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Curtis SL, Swan L. Aortopathy in pregnancy. BRITISH HEART JOURNAL 2022; 108:1851-1857. [PMID: 35144984 DOI: 10.1136/heartjnl-2021-319828] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 01/12/2022] [Indexed: 11/04/2022]
Abstract
Aortic dissection is one of the most common causes of death in pregnancy. Most cases are caused by hereditary thoracic aortopathy (HTA), and women are often unaware they are at risk. Awareness, early recognition and involvement of senior clinicians from the expert cardio-obstetric team are essential to facilitate early diagnosis and carefully planned and coordinated antenatal and postnatal care. Frequent imaging antenatally and good blood pressure control are key. Delivery needs particular attention with optimal pain control and techniques to minimise maternal effort. Dissection is most common post partum and a period of close surveillance with meticulous blood pressure control after delivery is crucial, as well as follow-up of the baby in paediatric services. All women with a family history of aortic dissection or sudden death should be investigated. Women with known HTA should be offered specialist individualised pre-pregnancy counselling, including advice about genetics and inheritance, before starting a family. Future research is directed towards more individualised risk assessment, pre-pregnancy advice and pharmacological options to reduce dissection risk.
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Affiliation(s)
| | - Lorna Swan
- Department of Adult Congenital Heart Disease, Golden Jubilee National Hospital West of Scotland Regional Heart and Lung Centre, Glasgow, UK
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Narula N, Devereux RB, Malonga GP, Hriljac I, Roman MJ. Pregnancy-Related Aortic Complications in Women With Marfan Syndrome. J Am Coll Cardiol 2021; 78:870-879. [PMID: 34446158 DOI: 10.1016/j.jacc.2021.06.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/16/2021] [Accepted: 06/23/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND The risk of pregnancy-associated vascular complications in Marfan syndrome (MFS) is uncertain because of ascertainment bias, prepartum lack of knowledge of diagnosis, and insufficient peripartum imaging data. Furthermore, U.S. and European guidelines differ in pregnancy recommendations in MFS. OBJECTIVES This study describes a single-center experience of 169 MFS women to address these gaps. METHODS Clinical, imaging, and pregnancy history were compared in never vs ever-pregnant MFS women, and pregnancy-associated vascular complications were described. RESULTS A total of 74 ever-pregnant women had 112 live births. Elective aortic root replacement occurred at a younger age in never-pregnant women (33 years vs 42 years; P = 0.0026). Although aortic dissection prevalence did not differ between never-pregnant vs ever-pregnant women (23% vs 31%; P = 0.25), it tended to occur at an earlier age in the former group (38 years vs 45 years; P = 0.07). Of observed "sanctioned" pregnancies with prepartum diameters ≤4.5 cm, mean pregnancy-related aortic diameters remained stable. In total, 5 dissections were associated with pregnancy: 2 type A in women unaware of their diagnosis; and 2 type B and 1 isolated coronary artery dissection in women aware of their diagnosis. Dissection rates were 5-fold higher in the pregnancy vs nonpregnancy period. CONCLUSIONS Pregnancy-related type A dissection only occurred in patients unaware of their diagnosis. Type B dissection remains an unpredictable complication. Although there were baseline differences between the never- and ever-pregnant groups, no difference in dissection risk was observed outside the peripartum period. Those with prepartum aortic diameters between 4.0 and 4.5 cm demonstrated stable aortic dimensions throughout pregnancy. These findings provide a rationale to update existing U.S. guidelines for the management of pregnancy in MFS.
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Affiliation(s)
- Nupoor Narula
- Division of Cardiology, Weill Cornell Medicine, New York, New York, USA. https://twitter.com/DrNupoorNarula
| | | | - Grace P Malonga
- Division of Cardiology, Weill Cornell Medicine, New York, New York, USA
| | - Ingrid Hriljac
- Division of Cardiology, Weill Cornell Medicine, New York, New York, USA
| | - Mary J Roman
- Division of Cardiology, Weill Cornell Medicine, New York, New York, USA.
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Patberg E, Duffy J, Hameed AB. Rupture of a Type B Aortic Dissection in a Postpartum Patient with Marfan Syndrome. AJP Rep 2019; 9:e256-e261. [PMID: 31435486 PMCID: PMC6702027 DOI: 10.1055/s-0039-1692712] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 05/14/2019] [Indexed: 02/06/2023] Open
Abstract
Background Pregnant women with Marfan syndrome (MFS) are known to be at increased risk of aortic dissection; however, cases of aortic rupture are extremely rare. There is lack of consensus on the exact site and size of aortic diameter measurement that increases this risk, and whether this applies to both Type A and Type B dissections. Case A 23-year-old G2P1001 with known Marfan syndrome who underwent an uncomplicated antepartum and intrapartum course. She experienced persistent backache 10 days postpartum that led to the diagnosis of Stanford Type B dissection. The patient was hospitalized for close observation. Dissection progressed to aortic rupture within 24 hours that required emergent thoracic endovascular aortic repair. She had an uncomplicated postoperative course. Conclusion Our report demonstrates rupture of a known aortic dissection within a very short time in the postpartum period. The case highlights the importance of patient education and close surveillance especially in the postpartum period. It also brings home the value of imaging of the whole aorta rather than focusing on the ascending alone. Multidisciplinary care and timely diagnosis and intervention likely led to the favorable outcome in our case.
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Affiliation(s)
- Elizabeth Patberg
- Department of Obstetrics and Gynecology, Irvine Medical Center, University of California, Orange, California
| | - Jennifer Duffy
- Department of Obstetrics and Gynecology, Irvine Medical Center, University of California, Orange, California
| | - Afshan B Hameed
- Department of Obstetrics and Gynecology, Irvine Medical Center, University of California, Orange, California
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Cheulot P, Saucedo M, Bouvier-Colle MH, Deneux Tharaux C, Kayem G. [Maternal mortality among women with Marfan syndrome or vascular Ehlers-Danlos syndrome in France, 2001-2012]. ACTA ACUST UNITED AC 2018; 47:30-35. [PMID: 30497941 DOI: 10.1016/j.gofs.2018.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To describe maternal deaths in France associated with Marfan's syndrome or vascular Ehlers-Danlos syndrome. STUDY DESIGN A retrospective descriptive study based on data from the national confidential enquiry into maternal deaths, in France, during 2001-2012. Characteristics of the patients, their pregnancies and details of their deaths were analysed. The specific maternal mortality ratio by Marfan's syndrome or vascular Ehlers-Danlos syndrome was estimated. RESULTS Among 973 maternal deaths that occurred during the study period, five (0.4%) had a Marfan's syndrome (n=3) or a vascular Ehlers-Danlos syndrome (n=2), confirmed or suspected. The maternal mortality ratio due to Marfan's syndrome or vascular Ehlers-Danlos syndrome between 2001 and 2012 was 0.04/100,000 live births (IC 95% [0.011-0.2]). Three maternal deaths were caused by aortic dissections and two by other arterial ruptures. The deaths have occurred after 37 weeks of pregnancy for 4 patients, and at fifteen days of post-partum for one patient. The median age of death was 30 years. Three patients were nulliparous. Marfan's syndrome and vascular Ehlers-Danlos syndrome were not identified before the death of these five patients. CONCLUSION Five patients with, or suspected to have, Marfan's syndrome or vascular Ehlers-Danlos syndrome were identified. Early diagnosis of these syndromes in pregnant women before life threatening events is very important, especially to refer them to appropriate care.
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Affiliation(s)
- P Cheulot
- Service de gynécologie-obstétrique, hôpital Armand-Trousseau, Assistance publique-Hôpitaux de Paris, 26, avenue du Dr Arnold-Netter, 75012 Paris, France.
| | - M Saucedo
- Inserm U1153, équipe EPOPé, épidémiologie obstétricale périnatale et pédiatrique, centre de recherche en statistiques et épidémiologie, université Paris Descartes, DHU risques et grossesse, 53, avenue de l'observatoire, 75014 Paris, France
| | - M H Bouvier-Colle
- Inserm U1153, équipe EPOPé, épidémiologie obstétricale périnatale et pédiatrique, centre de recherche en statistiques et épidémiologie, université Paris Descartes, DHU risques et grossesse, 53, avenue de l'observatoire, 75014 Paris, France
| | - C Deneux Tharaux
- Inserm U1153, équipe EPOPé, épidémiologie obstétricale périnatale et pédiatrique, centre de recherche en statistiques et épidémiologie, université Paris Descartes, DHU risques et grossesse, 53, avenue de l'observatoire, 75014 Paris, France
| | - G Kayem
- Service de gynécologie-obstétrique, hôpital Armand-Trousseau, Assistance publique-Hôpitaux de Paris, 26, avenue du Dr Arnold-Netter, 75012 Paris, France; Inserm U1153, équipe EPOPé, épidémiologie obstétricale périnatale et pédiatrique, centre de recherche en statistiques et épidémiologie, université Paris Descartes, DHU risques et grossesse, 53, avenue de l'observatoire, 75014 Paris, France
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Minsart AF, Mongeon FP, Laberge AM, Morin F, Dore A, Leduc L. Obstetric and cardiac outcomes in women with Marfan syndrome and an aortic root diameter ≤ 45mm. Eur J Obstet Gynecol Reprod Biol 2018; 230:68-72. [DOI: 10.1016/j.ejogrb.2018.09.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 08/10/2018] [Accepted: 09/10/2018] [Indexed: 01/16/2023]
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Williams D, Lindley KJ, Russo M, Habashi J, Dietz HC, Braverman AC. Pregnancy after Aortic Root Replacement in Marfan's Syndrome: A Case Series and Review of the Literature. AJP Rep 2018; 8:e234-e240. [PMID: 30473905 PMCID: PMC6193806 DOI: 10.1055/s-0038-1675347] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 08/30/2018] [Indexed: 11/03/2022] Open
Abstract
Objectives We sought to characterize pregnancy-related aortic complications in women with Marfan's syndrome who had prior aortic root replacement. Study Design This is a retrospective case series study and literature review of women with Marfan's syndrome with pregnancy after aortic root replacement. We surveyed women with Marfan's syndrome who had successful pregnancy after aortic root replacement using the Marfan Foundation Website and from two large tertiary care Marfan's clinics. Clinical data, counseling information, and details of pregnancy-related aortic complications were compiled. A literature review was performed assessing aortic outcomes in women with Marfan's syndrome with pregnancy after aortic surgery. Results Fourteen women with 20 pregnancies were identified. Two women had three pregnancies following root replacement for aortic dissection. There were no aortic dissections during the 20 pregnancies. In contrast, aortic dissection was frequently reported in the literature. Conclusions Women with Marfan's syndrome who become pregnant following aortic root replacement remain at risk for distal aortic dissection related to pregnancy. The exact risk is difficult to quantify but is not zero and women should be counseled accordingly.
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Affiliation(s)
- Dominique Williams
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Kathryn J Lindley
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Melissa Russo
- Department of Obstetrics and Gynecology, Warren Alpert Medical School at Brown University, Providence, Rhode Island
| | - Jennifer Habashi
- Johns Hopkins University School of Medicine, Howard Hughes Medical Institute, Baltimore, Maryland
| | - Harry C Dietz
- Johns Hopkins University School of Medicine, Howard Hughes Medical Institute, Baltimore, Maryland
| | - Alan C Braverman
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
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Makatsariya A, Radetskaya L, Bitsadze V, Khizroeva J, Khamani N, Makatsariya N. Prenatal care and labor in patients with mesenchimal dysplasias (Marfan syndrome, Ehlers-Danlos syndrome, hereditary hemorrhagic telangiectasia). J Matern Fetal Neonatal Med 2018; 33:373-379. [PMID: 29938556 DOI: 10.1080/14767058.2018.1493102] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Background: Mesenchymal dysplasias or inherited connective tissue diseases are the group of diseases with deficiency of various components of connective tissue. Connective tissue disorders can affect different organs: skeleton, sight organ, skin, lungs, heart. But the most dangerous is vascular wall insufficiency leading to high risk of hemorrhage, especially during pregnancy and delivery due to hemodynamic and hormonal effects on the walls of the modified vessels.Aim: To evaluate the risk of complications during the pregnancy and delivery in patients with mesenchymal dysplasias.Study design: Fifty-six pregnancies in patients with mesenchymal dysplasias, including subclinical forms of diseases: 23 with Marfan syndrome (I group), 22 with Ehlers-Danlos syndrome (II group), and 11 with Osler-Weber-Rendu syndrome (hereditary hemorrhagic telangiectasia) (III group) of the age from 18 to 36. The study included retrospective analysis (for the period from 1993 to 2005) and prospective study. Results of study showed high risk of life-threatening complications during pregnancy and delivery, especially the risk of hemorrhage and cardiovascular complications. In all the patients, we observed the progression of bleeding or development of bleeding in new localizations (epistaxis in 27 patients, easy brushing in 22, skin and mucosa telangiectasia in 20, gastrointestinal bleedings in 4, hemoptysis in 4, hematomas for minor traumas in 14, conjunctivas hemorrhages in 5).Conclusion: The pathogenesis of bleeding in such patients has mixed pattern: besides vascular wall pathology coagulation deficiency plays some role. The preferred delivery method for such patients is caesarean section. Deep vaginal ruptures and serious hemorrhage accompany vaginal delivery.
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Affiliation(s)
- Alexander Makatsariya
- Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Lyudmila Radetskaya
- Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Viktoriya Bitsadze
- Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Jamilya Khizroeva
- Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Nadin Khamani
- Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Natalya Makatsariya
- Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
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Rao P, Isselbacher EM. Preconception Counseling for Patients With Thoracic Aortic Aneurysms. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:50. [PMID: 29749581 DOI: 10.1007/s11936-018-0640-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
PURPOSE OF THE REVIEW Acute aortic dissection is a potentially catastrophic cardiovascular emergency that is associated with a high mortality rate. Pregnancy, with its attendant hormonal and physiological changes, increases the risk of dissection in women with known thoracic aortic aneurysms. In this review, we highlight the importance of preconception counseling to help women with known thoracic aortic aneurysms better understand their risk of dissection and the heritable nature of thoracic aortic disease and its associated syndromes. RECENT FINDINGS The risk of aortic dissection during pregnancy differs according to the underlying etiology of thoracic aortic aneurysm and the degree of aortic dilatation at baseline. Guideline-specific management of women with thoracic aortic aneurysms in pregnancy reduces their risk of dissection. Management of pregnant women with thoracic aortic aneurysms requires an intensive multidisciplinary approach to maximize the chances of a successful outcome for both the mother and fetus. Preconception counseling provides an opportunity to optimize patients medically and to consider potential prophylactic aortic repair prior to pregnancy.
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Affiliation(s)
- Prashant Rao
- Massachusetts General Hospital, 55 Fruit St., YAW-5800, Boston, MA, 02114, USA
| | - Eric M Isselbacher
- Massachusetts General Hospital, 55 Fruit St., YAW-5800, Boston, MA, 02114, USA.
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Goland S, Elkayam U. Pregnancy and Marfan syndrome. Ann Cardiothorac Surg 2017; 6:642-653. [PMID: 29270376 PMCID: PMC5721114 DOI: 10.21037/acs.2017.10.07] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 10/16/2017] [Indexed: 01/15/2023]
Abstract
Pregnancy in women with Marfan syndrome (MFS) presents challenges to the clinician and the patient due to the increased incidence of maternal complications and involvement of the fetus, and deserves special consideration. The leading cause of morbidity and mortality in MFS is aortic dissection. This article presents an extensive review of available clinical information and provides recommendations for the management of patients with MFS during pregnancy.
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Affiliation(s)
- Sorel Goland
- Heart Institute, Kaplan Medical Center, Rehovot, affiliated to Hebrew University, Jerusalem, Israel
| | - Uri Elkayam
- Department of Medicine, Division of Cardiovascular Disease, and Department of Obstetrics and Gynaecology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Kim SY, Wolfe DS, Taub CC. Cardiovascular outcomes of pregnancy in Marfan's syndrome patients: A literature review. CONGENIT HEART DIS 2017; 13:203-209. [DOI: 10.1111/chd.12546] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 09/24/2017] [Accepted: 09/25/2017] [Indexed: 11/30/2022]
Affiliation(s)
- So Yeon Kim
- Tufts Medical Center; Boston Massachusetts, USA
- Montefiore Medical Center; Bronx New York, USA
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Renard M, Muiño-Mosquera L, Manalo EC, Tufa S, Carlson EJ, Keene DR, De Backer J, Sakai LY. Sex, pregnancy and aortic disease in Marfan syndrome. PLoS One 2017; 12:e0181166. [PMID: 28708846 PMCID: PMC5510874 DOI: 10.1371/journal.pone.0181166] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 06/26/2017] [Indexed: 01/13/2023] Open
Abstract
Background Sex-related differences as well as the adverse effect of pregnancy on aortic disease outcome are well-established phenomena in humans with Marfan syndrome (MFS). The underlying mechanisms of these observations are largely unknown. Objectives In an initial (pilot) step we aimed to confirm the differences between male and female MFS patients as well as between females with and without previous pregnancy. We then sought to evaluate whether these findings are recapitulated in a pre-clinical model and performed in-depth cardiovascular phenotyping of mutant male and both nulliparous and multiparous female Marfan mice. The effect of 17β-estradiol on fibrillin-1 protein synthesis was compared in vitro using human aortic smooth muscle cells and fibroblasts. Results Our small retrospective study of aortic dimensions in a cohort of 10 men and 20 women with MFS (10 pregnant and 10 non-pregnant) confirmed that aortic root growth was significantly increased in the pregnant group compared to the non-pregnant group (0.64mm/year vs. 0.12mm/year, p = 0.018). Male MFS patients had significantly larger aortic root diameters compared to the non-pregnant and pregnant females at baseline and follow-up (p = 0.002 and p = 0.007, respectively), but no significant increase in aortic root growth was observed compared to the females after follow-up (p = 0.559 and p = 0.352). In the GT-8/+ MFS mouse model, multiparous female Marfan mice showed increased aortic diameters when compared to nulliparous females. Aortic dilatation in multiparous females was comparable to Marfan male mice. Moreover, increased aortic diameters were associated with more severe fragmentation of the elastic lamellae. In addition, 17β-estradiol was found to promote fibrillin-1 production by human aortic smooth muscle cells. Conclusions Pregnancy-related changes influence aortic disease severity in otherwise protected female MFS mice and patients. There may be a role for estrogen in the female sex protective effect.
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Affiliation(s)
- Marjolijn Renard
- Center for Medical Genetics Ghent, Ghent University, Ghent, Belgium
- * E-mail:
| | | | - Elise C. Manalo
- Department of Molecular & Medical Genetics and Biochemistry & Molecular Biology, Shriners Hospital for Children, Portland, Oregon, United States of America
| | - Sara Tufa
- Micro-Imaging Center, Shriners Hospital for Children, Portland, Oregon, United States of America
| | - Eric J. Carlson
- Department of Molecular & Medical Genetics and Biochemistry & Molecular Biology, Shriners Hospital for Children, Portland, Oregon, United States of America
| | - Douglas R. Keene
- Micro-Imaging Center, Shriners Hospital for Children, Portland, Oregon, United States of America
| | - Julie De Backer
- Center for Medical Genetics Ghent, Ghent University, Ghent, Belgium
| | - Lynn Y. Sakai
- Department of Molecular & Medical Genetics and Biochemistry & Molecular Biology, Shriners Hospital for Children, Portland, Oregon, United States of America
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Sayama S, Takeda N, Iriyama T, Inuzuka R, Maemura S, Fujita D, Yamauchi H, Nawata K, Bougaki M, Hyodo H, Shitara R, Nakayama T, Komatsu A, Nagamatsu T, Osuga Y, Fujii T. Peripartum type B aortic dissection in patients with Marfan syndrome who underwent aortic root replacement: a case series study. BJOG 2017; 125:487-493. [PMID: 28294527 DOI: 10.1111/1471-0528.14635] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To investigate pregnancy outcomes, especially the risk of pregnancy-related aortic dissection (AD), in patients with Marfan syndrome (MFS) after prophylactic aortic root replacement (ARR). DESIGN Retrospective case series study. SETTING Tertiary perinatal care centre at a university hospital. POPULATION Pregnant women fulfilling the revised Ghent nosology (2010) criteria for MFS who were managed at our institute. METHODS The pregnancy outcomes of all patients with MFS managed at our institute between 1982 and September 2016 were reviewed retrospectively based on medical records. MAIN OUTCOME MEASURES Obstetrical management and complication including the incidence of AD throughout the peripartum period. RESULTS Among 22 patients (28 pregnancies) who had been managed as potential MFS or related disorders, 14 (17 pregnancies) fulfilled the revised Ghent nosology (2010) criteria for MFS and were enrolled in this study. Five patients (five pregnancies) had received ARR before conception: three (60%) developed type B aortic dissection [AD(B)] during the peripartum period, compared with only one of 10 patients (12 pregnancies) without ARR (P < 0.05, Chi-square test). CONCLUSIONS Our study results suggest that MFS patients after prophylactic ARR are still at high risk of AD(B) during the peripartum period. Careful pre-pregnancy counselling and multidisciplinary care throughout the peripartum period are essential for the management of MFS, even after surgical repair of an ascending aortic aneurysm. TWEETABLE ABSTRACT MFS patients after prophylactic ARR are still at high risk of type B aortic dissection during the peripartum period.
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Affiliation(s)
- S Sayama
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - N Takeda
- Department of Cardiovascular Medicine, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - T Iriyama
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - R Inuzuka
- Department of Pediatrics, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - S Maemura
- Department of Cardiovascular Medicine, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - D Fujita
- Department of Cardiovascular Medicine, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - H Yamauchi
- Department of Cardiovascular Surgery, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - K Nawata
- Department of Cardiovascular Surgery, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - M Bougaki
- Department of Anesthesiology and Pain Relief Center, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - H Hyodo
- Department of Obstetrics and Gynecology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - R Shitara
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - T Nakayama
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - A Komatsu
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - T Nagamatsu
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - Y Osuga
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - T Fujii
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tokyo, Tokyo, Japan
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Smith K, Gros B. Pregnancy-related acute aortic dissection in Marfan syndrome: A review of the literature. CONGENIT HEART DIS 2017; 12:251-260. [PMID: 28371362 DOI: 10.1111/chd.12465] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 03/08/2017] [Accepted: 03/10/2017] [Indexed: 11/25/2022]
Abstract
A well-established association exists between acute aortic dissection and pregnancy, particularly in women with Marfan syndrome. However, there is debate regarding appropriate management guidelines. In particular, there are differing opinions regarding when prophylactic aortic root repair should be recommended as well as the efficacy of beta blockers in this clinical scenario. The current study evaluated 10 years of published literature (2005-2015) in the PubMed/Medline database. Fifty articles, describing 72 cases of women who presented with aortic dissection in the antepartum or postpartum period were identified. Comparisons on demographic variables and clinical outcomes between cases of women with Marfan syndrome (n = 36) and without Marfan syndrome (n = 36) were conducted. There were no significant differences in demographics (age, gravidity, parity) between the Marfan and non-Marfan cases. Marfan patients presented with antepartum dissections significantly earlier in pregnancy than those without Marfan syndrome (P = .002). However, there were no significant difference between the 2 groups in maternal mortality, fetal mortality, or obstetric outcomes (mode of delivery and gestational age at delivery). Eight cases described events in Marfan women with an aortic root diameter ≤40 mm. Six events occurred in Marfan women who were managed with beta blockers. Current guidelines rely on aortic root diameter for stratification of Marfan women into risk categories, but we identified several cases that would be missed by these guidelines. Specifically, the existing literature suggest that women with Marfan syndrome should take precautions throughout pregnancy, rather than the third trimester.
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Affiliation(s)
| | - Bernard Gros
- University of Central Florida College of Medicine
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15
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At the Heart of the Pregnancy: What Prenatal and Cardiovascular Genetic Counselors Need to Know about Maternal Heart Disease. J Genet Couns 2017; 26:669-688. [DOI: 10.1007/s10897-017-0081-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 02/14/2017] [Indexed: 01/25/2023]
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16
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De Backer J, Muiño-Mosquera L, Demulier L. Aortopathy. PREGNANCY AND CONGENITAL HEART DISEASE 2017. [DOI: 10.1007/978-3-319-38913-4_12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Roman MJ, Pugh NL, Hendershot TP, Devereux RB, Dietz H, Holmes K, Eagle KA, LeMaire SA, Milewicz DM, Morris SA, Pyeritz RE, Ravekes WJ, Shohet RV, Silberbach M. Aortic Complications Associated With Pregnancy in Marfan Syndrome: The NHLBI National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions (GenTAC). J Am Heart Assoc 2016; 5:JAHA.116.004052. [PMID: 27515814 PMCID: PMC5015314 DOI: 10.1161/jaha.116.004052] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The risk of aortic complications associated with pregnancy in women with Marfan syndrome (MFS) is not fully understood. METHODS AND RESULTS MFS women participating in the large National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions (GenTAC) were evaluated. Among 184 women with MFS in whom pregnancy information was available, 94 (51%) had a total of 227 pregnancies. Among the women with pregnancies, 10 (10.6%) experienced a pregnancy-related aortic complication (4 type A and 3 type B dissections, 1 coronary artery dissection, and 2 with significant [≥3 mm] aortic growth). Five of 7 aortic dissections, including all 3 type B, and the coronary dissection (75% of all dissections) occurred in the postpartum period. Only 5 of 8 women with pregnancy-associated dissection were aware of their MFS diagnosis. The rate of aortic dissection was higher during the pregnancy and postpartum period (5.4 per 100 person-years vs 0.6 per 100 person-years of nonpregnancy; rate ratio, 8.4 [95% CI=3.9, 18.4]; P<0.0001). CONCLUSIONS Pregnancy in MFS is associated with an increased risk of aortic dissection, both types A and B, particularly in the immediate postpartum period. Lack of knowledge of underlying MFS diagnosis before aortic dissection is a major contributing factor. These findings underscore the need for early diagnosis, prepregnancy risk counseling, and multidisciplinary peripartum management.
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Affiliation(s)
- Mary J Roman
- Division of Cardiology, Weill Cornell Medical College, New York, NY
| | - Norma L Pugh
- Biostatistics and Epidemiology Division, RTI International, Rockville, MD
| | | | | | - Hal Dietz
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kathryn Holmes
- Department of Pediatrics, Oregon Health & Sciences University, Portland, OR
| | - Kim A Eagle
- Division of Cardiology, University of Michigan Health System, Ann Arbor, MI
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX
| | - Dianna M Milewicz
- Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, Houston, TX
| | - Shaine A Morris
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Reed E Pyeritz
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - William J Ravekes
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ralph V Shohet
- Department of Medicine, John A. Burns School of Medicine, Honolulu, HI
| | - Michael Silberbach
- Department of Pediatrics, Oregon Health & Sciences University, Portland, OR
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Kamel H, Roman MJ, Pitcher A, Devereux RB. Pregnancy and the Risk of Aortic Dissection or Rupture: A Cohort-Crossover Analysis. Circulation 2016; 134:527-33. [PMID: 27492904 DOI: 10.1161/circulationaha.116.021594] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 06/15/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND Case series have described aortic dissection and rupture in pregnancy. Few population-based data exist to support an association. METHODS We performed a cohort-crossover study using data on all emergency department visits and acute care hospitalizations at nonfederal healthcare facilities in California, Florida, and New York. We included women ≥12 years of age with labor and delivery or abortive pregnancy outcome between 2005 and 2013. Our outcome was a composite of aortic dissection or rupture. Based on the timing of reported aortic complications during pregnancy, we defined the period of risk as 6 months before delivery until 3 months after delivery. We compared each patient's likelihood of aortic complications during this period with an equivalent 270-day period exactly 1 year later. Incidence rates and incidence rate ratios were computed using conditional Poisson regression with robust standard errors. RESULTS Among 6 566 826 pregnancies in 4 933 697 women, we identified 36 cases of aortic dissection or rupture during the pregnancy or postpartum period and 9 cases during the control period 1 year later. The rate of aortic complications was 5.5 (95% confidence interval, 4.0-7.8) per million patients during pregnancy and the postpartum period, in comparison with 1.4 (95% confidence interval, 0.7-2.9) per million during the equivalent period 1 year later. Pregnancy was associated with a significantly increased risk of aortic dissection or rupture (incidence rate ratio, 4.0; 95% confidence interval, 2.0-8.2) in comparison with the control period 1 year later. CONCLUSIONS The risk of aortic dissection or rupture is elevated during pregnancy and the postpartum period.
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Affiliation(s)
- Hooman Kamel
- From Department of Neurology (H.K.), Feil Family Brain and Mind Research Institute (H.K.), and Division of Cardiology M.J.R., R.B.D.), Weill Cornell Medicine, New York, NY; and Radcliffe Department of Medicine, Division of Cardiovascular Medicine, University of Oxford, Oxford, UK (A.P.).
| | - Mary J Roman
- From Department of Neurology (H.K.), Feil Family Brain and Mind Research Institute (H.K.), and Division of Cardiology M.J.R., R.B.D.), Weill Cornell Medicine, New York, NY; and Radcliffe Department of Medicine, Division of Cardiovascular Medicine, University of Oxford, Oxford, UK (A.P.)
| | - Alex Pitcher
- From Department of Neurology (H.K.), Feil Family Brain and Mind Research Institute (H.K.), and Division of Cardiology M.J.R., R.B.D.), Weill Cornell Medicine, New York, NY; and Radcliffe Department of Medicine, Division of Cardiovascular Medicine, University of Oxford, Oxford, UK (A.P.)
| | - Richard B Devereux
- From Department of Neurology (H.K.), Feil Family Brain and Mind Research Institute (H.K.), and Division of Cardiology M.J.R., R.B.D.), Weill Cornell Medicine, New York, NY; and Radcliffe Department of Medicine, Division of Cardiovascular Medicine, University of Oxford, Oxford, UK (A.P.)
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Pregnancy and Thoracic Aortic Disease: Managing the Risks. Can J Cardiol 2015; 32:78-85. [PMID: 26604124 DOI: 10.1016/j.cjca.2015.09.003] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 09/11/2015] [Accepted: 09/11/2015] [Indexed: 12/24/2022] Open
Abstract
The most common aortopathies in women of childbearing age are bicuspid aortic valve, coarctation of the aorta, Marfan syndrome, Ehlers-Danlos syndrome, Loeys-Dietz syndrome, SMAD3 aortopathy, Turner syndrome, and familial thoracic aneurysm and dissection. The hemodynamic and hormonal changes of pregnancy increase the risk of progressive dilatation or dissection of the aorta in these women. The presence of hypertension increases the risk further. Therefore, appropriate preconception counselling is advised. For women who become pregnant, serial follow-up by a specialized multidisciplinary team throughout pregnancy and postpartum period is required. In this review we discuss risk assessment and management strategies for women with aortopathies.
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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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Shim WJ. Role of echocardiography in the management of cardiac disease in women. J Cardiovasc Ultrasound 2014; 22:173-9. [PMID: 25580190 PMCID: PMC4286637 DOI: 10.4250/jcu.2014.22.4.173] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 11/25/2014] [Accepted: 11/27/2014] [Indexed: 12/14/2022] Open
Abstract
The widespread use of echocardiography has contributed to the early recognition of several distinct cardiac diseases in women. During pregnancy, safe monitoring of the disease process, as well as a better understanding of hemodynamics, is possible. During the use of potentially cardiotoxic drugs for breast cancer chemotherapy, echocardiographic patient monitoring is vital. Compared to men, the addition of an imaging modality to routine electrocardiogram monitoring during stress testing is more informative for diagnosing coronary disease in women. This review briefly discusses the role of echocardiography in the management of several women-specific cardiac diseases where echocardiography plays a pivotal role in disease management.
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Affiliation(s)
- Wan Joo Shim
- Division of Cardiology, Korea University Anam Hospital, Seoul, Korea
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Bradley EA, Zaidi AN, Goldsmith P, Sisk T, Colombo D, Roble S, Bradley D, Daniels C. Major adverse maternal cardiovascular-related events in those with aortopathies. What should we expect? Int J Cardiol 2014; 177:229-34. [DOI: 10.1016/j.ijcard.2014.09.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Revised: 08/26/2014] [Accepted: 09/15/2014] [Indexed: 11/30/2022]
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Abstract
Adults with congenital heart disease now form the largest group of women with cardiac disease becoming pregnant in the developed world. This is both a mark of impressive steps forward in the management of congenital heart disease and also a challenge to the medical community to develop systems of care that will best serve these women and their babies. Each woman with congenital heart disease presents a unique pattern of challenges for the cardiologist, obstetrician, and anesthesiologist, and their care should be tailored to deal with their individual circumstances. As this population of patients continues to grow, we must continue to learn and improve our diagnostic tools and management strategies to refine their care. This review intends to focus on reviewing the outcomes in this set of patients and also an approach to the assessment and the management of these patients, primarily for an audience of obstetricians, pediatricians, and anesthesiologists.
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Affiliation(s)
- Shaline Rao
- Division of Cardiology, Columbia University Medical Center, New York, NY
| | - Jonathan N Ginns
- Division of Cardiology, Columbia University Medical Center, New York, NY.
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Abstract
This review is intended to summarize the current knowledge from basic science and clinical medical literature cited within PubMed that pertain to gender-related factors and affect those individuals with hereditary ocular disorders. We consider gender-related biological factors that (a) affect disease onset and progression, (b) gender differences for major X-linked ocular disorders, (c) gender-specific conditions, (d) medications that may influence genetic eye disorders, and finally, (e) gender-related issues that influence the management and quality of life of these patients. Several studies have demonstrated the manner in which sex-related hormones in animal models are capable of influencing cell pathway and survival that are likely to affect hereditary eye disorders. There are very few clinical studies that provide compelling evidence for gender differences in human ocular conditions, other than for a number of X-linked disorders. Disease expression for X-linked disorders may be impacted by genetic mechanisms such as lyonization or uniparental disomy. Clinical evidence regarding the impact of gender-related medical conditions and therapies on eye conditions is extremely limited and primarily based on anecdotal evidence. Gender-specific factors may play a major role in the underlying biological pathways that influence the onset, rate of progression, and clinical findings associated with ocular genetic conditions. Clinicians need to be aware of the variable phenotypes observed in female carriers of X-linked disorders of gender specific issues, many of which are inadequately addressed in the current literature. Clinicians need to be sensitive to gender differences in social, cultural, and religious systems and they should also be aware of how their own gender biases may influence how they counsel patients. Finally, it is clear that the lack of effective clinical studies in this area creates an opportunity for future research that will have real benefits for these patients.
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van Hagen IM, Roos-Hesselink JW. Aorta pathology and pregnancy. Best Pract Res Clin Obstet Gynaecol 2014; 28:537-50. [DOI: 10.1016/j.bpobgyn.2014.03.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Revised: 03/07/2014] [Accepted: 03/18/2014] [Indexed: 01/15/2023]
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