BSA-adjusted left ventricular size. Routine ambulatory electrocardiographic monitoring may be useful for risk stratification in select MFS patients.
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Affiliation(s)
- Douglas Y Mah
- Departments of Cardiology and Pediatrics, Boston Children's Hospital, Boston, Massachusetts.
| | - Lynn A Sleeper
- Departments of Cardiology and Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Jane E Crosson
- Departments of Cardiology and Pediatrics, Johns Hopkins Children's Center, Baltimore, Maryland
| | - Richard J Czosek
- Departments of Cardiology and Pediatrics, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Barry A Love
- Departments of Cardiology and Pediatrics, Mount Sinai Kravis Children's Hospital in New York, New York City, New York
| | - Brian W McCrindle
- Departments of Cardiology and Pediatrics, SickKids Toronto, Toronto, Ontario, Canada
| | - Laura Muiño-Mosquera
- Departments of Cardiology and Pediatrics, Ghent University Hospital, Ghent, Belgium
| | - Aaron K Olson
- Departments of Cardiology and Pediatrics, Seattle Children's Hospital, Seattle, Washington
| | - Thomas A Pilcher
- Departments of Cardiology and Pediatrics, Primary Children's Hospital (Utah), Salt Lake City, Utah
| | | | - Maully J Shah
- Departments of Cardiology and Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Stephanie B Wechsler
- Departments of Cardiology and Pediatrics, Duke Children's Hospital, Durham, North Carolina
| | - Luciana T Young
- Departments of Cardiology and Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Ronald V Lacro
- Departments of Cardiology and Pediatrics, Boston Children's Hospital, Boston, Massachusetts
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18
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Predictors of Rapid Aortic Root Dilation and Referral for Aortic Surgery in Marfan Syndrome. Pediatr Cardiol 2018; 39:1453-1461. [PMID: 29948025 PMCID: PMC6150800 DOI: 10.1007/s00246-018-1916-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 05/31/2018] [Indexed: 01/15/2023]
Abstract
Few data exist regarding predictors of rapid aortic root dilation and referral for aortic surgery in Marfan syndrome (MFS). To identify independent predictors of the rate of aortic root (AoR) dilation and referral for aortic surgery, we investigated the data from the Pediatric Heart Network randomized trial of atenolol versus losartan in young patients with MFS. Data were analyzed from the echocardiograms at 0, 12, 24, and 36 months read in the core laboratory of 608 trial subjects, aged 6 months to 25 years, who met original Ghent criteria and had an AoR z-score (AoRz) > 3. Repeated measures linear and logistic regressions were used to determine multivariable predictors of AoR dilation. Receiver operator characteristic curves were used to determine cut-points in AoR dilation predicting referral for aortic surgery. Multivariable analysis showed rapid AoR dilation as defined by change in AoRz/year > 90th percentile was associated with older age, higher sinotubular junction z-score, and atenolol use (R2 = 0.01) or by change in AoR diameter (AoRd)/year > 90th percentile with higher sinotubular junction z-score and non-white race (R2 = 0.02). Referral for aortic root surgery was associated with higher AoRd, higher ascending aorta z-score, and higher sinotubular junction diameter:ascending aorta diameter ratio (R2 = 0.17). Change in AoRz of 0.72 SD units/year had 42% sensitivity and 92% specificity and change in AoRd of 0.34 cm/year had 38% sensitivity and 95% specificity for predicting referral for aortic surgery. In this cohort of young patients with MFS, no new robust predictors of rapid AoR dilation or referral for aortic root surgery were identified. Further investigation may determine whether generalized proximal aortic dilation and effacement of the sinotubular junction will allow for better risk stratification. Rate of AoR dilation cut-points had high specificity, but low sensitivity for predicting referral for aortic surgery, limiting their clinical use. Clinical Trial Number ClinicalTrials.gov number, NCT00429364.
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19
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Selamet Tierney ES, Levine JC, Sleeper LA, Roman MJ, Bradley TJ, Colan SD, Chen S, Campbell MJ, Cohen MS, De Backer J, Heydarian H, Hoskoppal A, Lai WW, Liou A, Marcus E, Nutting A, Olson AK, Parra DA, Pearson GD, Pierpont ME, Printz BF, Pyeritz RE, Ravekes W, Sharkey AM, Srivastava S, Young L, Lacro RV. Influence of Aortic Stiffness on Aortic-Root Growth Rate and Outcome in Patients With the Marfan Syndrome. Am J Cardiol 2018; 121:1094-1101. [PMID: 29631804 DOI: 10.1016/j.amjcard.2018.01.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 01/05/2018] [Accepted: 01/09/2018] [Indexed: 10/18/2022]
Abstract
The Pediatric Heart Network randomized trial of atenolol versus losartan in the Marfan syndrome showed no treatment differences in the rates of aortic-root growth or clinical outcomes. In this report we present treatment effects on aortic stiffness and determine whether baseline aortic stiffness predicts aortic-root growth and clinical outcomes. Echocardiograms at 0, 6, 12, 24, and 36 months from 608 subjects (6 months to 25 years) who met original Ghent criteria and had a maximum aortic-root z-score (ARz) >3 were centrally reviewed. Stiffness index (SI) and elastic modulus (EM) were calculated for aortic root and ascending aorta. Data were analyzed using multivariable mixed effects modeling and Cox regression. Heart rate-corrected aortic-root SI over 3 years decreased with atenolol but did not change with losartan (-0.298 ± 0.139 vs 0.141 ± 0.139/year, p = 0.01). In the entire cohort, above-median aortic-root SI (>9.1) and EM (>618 mm Hg) predicted a smaller annual decrease in ARz (p ≤0.001). Upper-quartile aortic-root EM (>914 mm Hg) predicted the composite outcome of aortic-root surgery, dissection, or death (hazard ratio 2.17, 95% confidence interval 1.02 to 4.63, p = 0.04). Crude 3-year event rates were 10.4% versus 3.2% for higher versus lower EM groups. In conclusion, atenolol was associated with a decrease in aortic-root SI, whereas losartan was not. Higher baseline aortic-root SI and EM were associated with a smaller decrease in ARz and increased risk for clinical outcomes. These data suggest that noninvasive aortic stiffness measures may identify patients at higher risk of progressive aortic enlargement and adverse clinical outcomes, potentially allowing for closer monitoring and more aggressive therapy.
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20
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MacFarlane EG, Haupt J, Dietz HC, Shore EM. TGF-β Family Signaling in Connective Tissue and Skeletal Diseases. Cold Spring Harb Perspect Biol 2017; 9:cshperspect.a022269. [PMID: 28246187 DOI: 10.1101/cshperspect.a022269] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The transforming growth factor β (TGF-β) family of signaling molecules, which includes TGF-βs, activins, inhibins, and numerous bone morphogenetic proteins (BMPs) and growth and differentiation factors (GDFs), has important functions in all cells and tissues, including soft connective tissues and the skeleton. Specific TGF-β family members play different roles in these tissues, and their activities are often balanced with those of other TGF-β family members and by interactions with other signaling pathways. Perturbations in TGF-β family pathways are associated with numerous human diseases with prominent involvement of the skeletal and cardiovascular systems. This review focuses on the role of this family of signaling molecules in the pathologies of connective tissues that manifest in rare genetic syndromes (e.g., syndromic presentations of thoracic aortic aneurysm), as well as in more common disorders (e.g., osteoarthritis and osteoporosis). Many of these diseases are caused by or result in pathological alterations of the complex relationship between the TGF-β family of signaling mediators and the extracellular matrix in connective tissues.
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Affiliation(s)
- Elena Gallo MacFarlane
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
| | - Julia Haupt
- Department of Orthopedic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania 19104.,Center for Research in FOP and Related Disorders, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | - Harry C Dietz
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205.,Howard Hughes Medical Institute, Bethesda, Maryland 21205
| | - Eileen M Shore
- Department of Orthopedic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania 19104.,Center for Research in FOP and Related Disorders, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania 19104.,Department of Genetics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania 19104
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21
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Abstract
Genetic aortic syndromes (GAS) include Marfan, Loeys-Dietz, vascular Ehlers-Danlos, and Turner syndrome as well as congenital bicuspid aortic valve. The clinical management of these diseases has certain similarities and differences. We employed medical strategy analysis to test the utility of genetic diagnostics in the management of GAS. We chose the standpoint of the cardiologist for our analysis. In the first step, the medical goals in the management of GAS are specified. In the second step, the accuracy of genetic diagnostics for GAS is examined. Finally, conclusions can be drawn about the utility of genetic diagnostics in managing GAS. We found that genetic diagnostics is necessary to exclude GAS, to diagnose GAS, and to specify disease types. Second, combining phenotype with genotype information maximizes the predictability of the course of disease. Third, with genetic diagnostics it is possible to predict the birth of children with causative mutations for GAS and to initiate drug therapy to prevent the onset of aortic dilatation or to slow down its progression to aortic aneurysm. Finally, genetic diagnostics improves prognostic predictions and thereby contributes to a better timing of elective surgery and to a better choice of procedures. The findings of our medical strategy analysis indicate the high utility of genetic diagnostics for managing GAS.
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22
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Shen YH, LeMaire SA. Molecular pathogenesis of genetic and sporadic aortic aneurysms and dissections. Curr Probl Surg 2017; 54:95-155. [PMID: 28521856 DOI: 10.1067/j.cpsurg.2017.01.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 01/16/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Ying H Shen
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX; Cardiovascular Research Institute, Baylor College of Medicine, Houston, TX.
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX; Cardiovascular Research Institute, Baylor College of Medicine, Houston, TX; Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston, TX.
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Abstract
Thoracic aortic aneurysm is a potentially life-threatening condition in that it places patients at risk for aortic dissection or rupture. However, our modern understanding of the pathogenesis of thoracic aortic aneurysm is quite limited. A genetic predisposition to thoracic aortic aneurysm has been established, and gene discovery in affected families has identified several major categories of gene alterations. The first involves mutations in genes encoding various components of the transforming growth factor beta (TGF-β) signaling cascade (FBN1, TGFBR1, TGFBR2, TGFB2, TGFB3, SMAD2, SMAD3 and SKI), and these conditions are known collectively as the TGF-β vasculopathies. The second set of genes encode components of the smooth muscle contractile apparatus (ACTA2, MYH11, MYLK, and PRKG1), a group called the smooth muscle contraction vasculopathies. Mechanistic hypotheses based on these discoveries have shaped rational therapies, some of which are under clinical evaluation. This review discusses published data on genes involved in thoracic aortic aneurysm and attempts to explain divergent hypotheses of aneurysm origin.
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Affiliation(s)
- Eric M Isselbacher
- From Thoracic Aortic Center (E.M.I., C.L.L.C., M.E.L.), Cardiovascular Genetics Program (M.E.L.), Cardiovascular Research Center (C.L.L.C., M.E.L.), and Cardiology Division (E.M.I., C.L.L.C., M.E.L.), Department of Medicine, and Pediatric Cardiology Division, Department of Pediatrics (M.E.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Christian Lacks Lino Cardenas
- From Thoracic Aortic Center (E.M.I., C.L.L.C., M.E.L.), Cardiovascular Genetics Program (M.E.L.), Cardiovascular Research Center (C.L.L.C., M.E.L.), and Cardiology Division (E.M.I., C.L.L.C., M.E.L.), Department of Medicine, and Pediatric Cardiology Division, Department of Pediatrics (M.E.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Mark E Lindsay
- From Thoracic Aortic Center (E.M.I., C.L.L.C., M.E.L.), Cardiovascular Genetics Program (M.E.L.), Cardiovascular Research Center (C.L.L.C., M.E.L.), and Cardiology Division (E.M.I., C.L.L.C., M.E.L.), Department of Medicine, and Pediatric Cardiology Division, Department of Pediatrics (M.E.L.), Massachusetts General Hospital, Harvard Medical School, Boston.
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24
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The effect of losartan on progressive aortic dilatation in patients with Marfan's syndrome: a meta-analysis of prospective randomized clinical trials. Int J Cardiol 2016; 217:190-4. [PMID: 27187761 DOI: 10.1016/j.ijcard.2016.04.186] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Revised: 04/20/2016] [Accepted: 04/30/2016] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To assess the effect of losartan therapy on progressive aortic dilatation and on clinical outcome in patients with Marfan's syndrome (MFS). METHODS The meta-analysis was instituted, which included studies identified by a systematic review of MEDLINE of peer-reviewed publications. Echocardiogram or MRI measurements of the aortic root dimension and outcome measures of death, cardiovascular surgery and aortic dissection or rupture were compared between patients who were treated and untreated with losartan therapy. RESULTS Six randomized trials with 1398 subjects met all the inclusion criteria and were included in the meta-analysis. Compared with non-losartan treatment, losartan therapy significantly decreased the rate of aortic dilatation (SMD=-0.13 with 95% CI -0.25 to 0.00, p=0.04). The clinical outcome beneficial was not observed in the losartan treatment group when compared with no losartan treatment group (odds ratio=1.04 with 95% CI of 0.57-1.87). CONCLUSION Given the current results of the meta-analysis and together with the lack of associated side effects, it would be reasonable to use losartan in MFS patients with aortic root dilatation. However, no clinical outcome benefits were observed in the losartan treatment group when compared with no losartan treatment group.
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25
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Singh MN, Lacro RV. Recent Clinical Drug Trials Evidence in Marfan Syndrome and Clinical Implications. Can J Cardiol 2015; 32:66-77. [PMID: 26724512 DOI: 10.1016/j.cjca.2015.11.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 11/04/2015] [Accepted: 11/04/2015] [Indexed: 01/08/2023] Open
Abstract
Marfan syndrome is a genetic disorder of connective tissue with principal manifestations in the cardiovascular, ocular, and skeletal systems. Cardiovascular disease, mainly progressive aortic root dilation and aortic dissection, is the leading cause of morbidity and mortality. The primary aims of this report were to examine the evidence related to medical therapy for Marfan syndrome, including recently completed randomized clinical trials on the efficacy of β-blockers and angiotensin II receptor blockers for the prophylactic treatment of aortic enlargement in Marfan syndrome, and to provide recommendations for medical therapy on the basis of available evidence. Medical therapy for Marfan syndrome should be individualized according to patient tolerance and risk factors such as age, aortic size, and family history of aortic dissection. The Pediatric Heart Network trial showed that atenolol and losartan each reduced the rate of aortic dilation. All patients with known or suspected Marfan syndrome and aortic root dilation should receive medical therapy with adequate doses of either β-blocker or angiotensin receptor blocker. The Pediatric Heart Network trial also showed that atenolol and losartan are more effective at reduction of aortic root z score in younger subjects, which suggests that medical therapy should be prescribed even in the youngest children with aortic dilation. For patients with Marfan syndrome without aortic dilation, the available evidence is less clear. If aortic dilation is severe and/or progressive, therapy with a combination of β-blocker and angiotensin receptor blocker should be considered, although trial results are mixed with respect to the efficacy of combination therapy vs monotherapy.
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Affiliation(s)
- Michael N Singh
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Ronald V Lacro
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.
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26
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Hu JH, Wei H, Jaffe M, Airhart N, Du L, Angelov SN, Yan J, Allen JK, Kang I, Wight TN, Fox K, Smith A, Enstrom R, Dichek DA. Postnatal Deletion of the Type II Transforming Growth Factor-β Receptor in Smooth Muscle Cells Causes Severe Aortopathy in Mice. Arterioscler Thromb Vasc Biol 2015; 35:2647-56. [PMID: 26494233 DOI: 10.1161/atvbaha.115.306573] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2014] [Accepted: 10/14/2015] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Prenatal deletion of the type II transforming growth factor-β (TGF-β) receptor (TBRII) prevents normal vascular morphogenesis and smooth muscle cell (SMC) differentiation, causing embryonic death. The role of TBRII in adult SMC is less well studied. Clarification of this role has important clinical implications because TBRII deletion should ablate TGF-β signaling, and blockade of TGF-β signaling is envisioned as a treatment for human aortopathies. We hypothesized that postnatal loss of SMC TBRII would cause aortopathy. APPROACH AND RESULTS We generated mice with either of 2 tamoxifen-inducible SMC-specific Cre (SMC-CreER(T2)) alleles and homozygous floxed Tgfbr2 alleles. Mice were injected with tamoxifen, and their aortas examined 4 and 14 weeks later. Both SMC-CreER(T2) alleles efficiently and specifically rearranged a floxed reporter gene and efficiently rearranged a floxed Tgfbr2 allele, resulting in loss of aortic medial TBRII protein. Loss of SMC TBRII caused severe aortopathy, including hemorrhage, ulceration, dissection, dilation, accumulation of macrophage markers, elastolysis, abnormal proteoglycan accumulation, and aberrant SMC gene expression. All areas of the aorta were affected, with the most severe pathology in the ascending aorta. Cre-mediated loss of SMC TBRII in vitro ablated both canonical and noncanonical TGF-β signaling and reproduced some of the gene expression abnormalities detected in vivo. CONCLUSIONS SMC TBRII plays a critical role in maintaining postnatal aortic homeostasis. Loss of SMC TBRII disrupts TGF-β signaling, acutely alters SMC gene expression, and rapidly results in severe and durable aortopathy. These results suggest that pharmacological blockade of TGF-β signaling in humans could cause aortic disease rather than prevent it.
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Affiliation(s)
- Jie Hong Hu
- From the Department of Medicine, University of Washington School of Medicine, Seattle, WA (J.H.H., H.W., M.J., N.A., L.D., S.N.A., J.Y., J.K.A., K.F., A.S., R.E., D.A.D); and the Matrix Biology Program at the Benaroya Research Institute, Seattle, WA (I.K., T.N.W.)
| | - Hao Wei
- From the Department of Medicine, University of Washington School of Medicine, Seattle, WA (J.H.H., H.W., M.J., N.A., L.D., S.N.A., J.Y., J.K.A., K.F., A.S., R.E., D.A.D); and the Matrix Biology Program at the Benaroya Research Institute, Seattle, WA (I.K., T.N.W.)
| | - Mia Jaffe
- From the Department of Medicine, University of Washington School of Medicine, Seattle, WA (J.H.H., H.W., M.J., N.A., L.D., S.N.A., J.Y., J.K.A., K.F., A.S., R.E., D.A.D); and the Matrix Biology Program at the Benaroya Research Institute, Seattle, WA (I.K., T.N.W.)
| | - Nathan Airhart
- From the Department of Medicine, University of Washington School of Medicine, Seattle, WA (J.H.H., H.W., M.J., N.A., L.D., S.N.A., J.Y., J.K.A., K.F., A.S., R.E., D.A.D); and the Matrix Biology Program at the Benaroya Research Institute, Seattle, WA (I.K., T.N.W.)
| | - Liang Du
- From the Department of Medicine, University of Washington School of Medicine, Seattle, WA (J.H.H., H.W., M.J., N.A., L.D., S.N.A., J.Y., J.K.A., K.F., A.S., R.E., D.A.D); and the Matrix Biology Program at the Benaroya Research Institute, Seattle, WA (I.K., T.N.W.)
| | - Stoyan N Angelov
- From the Department of Medicine, University of Washington School of Medicine, Seattle, WA (J.H.H., H.W., M.J., N.A., L.D., S.N.A., J.Y., J.K.A., K.F., A.S., R.E., D.A.D); and the Matrix Biology Program at the Benaroya Research Institute, Seattle, WA (I.K., T.N.W.)
| | - James Yan
- From the Department of Medicine, University of Washington School of Medicine, Seattle, WA (J.H.H., H.W., M.J., N.A., L.D., S.N.A., J.Y., J.K.A., K.F., A.S., R.E., D.A.D); and the Matrix Biology Program at the Benaroya Research Institute, Seattle, WA (I.K., T.N.W.)
| | - Julie K Allen
- From the Department of Medicine, University of Washington School of Medicine, Seattle, WA (J.H.H., H.W., M.J., N.A., L.D., S.N.A., J.Y., J.K.A., K.F., A.S., R.E., D.A.D); and the Matrix Biology Program at the Benaroya Research Institute, Seattle, WA (I.K., T.N.W.)
| | - Inkyung Kang
- From the Department of Medicine, University of Washington School of Medicine, Seattle, WA (J.H.H., H.W., M.J., N.A., L.D., S.N.A., J.Y., J.K.A., K.F., A.S., R.E., D.A.D); and the Matrix Biology Program at the Benaroya Research Institute, Seattle, WA (I.K., T.N.W.)
| | - Thomas N Wight
- From the Department of Medicine, University of Washington School of Medicine, Seattle, WA (J.H.H., H.W., M.J., N.A., L.D., S.N.A., J.Y., J.K.A., K.F., A.S., R.E., D.A.D); and the Matrix Biology Program at the Benaroya Research Institute, Seattle, WA (I.K., T.N.W.)
| | - Kate Fox
- From the Department of Medicine, University of Washington School of Medicine, Seattle, WA (J.H.H., H.W., M.J., N.A., L.D., S.N.A., J.Y., J.K.A., K.F., A.S., R.E., D.A.D); and the Matrix Biology Program at the Benaroya Research Institute, Seattle, WA (I.K., T.N.W.)
| | - Alexandra Smith
- From the Department of Medicine, University of Washington School of Medicine, Seattle, WA (J.H.H., H.W., M.J., N.A., L.D., S.N.A., J.Y., J.K.A., K.F., A.S., R.E., D.A.D); and the Matrix Biology Program at the Benaroya Research Institute, Seattle, WA (I.K., T.N.W.)
| | - Rachel Enstrom
- From the Department of Medicine, University of Washington School of Medicine, Seattle, WA (J.H.H., H.W., M.J., N.A., L.D., S.N.A., J.Y., J.K.A., K.F., A.S., R.E., D.A.D); and the Matrix Biology Program at the Benaroya Research Institute, Seattle, WA (I.K., T.N.W.)
| | - David A Dichek
- From the Department of Medicine, University of Washington School of Medicine, Seattle, WA (J.H.H., H.W., M.J., N.A., L.D., S.N.A., J.Y., J.K.A., K.F., A.S., R.E., D.A.D); and the Matrix Biology Program at the Benaroya Research Institute, Seattle, WA (I.K., T.N.W.).
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Fibrillin-containing microfibrils are key signal relay stations for cell function. J Cell Commun Signal 2015; 9:309-25. [PMID: 26449569 DOI: 10.1007/s12079-015-0307-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 09/29/2015] [Indexed: 12/26/2022] Open
Abstract
Fibrillins constitute the backbone of microfibrils in the extracellular matrix of elastic and non-elastic tissues. Mutations in fibrillins are associated with a wide range of connective tissue disorders, the most common is Marfan syndrome. Microfibrils are on one hand important for structural stability in some tissues. On the other hand, microfibrils are increasingly recognized as critical mediators and drivers of cellular signaling. This review focuses on the signaling mechanisms initiated by fibrillins and microfibrils, which are often dysregulated in fibrillin-associated disorders. Fibrillins regulate the storage and bioavailability of growth factors of the TGF-β superfamily. Cells sense microfibrils through integrins and other receptors. Fibrillins potently regulate pathways of the immune response, inflammation and tissue homeostasis. Emerging evidence show the involvement of microRNAs in disorders caused by fibrillin deficiency. A thorough understanding of fibrillin-mediated cell signaling pathways will provide important new leads for therapeutic approaches of the underlying disorders.
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28
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Abstract
PURPOSE OF REVIEW Because of the relatively small numbers of pediatric patients with congenital heart disease cared for in any individual center, there is a significant need for multicenter clinical studies to validate new medical or surgical therapies. The Pediatric Heart Network (PHN), with 15 years of experience in multicenter clinical research, has tackled numerous challenges when conducting multicenter studies. RECENT FINDINGS This review describes the challenges encountered and the strategies employed to conduct high-quality, collaborative research in pediatric cardiovascular disease. SUMMARY Sharing lessons learned from the PHN can provide guidance to investigators interested in conducting pediatric multicenter studies.
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29
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Ewans LJ, Roberts P, Adès L. Losartan therapy for cardiac disease in paediatricMarfan syndrome. J Paediatr Child Health 2015; 51:927-31. [PMID: 26333075 DOI: 10.1111/jpc.12823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/04/2014] [Indexed: 10/23/2022]
Abstract
A case of severe early-onset Marfan syndrome (MFS) led us to ask the question: 'Should an ARB, particularly losartan [intervention], compared with beta blockade alone [comparison], be commenced in all paediatric MFS patients [patient] with aortic root dilatation [outcome]?' The current literature was critically appraised to address this question.
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Affiliation(s)
- Lisa J Ewans
- Clinical Genetics, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Phillip Roberts
- Paediatric Cardiology, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Lesley Adès
- Clinical Genetics, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
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30
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Attenhofer Jost CH, Greutmann M, Connolly HM, Weber R, Rohrbach M, Oxenius A, Kretschmar O, Luscher TF, Matyas G. Medical treatment of aortic aneurysms in Marfan syndrome and other heritable conditions. Curr Cardiol Rev 2015; 10:161-71. [PMID: 24527681 PMCID: PMC4021286 DOI: 10.2174/1573403x1002140506124902] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2013] [Revised: 12/22/2013] [Accepted: 02/06/2014] [Indexed: 01/15/2023] Open
Abstract
Thoracic aortic
aneurysms can be triggered by genetic disorders such as Marfan syndrome (MFS)
and related aortic diseases as well as by inflammatory disorders such as giant
cell arteritis or atherosclerosis. In all these conditions, cardiovascular risk
factors, such as systemic arterial hypertension, may contribute to faster rate
of aneurysm progression. Optimal medical management to prevent progressive
aortic dilatation and aortic dissection is unknown. β-blockers have been the
mainstay of medical treatment for many years despite limited evidence of
beneficial effects. Recently, losartan, an angiotensin II type I receptor
antagonist (ARB), has shown promising results in a mouse model of MFS and
subsequently in humans with MFS and hence is increasingly used. Several ongoing
trials comparing losartan to β-blockers and/or placebo will better define the
role of ARBs in the near future. In addition, other medications, such as statins
and tetracyclines have demonstrated potential benefit in experimental aortic
aneurysm studies. Given the advances in our understanding of molecular
mechanisms triggering aortic dilatation and dissection, individualized
management tailored to the underlying genetic defect may be on the horizon of
individualized medicine. We anticipate that ongoing research will address the
question whether such genotype/pathogenesis-driven
treatments can replace current phenotype/syndrome-driven strategies and whether
other forms of aortopathies should be treated similarly. In this work, we review
currently used and promising medical treatment options for patients with
heritable aortic aneurysmal disorders.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Gabor Matyas
- Cardiovascular Center Zurich, Klinik Im Park, Seestr. 220, CH-8027 Zurich, Switzerland.
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31
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Broberg CS, Therrien J. Understanding and treating aortopathy in bicuspid aortic valve. Trends Cardiovasc Med 2015; 25:445-51. [DOI: 10.1016/j.tcm.2014.12.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 11/12/2014] [Accepted: 12/10/2014] [Indexed: 10/24/2022]
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32
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Engineered mutations in fibrillin-1 leading to Marfan syndrome act at the protein, cellular and organismal levels. MUTATION RESEARCH-REVIEWS IN MUTATION RESEARCH 2015; 765:7-18. [DOI: 10.1016/j.mrrev.2015.04.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 03/22/2015] [Accepted: 04/27/2015] [Indexed: 11/19/2022]
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Mathieu P, Bossé Y, Huggins GS, Della Corte A, Pibarot P, Michelena HI, Limongelli G, Boulanger MC, Evangelista A, Bédard E, Citro R, Body SC, Nemer M, Schoen FJ. The pathology and pathobiology of bicuspid aortic valve: State of the art and novel research perspectives. JOURNAL OF PATHOLOGY CLINICAL RESEARCH 2015; 1:195-206. [PMID: 27499904 PMCID: PMC4939890 DOI: 10.1002/cjp2.21] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 03/25/2015] [Indexed: 12/12/2022]
Abstract
Bicuspid aortic valve is the most prevalent cardiac valvular malformation. It is associated with a high rate of long‐term morbidity including development of calcific aortic valve disease, aortic regurgitation and concomitant thoracic aortic aneurysm and dissection. Recently, basic and translational studies have identified some key processes involved in the development of bicuspid aortic valve and its morbidity. The development of aortic valve disease and thoracic aortic aneurysm and dissection is the result of complex interactions between genotypes, environmental risk factors and specific haemodynamic conditions created by bicuspid aortic valve anatomy. Herein, we review the pathobiology of bicuspid aortic valve with a special emphasis on translational aspects of these basic findings. Important but unresolved problems in the pathology of bicuspid aortic valve and thoracic aortic aneurysm and dissection are discussed, along with the molecular processes involved.
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Affiliation(s)
- Patrick Mathieu
- Laboratoire d'Études Moléculaires des Valvulopathies (LEMV), Groupe de Recherche en Valvulopathies (GRV), Department of Surgery Quebec Heart and Lung Institute/Research Center, Laval University Quebec Canada
| | - Yohan Bossé
- Department of Molecular Medicine, Quebec Heart and Lung Institute/Research Center Laval University Québec Canada
| | - Gordon S Huggins
- Molecular Cardiology Research Institute Center for Translational Genomics, Tufts Medical Center Boston Massachussetts USA
| | - Alessandro Della Corte
- Department of Cardiothoracic Sciences, Cardiac Surgery Second University of Naples 80131 Naples Italy
| | - Philippe Pibarot
- Department of Molecular Medicine, Quebec Heart and Lung Institute/Research Center Laval University Québec Canada
| | - Hector I Michelena
- Division of Cardiovascular Diseases, Mayo Clinic Rochester Minnesota USA
| | - Giuseppe Limongelli
- Department of Cardiology and Cardiothoracic and Respiratory Sciences, Cardiologia SUN, Monaldi Hospital, AO Colli Naples Italy
| | - Marie-Chloé Boulanger
- Laboratoire d'Études Moléculaires des Valvulopathies (LEMV), Groupe de Recherche en Valvulopathies (GRV), Department of Surgery Quebec Heart and Lung Institute/Research Center, Laval University Quebec Canada
| | - Arturo Evangelista
- Department of Cardiology Hospital Universitary Vall d'Hebron Barcelona Spain
| | - Elisabeth Bédard
- Department of Molecular Medicine, Quebec Heart and Lung Institute/Research Center Laval University Québec Canada
| | - Rodolfo Citro
- Heart Department University Hospital "San Giovanni di Dio e Ruggi d'Aragona" Salerno Italy
| | - Simon C Body
- Department of Anesthesiology, Perioperative and Pain Medicine Center for Perioperative Genomics, Brigham and Women's Hospital Boston Massachusetts USA
| | - Mona Nemer
- Laboratory for Cardiac Development and Differentiation University of Ottawa Ontario Canada
| | - Frederick J Schoen
- Department of Pathology Brigham and Women's Hospital, Harvard Medical School USA
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Proost D, Vandeweyer G, Meester JAN, Salemink S, Kempers M, Ingram C, Peeters N, Saenen J, Vrints C, Lacro RV, Roden D, Wuyts W, Dietz HC, Mortier G, Loeys BL, Van Laer L. Performant Mutation Identification Using Targeted Next-Generation Sequencing of 14 Thoracic Aortic Aneurysm Genes. Hum Mutat 2015; 36:808-14. [PMID: 25907466 DOI: 10.1002/humu.22802] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 04/08/2015] [Indexed: 02/07/2023]
Abstract
At least 14 causative genes have been identified for both syndromic and nonsyndromic forms of thoracic aortic aneurysm/dissection (TAA), an important cause of death in the industrialized world. Molecular confirmation of the diagnosis is increasingly important for gene-tailored patient management but consecutive, conventional molecular TAA gene screening is expensive and labor-intensive. To circumvent these problems, we developed a TAA gene panel for next-generation sequencing of 14 TAA genes. After validation, we applied the assay to 100 Marfan patients. We identified 90 FBN1 mutations, 44 of which were novel. In addition, Multiplex ligation-dependent probe amplification identified large deletions in six of the remaining samples, whereas false-negative results were excluded by Sanger sequencing of FBN1, TGFBR1, and TGFBR2 in the last four samples. Subsequently, we screened 55 syndromic and nonsyndromic TAA patients. We identified causal mutations in 15 patients (27%), one in each of the six following genes: ACTA2, COL3A1, TGFBR1, MYLK, SMAD3, SLC2A10 (homozygous), two in NOTCH1, and seven in FBN1. We conclude that our approach for TAA genetic testing overcomes the intrinsic hurdles of consecutive Sanger sequencing of all candidate genes and provides a powerful tool for the elaboration of clinical phenotypes assigned to different genes.
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Affiliation(s)
- Dorien Proost
- Department of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Geert Vandeweyer
- Department of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Josephina A N Meester
- Department of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Simone Salemink
- Department of Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marlies Kempers
- Department of Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Christie Ingram
- Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Nils Peeters
- Department of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Johan Saenen
- Department of Cardiology, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Christiaan Vrints
- Department of Cardiology, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | | | - Dan Roden
- Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Wim Wuyts
- Department of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Harry C Dietz
- McKusick Nathans Institute for Genetic Medicine, Johns Hopkins University Hospital, Baltimore, Maryland
| | - Geert Mortier
- Department of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Bart L Loeys
- Department of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium.,Department of Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lut Van Laer
- Department of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
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35
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Muiño Mosquera L, De Backer J. Managing aortic aneurysms and dissections during pregnancy. Expert Rev Cardiovasc Ther 2015; 13:703-14. [DOI: 10.1586/14779072.2015.1042862] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Pitcher A, Emberson J, Lacro RV, Sleeper LA, Stylianou M, Mahony L, Pearson GD, Groenink M, Mulder BJ, Zwinderman AH, De Backer J, De Paepe AM, Arbustini E, Erdem G, Jin XY, Flather MD, Mullen MJ, Child AH, Forteza A, Evangelista A, Chiu HH, Wu MH, Sandor G, Bhatt AB, Creager MA, Devereux RB, Loeys B, Forfar JC, Neubauer S, Watkins H, Boileau C, Jondeau G, Dietz HC, Baigent C. Design and rationale of a prospective, collaborative meta-analysis of all randomized controlled trials of angiotensin receptor antagonists in Marfan syndrome, based on individual patient data: A report from the Marfan Treatment Trialists' Collaboration. Am Heart J 2015; 169:605-12. [PMID: 25965707 PMCID: PMC4441104 DOI: 10.1016/j.ahj.2015.01.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2014] [Accepted: 01/17/2015] [Indexed: 12/01/2022]
Abstract
Rationale A number of randomized trials are underway, which will address the effects of angiotensin receptor blockers (ARBs) on aortic root enlargement and a range of other end points in patients with Marfan syndrome. If individual participant data from these trials were to be combined, a meta-analysis of the resulting data, totaling approximately 2,300 patients, would allow estimation across a number of trials of the treatment effects both of ARB therapy and of β-blockade. Such an analysis would also allow estimation of treatment effects in particular subgroups of patients on a range of end points of interest and would allow a more powerful estimate of the effects of these treatments on a composite end point of several clinical outcomes than would be available from any individual trial. Design A prospective, collaborative meta-analysis based on individual patient data from all randomized trials in Marfan syndrome of (i) ARBs versus placebo (or open-label control) and (ii) ARBs versus β-blockers will be performed. A prospective study design, in which the principal hypotheses, trial eligibility criteria, analyses, and methods are specified in advance of the unblinding of the component trials, will help to limit bias owing to data-dependent emphasis on the results of particular trials. The use of individual patient data will allow for analysis of the effects of ARBs in particular patient subgroups and for time-to-event analysis for clinical outcomes. The meta-analysis protocol summarized in this report was written on behalf of the Marfan Treatment Trialists' Collaboration and finalized in late 2012, without foreknowledge of the results of any component trial, and will be made available online (http://www.ctsu.ox.ac.uk/research/meta-trials).
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Goldfinger JZ, Halperin JL, Marin ML, Stewart AS, Eagle KA, Fuster V. Thoracic aortic aneurysm and dissection. J Am Coll Cardiol 2015; 64:1725-39. [PMID: 25323262 DOI: 10.1016/j.jacc.2014.08.025] [Citation(s) in RCA: 229] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 08/26/2014] [Accepted: 08/26/2014] [Indexed: 11/27/2022]
Abstract
Aortic dissection is the most devastating complication of thoracic aortic disease. In the more than 250 years since thoracic aortic dissection was first described, much has been learned about diseases of the thoracic aorta. In this review, we describe normal thoracic aortic size; risk factors for dissection, including genetic and inflammatory conditions; the underpinnings of genetic diseases associated with aneurysm and dissection, including Marfan syndrome and the role of transforming growth factor beta signaling; data on the role for medical therapies in aneurysmal disease, including beta-blockers, angiotensin receptor blockers, and angiotensin-converting enzyme inhibitors; prophylactic surgery for aneurysm; surgical techniques for the aortic root; and surgical and endovascular management of aneurysm and dissection for different aortic segments.
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Affiliation(s)
- Judith Z Goldfinger
- Department of Medicine, Division of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jonathan L Halperin
- Department of Medicine, Division of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michael L Marin
- Department of Surgery, Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Allan S Stewart
- Department of Cardiothoracic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kim A Eagle
- Department of Medicine, Samuel and Jean A. Frankel Cardiovascular Center, University of Michigan Health System and Medical School, Ann Arbor, Michigan
| | - Valentin Fuster
- Department of Medicine, Division of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, New York.
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A randomized, double blind pilot study to assess the effects of losartan vs. atenolol on the biophysical properties of the aorta in patients with Marfan and Loeys–Dietz syndromes. Int J Cardiol 2015; 179:470-5. [DOI: 10.1016/j.ijcard.2014.11.082] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 10/23/2014] [Accepted: 11/06/2014] [Indexed: 11/22/2022]
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Mallat Z, Daugherty A. AT1 receptor antagonism to reduce aortic expansion in Marfan syndrome: lost in translation or in need of different interpretation? Arterioscler Thromb Vasc Biol 2014; 35:e10-2. [PMID: 25550201 DOI: 10.1161/atvbaha.114.305173] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Ziad Mallat
- From the Division of Cardiovascular Medicine, Department of Medicine, University of Cambridge, Cambridge, United Kingdom (Z.M.); and Saha Cardiovascular Research Center, University of Kentucky, Lexington (A.D.)
| | - Alan Daugherty
- From the Division of Cardiovascular Medicine, Department of Medicine, University of Cambridge, Cambridge, United Kingdom (Z.M.); and Saha Cardiovascular Research Center, University of Kentucky, Lexington (A.D.)
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40
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The evolution of surgical and medical treatment of aortic root aneurysm. Front Med 2014; 8:427-32. [PMID: 25445173 DOI: 10.1007/s11684-014-0385-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Accepted: 11/25/2014] [Indexed: 10/24/2022]
Abstract
Since first report of aortic root replacement in 1968, the surgical risk and long term outcome of patients with aortic root aneurysm have been continuously improving. In the last 30 years, the surgical approach is also evolving towards more valve conservation with prophylactical intervention at an earlier clinical stage. Translational research has also led to emerging surgical innovation and new drug therapy. Their efficacies are currently under vigorous clinical trials and evaluations.
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Lacro RV, Dietz HC, Sleeper LA, Yetman AT, Bradley TJ, Colan SD, Pearson GD, Selamet Tierney ES, Levine JC, Atz AM, Benson DW, Braverman AC, Chen S, De Backer J, Gelb BD, Grossfeld PD, Klein GL, Lai WW, Liou A, Loeys BL, Markham LW, Olson AK, Paridon SM, Pemberton VL, Pierpont ME, Pyeritz RE, Radojewski E, Roman MJ, Sharkey AM, Stylianou MP, Wechsler SB, Young LT, Mahony L. Atenolol versus losartan in children and young adults with Marfan's syndrome. N Engl J Med 2014; 371:2061-71. [PMID: 25405392 PMCID: PMC4386623 DOI: 10.1056/nejmoa1404731] [Citation(s) in RCA: 335] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Aortic-root dissection is the leading cause of death in Marfan's syndrome. Studies suggest that with regard to slowing aortic-root enlargement, losartan may be more effective than beta-blockers, the current standard therapy in most centers. METHODS We conducted a randomized trial comparing losartan with atenolol in children and young adults with Marfan's syndrome. The primary outcome was the rate of aortic-root enlargement, expressed as the change in the maximum aortic-root-diameter z score indexed to body-surface area (hereafter, aortic-root z score) over a 3-year period. Secondary outcomes included the rate of change in the absolute diameter of the aortic root; the rate of change in aortic regurgitation; the time to aortic dissection, aortic-root surgery, or death; somatic growth; and the incidence of adverse events. RESULTS From January 2007 through February 2011, a total of 21 clinical centers enrolled 608 participants, 6 months to 25 years of age (mean [±SD] age, 11.5±6.5 years in the atenolol group and 11.0±6.2 years in the losartan group), who had an aortic-root z score greater than 3.0. The baseline-adjusted rate of change in the mean (±SE) aortic-root z score did not differ significantly between the atenolol group and the losartan group (-0.139±0.013 and -0.107±0.013 standard-deviation units per year, respectively; P=0.08). Both slopes were significantly less than zero, indicating a decrease in the aortic-root diameter relative to body-surface area with either treatment. The 3-year rates of aortic-root surgery, aortic dissection, death, and a composite of these events did not differ significantly between the two treatment groups. CONCLUSIONS Among children and young adults with Marfan's syndrome who were randomly assigned to losartan or atenolol, we found no significant difference in the rate of aortic-root dilatation between the two treatment groups over a 3-year period. (Funded by the National Heart, Lung, and Blood Institute and others; ClinicalTrials.gov number, NCT00429364.).
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Affiliation(s)
- Ronald V Lacro
- From Boston Children's Hospital, Boston (R.V.L., S.D.C., E.S.S.T., J.C.L.); Johns Hopkins University School of Medicine, Baltimore (H.C.D.); New England Research Institutes, Watertown, MA (L.A.S., S.D.C., S.C., G.L.K.); Primary Children's Hospital and the University of Utah, Salt Lake City (A.T.Y.); Hospital for Sick Children, Toronto (T.J.B., E.R.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.D.P., V.L.P., M.P.S.); Medical University of South Carolina, Charleston (A.M.A.); Cincinnati Children's Medical Center, Cincinnati (D.W.B.); Washington University School of Medicine, St. Louis (A.C.B., A.M.S.); Ghent University Hospital, Ghent, Belgium (J.D.B., B.L.L.); Icahn School of Medicine at Mount Sinai (B.D.G.), Children's Hospital of New York (W.W.L.), and Weill Medical College of Cornell University (M.J.R.) - all in New York; Rady Children's Hospital, University of California, San Diego (P.D.G.); Texas Children's Hospital, Houston (A.L.); Vanderbilt University School of Medicine, Nashville (L.W.M.); Seattle Children's Hospital, Seattle (A.K.O.); Children's Hospital of Philadelphia (S.M.P.) and the University of Pennsylvania (R.E.P.), Philadelphia; Children's Hospital and Clinics of Minnesota, Minneapolis (M.E.P.); Duke University Medical Center, Durham, NC (S.B.W.); Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (L.T.Y.); and the University of Texas Southwestern Medical Center, Dallas (L.M.)
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What is the optimal medical therapy for Marfan syndrome? J Pediatr 2014; 165:889-90. [PMID: 25217843 DOI: 10.1016/j.jpeds.2014.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 08/05/2014] [Indexed: 12/29/2022]
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Loeys BL. Angiotensin receptor blockers: a panacea for Marfan syndrome and related disorders? Drug Discov Today 2014; 20:262-6. [PMID: 25281853 DOI: 10.1016/j.drudis.2014.09.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 09/13/2014] [Accepted: 09/26/2014] [Indexed: 11/29/2022]
Abstract
The study of mouse models for Marfan syndrome, an autosomal dominant connective tissue disorder caused by mutations in fibrillin-1 (FBN1), has shifted our understanding of the pathogenesis of thoracic aortic aneurysm significantly. Multiple lines of evidence support the notion that dysregulation of canonical and noncanonical transforming growth factor (TGF)β signaling is the responsible pathway in this and related thoracic aortic aneurysm conditions. This exciting knowledge has opened numerous new treatment options, including antagonism of the angiotensin II receptor blocker type 1 (AT1R). In this review, we summarize the current knowledge, the first human losartan Marfan trial results and future therapeutic perspectives for aortic disease in Marfan patients.
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Affiliation(s)
- Bart L Loeys
- Center for Medical Genetics, Antwerp University Hospital/University of Antwerp, Prins Boudewijnlaan 43, 2650 Antwerp, Belgium.
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BMP signaling modulation attenuates cerebral arteriovenous malformation formation in a vertebrate model. J Cereb Blood Flow Metab 2014; 34:1688-94. [PMID: 25052553 PMCID: PMC4269730 DOI: 10.1038/jcbfm.2014.134] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Revised: 06/02/2014] [Accepted: 06/30/2014] [Indexed: 12/22/2022]
Abstract
Cerebral arteriovenous malformations (AVMs) are vascular anomalies that carry a high risk of stroke and death. To test potential AVM therapies, a reverse genetics approach was used to model AVMs in zebrafish. Antisense morpholino oligonucleotides were used to knockdown activin receptor-like kinase I (alk1), which encodes a transforming growth factor (TGF)-beta family type I receptor implicated in a subset of human AVMs. Knockdown of alk1 caused a spectrum of morphologic, functional, and molecular defects that resemble those seen in humans with AVMs. It was found that losartan, an angiotensin II receptor antagonist, attenuated abnormal blood vessel morphology and systemic manifestations of high-output arteriovenous shunting in vivo. SMAD1 phosphorylation was significantly decreased in alk1 morphants compared with uninjected organisms (0.189±0.0201, 0.429±0.0164, P=0.0002). After treatment, morphant SMAD1 levels approached uninjected levels (0.326±0.0360, P=0.0355) and were significantly higher than those seen in the morphant-control group (P=0.0294). These data suggest that modulating the BMP signaling pathway with losartan, a drug in widespread clinical use in humans as an antihypertensive, may have the potential to be further evaluated as a therapeutic strategy for patients with AVMs.
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New Innovations: Therapies for Genetic Conditions. CURRENT GENETIC MEDICINE REPORTS 2014. [DOI: 10.1007/s40142-014-0043-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, Evangelista A, Falk V, Frank H, Gaemperli O, Grabenwöger M, Haverich A, Iung B, Manolis AJ, Meijboom F, Nienaber CA, Roffi M, Rousseau H, Sechtem U, Sirnes PA, Allmen RSV, Vrints CJM. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J 2014; 35:2873-926. [PMID: 25173340 DOI: 10.1093/eurheartj/ehu281] [Citation(s) in RCA: 2794] [Impact Index Per Article: 279.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Delling FN, Vasan RS. Epidemiology and pathophysiology of mitral valve prolapse: new insights into disease progression, genetics, and molecular basis. Circulation 2014; 129:2158-70. [PMID: 24867995 DOI: 10.1161/circulationaha.113.006702] [Citation(s) in RCA: 162] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Francesca N Delling
- From the Framingham Heart Study, Framingham, MA (F.N.D., R.S.V.); Department of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (F.N.D.); and Cardiology Section, and Preventive Medicine Section, Boston University School of Medicine, Boston, MA (R.S.V.).
| | - Ramachandran S Vasan
- From the Framingham Heart Study, Framingham, MA (F.N.D., R.S.V.); Department of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (F.N.D.); and Cardiology Section, and Preventive Medicine Section, Boston University School of Medicine, Boston, MA (R.S.V.)
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Achelrod D, Blankart CR, Linder R, von Kodolitsch Y, Stargardt T. The economic impact of Marfan syndrome: a non-experimental, retrospective, population-based matched cohort study. Orphanet J Rare Dis 2014; 9:90. [PMID: 24954169 PMCID: PMC4082619 DOI: 10.1186/1750-1172-9-90] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 06/17/2014] [Indexed: 01/01/2023] Open
Abstract
Background Marfan syndrome is a rare disease of the connective tissues, affecting multiple organ systems. Elevated morbidity and mortality in these patients raises the issue of costs for sickness funds and society. To date, there has been no study analysing the costs of Marfan syndrome from a sickness fund and societal perspective. Objective To estimate excess health resource utilisation, direct (non-)medical and indirect costs attributable to Marfan syndrome from a healthcare payer and a societal perspective in Germany in 2008. Methods A retrospective matched cohort study design is applied, using claims data. For isolating the causal effect of Marfan syndrome on excess costs, a genetic matching algorithm was used to reduce differences in observable characteristics between Marfan syndrome patients and the control group. 892 patients diagnosed with Marfan syndrome (ICD-10 Q87.4) were matched from a pool of 26,645 control individuals. After matching, we compared health resource utilisation and costs. Results From the sickness fund perspective, an average Marfan syndrome patient generates excess annual costs of €2496 compared with a control individual. From the societal perspective, excess annual costs amount to €15,728. For the sickness fund, the strongest cost drivers are inpatient treatment and care by non-physicians. From the sickness fund perspective, the third (25–41 years) and first (0–16 years) age quartiles reveal the greatest surplus in total costs. Marfan syndrome patients have 39% more physician contacts, a 153% longer average length of hospital stay, 119% more inpatient stays, 33% more prescriptions, 236% more medical imaging and 20% higher average prescription costs than control individuals. Depending on the prevalence, the economic impact from the sickness fund perspective ranges between €24.0 million and €61.4 million, whereas the societal economic impact extends from €151.3 million to €386.9 million. Conclusions Relative to its low frequency, Marfan syndrome requires high healthcare expenditure. Not only the high costs of Marfan syndrome but also its burden on patients’ lives call for more awareness from policy-makers, physicians and clinical researchers. Consequently, the diagnosis and treatment of Marfan syndrome should begin as soon as possible in order to prevent disease complications, early mortality and substantial healthcare expenditure.
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Affiliation(s)
- Dmitrij Achelrod
- Hamburg Center for Health Economics (HCHE), Universität Hamburg, Esplanade 36, 20354 Hamburg, Germany.
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Koo HK, Lawrence KAK, Musini VM. Beta-blockers for preventing aortic dissection in Marfan's syndrome. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2014. [DOI: 10.1002/14651858.cd011103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Hyun-Kyoung Koo
- University of British Columbia; Department of Anesthesiology, Pharmacology and Therapeutics; 217-2176 Health Sciences Mall Vancouver British Columbia Canada V6T 1Z3
| | - Kendra AK Lawrence
- Vancouver Coastal Health Authority; Department of Medicine/Transitional Care Unit; 2307-1255 Bidwell Street Vancouver British Columbia Canada V6G 2K8
| | - Vijaya M Musini
- University of British Columbia; Department of Anesthesiology, Pharmacology and Therapeutics; 217-2176 Health Sciences Mall Vancouver British Columbia Canada V6T 1Z3
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