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Yagyu T, Noguchi T. Diagnosis and treatment of cardiovascular disease in patients with heritable connective tissue disorders or heritable thoracic aortic diseases. Cardiovasc Interv Ther 2024; 39:126-136. [PMID: 38182694 DOI: 10.1007/s12928-023-00977-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 11/28/2023] [Indexed: 01/07/2024]
Abstract
Patients with heritable connective tissue disorders (HCTDs), represented by Marfan syndrome, can develop fatal aortic and/or arterial complications before age 50. Therefore, accurate diagnosis, appropriate medical treatment, and early prophylactic surgical treatment of aortic and arterial lesions are essential to improve prognosis. Patients with HCTDs generally present with specific physical features due to connective tissue abnormalities, while some patients with heritable thoracic aortic diseases (HTADs) have few distinctive physical characteristics. The development of genetic testing has made it possible to provide accurate diagnoses for patients with HCTDs/HTADs. This review provides an overview of the diagnosis and treatment of HCTDs/HTADs, including current evidence on cardiovascular interventions for this population.
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Affiliation(s)
- Takeshi Yagyu
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1, Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan.
- Department of Genomic Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1, Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
- Department of Genomic Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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David TE, Park J, Tatangelo M, Steve Fan CP, Ouzounian M. Cardiovascular Events After Aortic Root Repair in Patients With Marfan Syndrome. J Am Coll Cardiol 2023; 82:1068-1076. [PMID: 37673508 DOI: 10.1016/j.jacc.2023.06.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 06/12/2023] [Accepted: 06/16/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND The usefulness of aortic valve sparing operations to treat aortic root aneurysm in patients with Marfan syndrome (MS) remains controversial. OBJECTIVES The purpose of this study was to evaluate the occurrence of cardiovascular events in patients with MS who have undergone valve-preserving aortic root replacement. METHODS Patients with MS who had aortic valve sparing operations (reimplantation of the aortic valve or remodeling of the aortic root) from 1988 through 2019 were followed prospectively for a median of 14 years. Pertinent data from clinical, echocardiographic, computed tomography, and magnetic resonance images of the aorta were collected and analyzed. RESULTS There were 189 patients whose mean age was 36 years, and 67% were men. Ten patients presented with acute type A dissection and 29 had mitral regurgitation. There were 52 patients at risk at 20 years. Mortality rate at 20 years was 21.5% (95% CI: 14.7%-30.8%); advancing age and preoperative aortic dissections were associated with increased risk of death by multivariable analysis. At 20 years, the cumulative incidence of moderate or severe aortic insufficiency was 14.5% (95% CI: 9.5%-22.0%), reoperation on the aortic valve was 7.5% (95% CI: 3.9%-14.7%), and new distal aortic dissections was 19.9% (95% CI: 13.9%-28.5%). Remodeling of aortic root was associated with greater risk of developing aortic insufficiency and aortic valve reoperation than reimplantation of the aortic valve. CONCLUSIONS Aortic valve sparing operations provide stable aortic valve function and low rates of valve-related complications during the first 2 decades of follow-up but aortic dissections remain problematic in patients with MS.
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Affiliation(s)
- Tirone E David
- Division of Cardiovascular Surgery of Toronto General Hospital, Peter Munk Cardiac Centre at University Health Network and University of Toronto, Toronto, Ontario, Canada.
| | - Joy Park
- Division of Cardiovascular Surgery of Toronto General Hospital, Peter Munk Cardiac Centre at University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Mark Tatangelo
- Division of Cardiovascular Surgery of Toronto General Hospital, Peter Munk Cardiac Centre at University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Chun-Po Steve Fan
- Division of Cardiovascular Surgery of Toronto General Hospital, Peter Munk Cardiac Centre at University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery of Toronto General Hospital, Peter Munk Cardiac Centre at University Health Network and University of Toronto, Toronto, Ontario, Canada
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Pellenc Q, Girault A, Eliahou L, Milleron O, Jondeau G. Thoracic aneurysm endovascular repair of extremely tortuous aorta in neonatal Marfan syndrome patient with major scoliosis. J Vasc Surg Cases Innov Tech 2023; 9:101198. [PMID: 37274438 PMCID: PMC10238443 DOI: 10.1016/j.jvscit.2023.101198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 04/04/2023] [Indexed: 06/06/2023] Open
Affiliation(s)
- Quentin Pellenc
- Department of Vascular and Endovascular Surgery, La Cote Health Care Group, Morges, Switzerland
- French National Referral Center for Marfan Disease and Related Disorders, Bichat Hospital, Assistance Publique–Hopitaux de Paris, Paris, France
| | - Antoine Girault
- Department of Vascular and Thoracic Surgery, Bichat Hospital, Assistance Publique–Hopitaux de Paris, Paris, France
| | - Ludivine Eliahou
- French National Referral Center for Marfan Disease and Related Disorders, Bichat Hospital, Assistance Publique–Hopitaux de Paris, Paris, France
- Department of Cardiology, Bichat Hospital, Assistance Publique–Hopitaux de Paris, Paris, France
| | - Olivier Milleron
- French National Referral Center for Marfan Disease and Related Disorders, Bichat Hospital, Assistance Publique–Hopitaux de Paris, Paris, France
- Department of Cardiology, Bichat Hospital, Assistance Publique–Hopitaux de Paris, Paris, France
- INSERM U 1148, LVTS, Bichat Hospital, Paris, France
- Université de Paris, Paris, France
| | - Guillaume Jondeau
- French National Referral Center for Marfan Disease and Related Disorders, Bichat Hospital, Assistance Publique–Hopitaux de Paris, Paris, France
- Department of Cardiology, Bichat Hospital, Assistance Publique–Hopitaux de Paris, Paris, France
- INSERM U 1148, LVTS, Bichat Hospital, Paris, France
- Université de Paris, Paris, France
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Sénémaud J, Gaudry M, Jouve E, Blanchard A, Milleron O, Dulac Y, Olivier-Faivre L, Stephan D, Odent S, Lanéelle D, Dupuis-Girod S, Jondeau G, Bal-Theoleyre L. Primary Non-Aortic Lesions Are Not Rare in Marfan Syndrome and Are Associated with Aortic Dissection Independently of Age. J Clin Med 2023; 12:jcm12082902. [PMID: 37109238 PMCID: PMC10141376 DOI: 10.3390/jcm12082902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/10/2023] [Accepted: 04/15/2023] [Indexed: 04/29/2023] Open
Abstract
PURPOSE The study sought to estimate the prevalence of primary non-aortic lesions (PNAL) unrelated to extension of aortic dissection (AD) in a cohort of patients with Marfan syndrome (MFS). METHODS Adult patients presenting with pathogenic FBN1 mutations and an available pan-aortic contrast-enhanced CTA in eight French MFS clinics from April to October 2018 were included. Clinical and radiological data, particularly the presence of aortic lesions and PNAL (including aneurysm and ectasia), were retrospectively analyzed. RESULTS Out of 138 patients, 28 (20.3%) had PNAL. In total, 27 aneurysms in 13 patients and 41 ectasias in 19 patients were reported mainly in the subclavian, iliac, and vertebral segments. Four patients (31%) with aneurysms and none with ectasia required prophylactic intervention during follow-up (median: 46 months). In multivariate analysis, factors associated with PNAL were history of AD (OR = 3.9, 95%CI: 1.3-12.1, p = 0.018), history of previous descending aortic surgery (OR = 10.3, 95%CI: 2.2-48.3, p = 0.003) and age (per 10 years OR = 1.6, 95%CI: 1.1-2.4, p = 0.008). CONCLUSION PNAL is not rare in MFS patients with evolutive aortic disease. Natural history may differ between aneurysms and ectasia, emphasizing the need for standardized definitions and systematic screening for PNAL.
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Affiliation(s)
- Jean Sénémaud
- Service de Chirurgie Vasculaire, Thoracique et de Transplantation Pulmonaire, AP-HP, CHU Bichat, 75018 Paris, France
| | - Marine Gaudry
- Service de Chirurgie Vasculaire, AP-HM, CHU La Timone, 13385 Marseille, France
| | - Elisabeth Jouve
- Service d'Evaluation Médicale, AP-HM, CHU La Conception, 13005 Marseille, France
| | - Arnaud Blanchard
- Centre de Référence Constitutif Pour le Syndrome de Marfan et Apparentés, Centre Aorte Timone, AP-HM, CHU La Timone Adultes, 13014 Marseille, France
| | - Olivier Milleron
- Centre National de Référence Pour le Syndrome de Marfan et Apparentés, VASCERN HTAD European Reference Centre, Service de Cardiologie, AP-HP, CHU Bichat, INSERM U 1148 LVTS, Université de Paris, 75014 Paris, France
| | - Yves Dulac
- Centre de Référence Constitutif Pour le Syndrome de Marfan et Apparentés, Hôpital des Enfants, CHU de Toulouse, 31300 Toulouse, France
| | - Laurence Olivier-Faivre
- Centre de Compétence Pour le Syndrome de Marfan et Apparentés, Hôpital des Enfants, CHU de Dijon, 21000 Dijon, France
| | - Dominique Stephan
- Centre de Compétence Pour le Syndrome de Marfan et Apparentés, CHU Nouvel Hôpital Civil, 67000 Strasbourg, France
| | - Sylvie Odent
- Centre de Compétence Pour le Syndrome de Marfan et Apparentés, Hôpital Sud, CHU de Rennes, 35200 Rennes, France
| | - Damien Lanéelle
- Centre de Compétence Pour le Syndrome de Marfan et Apparentés, CHU de la Côte de Nacre, 14033 Caen, France
| | - Sophie Dupuis-Girod
- Centre de Compétence Pour le Syndrome de Marfan et Apparentés, CHU Hôpital Louis Pradel, 69500 Lyon, France
| | - Guillaume Jondeau
- Centre National de Référence Pour le Syndrome de Marfan et Apparentés, VASCERN HTAD European Reference Centre, Service de Cardiologie, AP-HP, CHU Bichat, INSERM U 1148 LVTS, Université de Paris, 75014 Paris, France
| | - Laurence Bal-Theoleyre
- Centre de Référence Constitutif Pour le Syndrome de Marfan et Apparentés, Centre Aorte Timone, AP-HM, CHU La Timone Adultes, 13014 Marseille, France
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The Role of Genetic Testing in Patients with Heritable Thoracic Aortic Diseases. Diagnostics (Basel) 2023; 13:diagnostics13040772. [PMID: 36832261 PMCID: PMC9955043 DOI: 10.3390/diagnostics13040772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/13/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023] Open
Abstract
Heritable thoracic aortic disease (HTAD) is a term used to define a large group of disorders characterized by the occurrence of aortic events, mainly represented by aneurysm or dissection. These events generally involve the ascending aorta, although the involvement of other districts of the aorta or peripheral vessels may occur. HTAD can be classified as non-syndromic if the disorder is limited to the aorta, and syndromic when associated with extra-aortic features. About 20-25% of patients with non-syndromic HTAD exhibit a family history of aortic disease. Thus, a careful clinical evaluation of the proband and the first-degree family members is required to differentiate familial and sporadic cases. Genetic testing is essential since it allows confirmation of the etiological diagnosis of HTAD (particularly in patients with a significant family history) and may guide family screening. In addition, genetic diagnosis significantly impacts patients' management since the different conditions significantly differ with respect to natural history and treatment strategies. The prognosis in all HTADs is determined by the progressive dilation of the aorta, potentially leading to acute aortic events, such as dissection or rupture. Moreover, the prognosis varies according to the underlying genetic mutations. This review aims to describe the clinical characteristics and natural history of the most common HTADs, with particular emphasis on the role of genetic testing in risk stratification and management.
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Vascular Involvements Are Common in the Branch Arteries of the Abdominal Aorta Rather Than in the Aorta in Vascular Ehlers-Danlos Syndrome. CJC Open 2022; 5:72-76. [PMID: 36700191 PMCID: PMC9869355 DOI: 10.1016/j.cjco.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022] Open
Abstract
Background Vascular Ehlers-Danlos syndrome (vEDS) is a rare disorder with poor prognosis, owing to associated vascular complications. However, the most prevalent arterial problems in patients with vEDS are not well known. Methods We retrospectively examined 20 consecutive patients diagnosed with vEDS and examined their clinical events, image findings, and therapies. Results The age at first complication requiring admission was 29 ± 13 years. The observational period was 67 ± 30 months. Of the 20 patients, 17 took celiprolol at final assessment. At the final follow-up, the total number of complications relating to lesions and requiring admission was 16 for pulmonary lesions (8 patients), 16 for bowel lesions (8 patients), 5 for tendon/ligament lesions (2 patients), 18 for the branch arteries of the abdominal aorta (10 patients), 2 for the aorta (2 patients), and 7 for other arteries (6 patients). Of 54 arterial involvements (aneurysms, dissections, and ruptures), both with and without symptoms, 43 (80%) were in branches of the abdominal aorta (celiac artery and branches, 8; superior mesenteric artery, 4; renal arteries, 3; iliac arteries and branches, 28), 2 (4%) were in the aorta, and 9 were in other arteries. The diameter of the sinus of Valsalva was 29 ± 5 mm, within the normal range. During follow-up, 3 patients died due to suspected ruptures in a branch of the celiac artery, the superior mesenteric artery, and the aorta. Conclusion Our findings indicate that lesions involving the branch arteries of the abdominal aorta, rather than aorta, were the most prevalent lesion type in patients with vEDS.
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Requejo-Garcia L, Martinez-Lopez R, Plana-Andani E, Medina P, Hernandiz-Martinez A, Miralles-Hernández M. Extra-Thoracic Aneurysms in Marfan Syndrome: A Systematic Review of the Literature. Ann Vasc Surg 2022; 87:548-559. [PMID: 36029951 DOI: 10.1016/j.avsg.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 07/31/2022] [Accepted: 08/07/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Marfan syndrome (MS) most often shows as thoracic aortic aneurysm (TAA) or aortic dissection, but it may also involve other vascular territories. OBJECTIVE To identify those extra-thoracic vascular manifestations most frequently associated with MS. METHODOLOGY Systematic review of the literature with PRISMA criteria. The following databases were included: Medline, Embase, Web of Science (WOS), Cumulative Index of Nursing and Health Sciences Literature (CINHAL); Spanish database MEDESY Cochrane Central Register of Controlled Trials (CENTRAL). RESULTS 10,008 articles were identified, leaving 155 for the first stage of data analysis (total incidence of aneurysms) and 83 for the second (descriptive data analysis). Overall, 518 aneurysms were identified: 149 in the head and neck, 94 in the extremities 275 in the aortic, iliac and visceral sectors. Mostly, they were simultaneously discovered during studies of the AAT. In the abdominal aorta, the presentation with rupture in 11 of 32 patients stands out. Resection and bypass was the most frequently used method for repair in the treated cases. CONCLUSIONS Although its frequency in the general population is unknown, this systematic review suggests that extra-thoracic aneurysmal arterial involvement in the MS may be more frequent than expected. We believe screening for aneurysms in other vascular sectors may be advisable, especially in patients with MS and AAT.
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Affiliation(s)
- L Requejo-Garcia
- Angiology and Vascular Surgery Department. Hospital Universitario de La Ribera, Alzira, Valencia
| | - R Martinez-Lopez
- Angiology and Vascular Surgery Department. Hospital Universitario y Politécnico La Fe, Valencia
| | - E Plana-Andani
- Angiology and Vascular Surgery Department. Hospital Universitario y Politécnico La Fe, Valencia; Research Group on hemostasis, Thrombosis, Arteriosclerosis and Vascular Biology. Instituto de Investigación Sanitara-Hospital La Fe, Valencia
| | - P Medina
- Research Group on hemostasis, Thrombosis, Arteriosclerosis and Vascular Biology. Instituto de Investigación Sanitara-Hospital La Fe, Valencia
| | - A Hernandiz-Martinez
- Research Group on Regeneration and Heart Transplantation. Instituto de Investigación Sanitara-Hospital La Fe, Valencia
| | - M Miralles-Hernández
- Angiology and Vascular Surgery Department. Hospital Universitario y Politécnico La Fe, Valencia; Research Group on hemostasis, Thrombosis, Arteriosclerosis and Vascular Biology. Instituto de Investigación Sanitara-Hospital La Fe, Valencia.
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Pellenc Q, Boitet A, Roussel A, Milleron O, Mordant P, Senemaud J, Cerceau P, Jondeau G, Castier Y. Non-Dissecting Distal Aortic and Peripheral Arterial Aneurysms in Patients With Marfan Syndrome. Front Cardiovasc Med 2022; 9:827357. [PMID: 35360038 PMCID: PMC8962944 DOI: 10.3389/fcvm.2022.827357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 01/28/2022] [Indexed: 11/13/2022] Open
Abstract
Background In Marfan syndrome (MFS), an aortic or peripheral arterial dilatation is usually the consequence of aortic dissection. Non-dissecting distal aortic and peripheral aneurysms (DAPA) are barely described. We sought to determine the incidence and prognostic impact of non-dissecting DAPA, requiring a surgical repair in a large population of patients with MFS. Methods The patients referred to the French MFS reference center were included in a prospective database, and the patients treated for a non-dissecting DAPA between 2013 and 2020 were retrospectively reviewed. The first-line therapy was open surgery. The patients unfit for open repair or experiencing life-threatening complications underwent endovascular repair. Results Among 1,575 patients with MFS, 19 (1.2%) were operated for 25 non-dissecting DAPA. The mean age was 42.4 ± 11.5 years. Non-dissecting DAPA involved the subclavian or axillary artery (n = 12), the descending or thoracoabdominal aorta (n = 6), the abdominal aorta andiliac arteries (n = 6), and the popliteal artery (n = 1). Open and endovascular repairs were performed in 22 and three cases, respectively. After a median follow-up of 54.2 months, no local recurrence was noticed and no secondary procedure was performed. Eight patients presented a new aortic event, including two aortic dissections and seven new aortic surgeries. Compared to the overall MFS population, the non-dissecting DAPA group presented a significantly higher risk of an aortic event (100 vs. 28%, p < 0.0001), a higher risk of aortic dissection (53 vs. 8%, p < 0.0001), and a higher rate of pejorative genetic mutations (68 vs. 40%, p = 0.011). Conclusion Among the patients with MFS, the diagnosis of non-dissecting DAPA is infrequent but is associated with a significant adverse outcome, thus, advocating for a specific follow-up.
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Affiliation(s)
- Quentin Pellenc
- Department of Vascular and Thoracic Surgery, Bichat Hospital, Assistance Publique–Hopitaux de Paris (AP-HP), Paris, France
- Centre de Référence pour le Syndrome de Marfan et apparentés, Bichat Hospital, Assistance Publique–Hopitaux de Paris (AP-HP), Paris, France
- INSERM U 1148, LVTS, Bichat Hospital, Paris, France
- Université de Paris, Paris, France
- *Correspondence: Quentin Pellenc
| | - Auréline Boitet
- Department of Vascular and Thoracic Surgery, Bichat Hospital, Assistance Publique–Hopitaux de Paris (AP-HP), Paris, France
| | - Arnaud Roussel
- Department of Vascular and Thoracic Surgery, Bichat Hospital, Assistance Publique–Hopitaux de Paris (AP-HP), Paris, France
- Université de Paris, Paris, France
| | - Olivier Milleron
- Centre de Référence pour le Syndrome de Marfan et apparentés, Bichat Hospital, Assistance Publique–Hopitaux de Paris (AP-HP), Paris, France
- INSERM U 1148, LVTS, Bichat Hospital, Paris, France
- Department of Cardiology, Bichat Hospital, Assistance Publique–Hopitaux de Paris (AP-HP), Paris, France
| | - Pierre Mordant
- Department of Vascular and Thoracic Surgery, Bichat Hospital, Assistance Publique–Hopitaux de Paris (AP-HP), Paris, France
- Université de Paris, Paris, France
| | - Jean Senemaud
- Department of Vascular and Thoracic Surgery, Bichat Hospital, Assistance Publique–Hopitaux de Paris (AP-HP), Paris, France
- INSERM U 1148, LVTS, Bichat Hospital, Paris, France
- Université de Paris, Paris, France
| | - Pierre Cerceau
- Department of Vascular and Thoracic Surgery, Bichat Hospital, Assistance Publique–Hopitaux de Paris (AP-HP), Paris, France
| | - Guillaume Jondeau
- Centre de Référence pour le Syndrome de Marfan et apparentés, Bichat Hospital, Assistance Publique–Hopitaux de Paris (AP-HP), Paris, France
- INSERM U 1148, LVTS, Bichat Hospital, Paris, France
- Université de Paris, Paris, France
- Department of Cardiology, Bichat Hospital, Assistance Publique–Hopitaux de Paris (AP-HP), Paris, France
| | - Yves Castier
- Department of Vascular and Thoracic Surgery, Bichat Hospital, Assistance Publique–Hopitaux de Paris (AP-HP), Paris, France
- INSERM U 1148, LVTS, Bichat Hospital, Paris, France
- Université de Paris, Paris, France
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Tehrani AY, Ciufolini MA, Bernatchez P. Nitric oxide in the Marfan vasculature: Friend or foe? Nitric Oxide 2021; 116:27-34. [PMID: 34478846 DOI: 10.1016/j.niox.2021.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 08/13/2021] [Accepted: 08/25/2021] [Indexed: 10/20/2022]
Abstract
Marfan syndrome (MFS) is a connective tissue disorder caused by mutations in the FBN1 gene, which encodes fibrillin-1, a protein essential for the formation and stabilization of elastic fibers as well as signaling homeostasis. Progressive aortic root widening is the most serious manifestation of MFS as it can lead to aortic dissection, aneurysm formation and rupture. However, despite their ability to decrease the hemodynamic stress the aorta is subjected to, anti-hypertensive medications often lead to underwhelming reductions in the rate of aortic root dilation, which illustrates how fragmental our understanding of MFS-associated aortic remodeling is. This manuscript summarizes recent evidence that document nitric oxide (NO) synthase (NOS)-related changes to the vasculature during the pathogenesis of MFS and how they result in a unique state of vascular dysfunction that likely plays a causal role in the aortic root widening process. We also review how clinic-approved and experimental therapies as well lifestyle approaches may promote aortic root stability by correcting NO homeostasis, which if properly optimized may improve outcomes in this population afflicted by a notoriously refractory type of aortopathy.
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Affiliation(s)
- Arash Y Tehrani
- Centre for Heart + Lung Innovation, St. Paul's Hospital, Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, University of British Columbia (UBC), Vancouver, Canada
| | | | - Pascal Bernatchez
- Centre for Heart + Lung Innovation, St. Paul's Hospital, Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, University of British Columbia (UBC), Vancouver, Canada.
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Abstract
Marfan syndrome (MFS) is an autosomal dominant, age-related but highly penetrant condition with substantial intrafamilial and interfamilial variability. MFS is caused by pathogenetic variants in FBN1, which encodes fibrillin-1, a major structural component of the extracellular matrix that provides support to connective tissues, particularly in arteries, the pericondrium and structures in the eye. Up to 25% of individuals with MFS have de novo variants. The most prominent manifestations of MFS are asymptomatic aortic root aneurysms, aortic dissections, dislocation of the ocular lens (ectopia lentis) and skeletal abnormalities that are characterized by overgrowth of the long bones. MFS is diagnosed based on the Ghent II nosology; genetic testing confirming the presence of a FBN1 pathogenetic variant is not always required for diagnosis but can help distinguish MFS from other heritable thoracic aortic disease syndromes that can present with skeletal features similar to those in MFS. Untreated aortic root aneurysms can progress to life-threatening acute aortic dissections. Management of MFS requires medical therapy to slow the rate of growth of aneurysms and decrease the risk of dissection. Routine surveillance with imaging techniques such as transthoracic echocardiography, CT or MRI is necessary to monitor aneurysm growth and determine when to perform prophylactic repair surgery to prevent an acute aortic dissection.
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Pyeritz RE. Marfan Syndrome: Expanding the Cardiovascular Phenotype? J Am Coll Cardiol 2021; 77:3013-3015. [PMID: 34140104 DOI: 10.1016/j.jacc.2021.04.073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 04/28/2021] [Accepted: 04/28/2021] [Indexed: 01/20/2023]
Affiliation(s)
- Reed E Pyeritz
- Division of Human Genetics and Translational Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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