Skip to main content

Marfan and Marfan-like syndromes

Summary

With the help of both clinical and genetic diagnostic tools, the spectrum of inherited disorders affecting the arterial system has extended tremendously over the past decades. Discriminating these different entities is important since prognosis and treatment may differ substantially according to the diagnosis. Here we provide an overview of the current clinical and genetic knowledge on classic Marfan syndrome as well as on Marfan related disorders. Through our increased understanding of the pathophysiological mechanisms underlying aneurysm formation in these monogenetic conditions, new therapeutic strategies have emerged and are now being developed. This may serve as a nice example of translational medicine were detailed knowledge of the complex molecular pathways in rare disorders may help us to improve diagnosis and treatment of more common conditions.

References

  1. Dietz HC, Cutting GR, Pyeritz RE, Maslen CL, Sakai LY, Corson GM, et al. Marfan syndrome caused by a recurrent de novo missense mutation in the fibrillin gene. Nature 1991 Jul 25;352(6333):337–9.

    Google Scholar 

  2. Rosenbloom J, Abrams WR, Mecham R. Extracellular matrix 4: the elastic fiber. FASEB J 1993 Oct;7(13):1208–18.

    Google Scholar 

  3. Pereira L, Andrikopoulos K, Tian J, Lee SY, Keene DR, Ono R, et al. Targetting of the gene encoding fibrillin-1 recapitulates the vascular aspect of Marfan syndrome. Nat Genet 1997 Oct; 17(2):218–22.

    Google Scholar 

  4. Pereira L, Lee SY, Gayraud B, Andrikopoulos K, Shapiro SD, Bunton T, et al. Pathogenetic sequence for aneurysm revealed in mice underexpressing fibrillin-1. Proc Natl Acad Sci U S A 1999 Mar 30;96(7):3819–23.

    Google Scholar 

  5. Judge DP, Biery NJ, Keene DR, Geubtner J, Myers L, Huso DL, et al. Evidence for a critical contribution of haploinsufficiency in the complex pathogenesis of Marfan syndrome. J Clin Invest 2004 Jul;114(2):172–81.

    Google Scholar 

  6. Bunton TE, Biery NJ, Myers L, Gayraud B, Ramirez F, Dietz HC. Phenotypic alteration of vascular smooth muscle cells precedes elastolysis in a mouse model of Marfan syndrome. Circ Res 2001 Jan 19;88(1):37–43.

    Google Scholar 

  7. Dallas SL, Keene DR, Bruder SP, Saharinen J, Sakai LY, Mundy GR, et al. Role of the latent transforming growth factor beta binding protein 1 in fibrillin-containing microfibrils in bone cells in vitro and in vivo. J Bone Miner Res 2000 Jan; 15(1):68–81.

    Google Scholar 

  8. Dallas SL, Miyazono K, Skerry TM, Mundy GR, Bonewald LF. Dual role for the latent transforming growth factor-beta binding protein in storage of latent TGF-beta in the extracellular matrix and as a structural matrix protein. J Cell Biol 1995 Oct; 131(2):539–49.

    Google Scholar 

  9. Saharinen J, Hyytiainen M, Taipale J, Keski-Oja J. Latent transforming growth factor-beta binding proteins (LTBPs) – structural extracellular matrix proteins for targeting TGF-beta action. Cytokine Growth Factor Rev 1999 Jun;10(2): 99–117.

    Google Scholar 

  10. Isogai Z, Ono RN, Ushiro S, Keene DR, Chen Y, Mazzieri R, et al. Latent transforming growth factor beta-binding protein 1 interacts with fibrillin and is a microfibril-associated protein. J Biol Chem 2003 Jan 24;278(4):2750–7.

    Google Scholar 

  11. Neptune ER, Frischmeyer PA, Arking DE, Myers L, Bunton TE, Gayraud B, et al. Dysregulation of TGF-beta activation contributes to pathogenesis in Marfan syndrome. Nat Genet 2003 Mar;33(3):407–11.

    Google Scholar 

  12. De Paepe A, Devereux RB, Dietz HC, Hennekam RC, Pyeritz RE. Revised diagnostic criteria for the Marfan syndrome. Am J Med Genet 1996;62(4):417–26.

    Google Scholar 

  13. Tiecke F, Katzke S, Booms P, Robinson PN, Neumann L, Godfrey M, et al. Classic, atypically severe and neonatal Mar-fan syndrome: twelve mutations and genotype–phenotype correlations in FBN1 exons 24–40. Eur J Hum Genet 2001 Jan; 9(1):13–21.

    Google Scholar 

  14. Kainulainen K, Karttunen L, Puhakka L, Sakai L, Peltonen L. Mutations in the fibrillin gene responsible for dominant ectopia lentis and neonatal Marfan syndrome. Nat Genet 1994 Jan; 6(1):64–9.

    Google Scholar 

  15. Putnam EA, Cho M, Zinn AB, Towbin JA, Byers PH, Milewicz DM. Delineation of the Marfan phenotype associated with mutations in exons 23–32 of the FBN1 gene. Am J Med Genet 1996 Mar 29;62(3):233–42.

    Google Scholar 

  16. Black C, Withers AP, Gray JR, Bridges AB, Craig A, Baty DU, et al. Correlation of a recurrent FBN1 mutation (R122C) with an atypical familial Marfan syndrome phenotype. Hum Mutat 1998;(Suppl. 1):S198–200.

  17. De Backer J, Loeys B, Leroy B, Coucke P, Dietz H, De Paepe A. Utility of molecular analyses in the exploration of extreme intrafamilial variability in the Marfan syndrome. Clin Genet 2007 Sep;72(3):188–98.

    Google Scholar 

  18. Judge DP, Dietz HC. Marfan’s syndrome. Lancet 2005 Dec 3; 366(9501):1965–76.

  19. Roman MJ, Devereux RB, Kramer-Fox R, O’Loughlin J. Two-dimensional echocardiographic aortic root dimensions in normal children and adults. Am J Cardiol 1989;64(8):507–12.

    Google Scholar 

  20. Apter JT. Correlation of visco-elastic properties with microscopic structure of large arteries. IV. Thermal responses of collagen, elastin, smooth muscle, and intact arteries. Circ Res 1967 Dec;21(6):901–18.

    Google Scholar 

  21. Pyeritz RE. Marfan syndrome: current and future clinical and genetic management of cardiovascular manifestations. Semin Thorac Cardiovasc Surg 1993 Jan;5(1):11–6.

    Google Scholar 

  22. Roman MJ, Rosen SE, Kramer-Fox R, Devereux RB. Prognostic significance of the pattern of aortic root dilation in the Marfan syndrome. J Am Coll Cardiol 1993;22(5):1470–6.

    Google Scholar 

  23. Dapunt OE, Galla JD, Sadeghi AM, Lansman SL, Mezrow CK, de Asla RA, et al. The natural history of thoracic aortic aneurysms. J Thorac Cardiovasc Surg 1994 May;107(5):1323–32 [discussion 32–3].

  24. Pyeritz RE. Genetics and cardiovascular disease. In: Braunwald E, editor. Cardiovascular disease. Philadelphia: Saunders; 1992. p. 1641–3.

    Google Scholar 

  25. Groenink M, Lohuis TA, Tijssen JG, Naeff MS, Hennekam RC, van der Wall EE, et al. Survival and complication free survival in Marfan’s syndrome: implications of current guidelines. Heart 1999;82(4):499–504.

    Google Scholar 

  26. Legget ME, Unger TA, O’Sullivan CK, Zwink TR, Bennett RL, Byers PH, et al. Aortic root complications in Marfan’s syndrome: identification of a lower risk group. Heart 1996 Apr; 75(4):389–95.

    Google Scholar 

  27. Silverman DI, Gray J, Roman MJ, Bridges A, Burton K, Boxer M, et al. Family history of severe cardiovascular disease in Marfan syndrome is associated with increased aortic diameter and decreased survival. J Am Coll Cardiol 1995;26(4):1062–7.

    Google Scholar 

  28. Jondeau G, Boutouyrie P, Lacolley P, Laloux B, Dubourg O, Bourdarias JP, et al. Central pulse pressure is a major determinant of ascending aorta dilation in Marfan syndrome. Circulation 1999;99(20):2677–81.

    Google Scholar 

  29. Adams JN, Brooks M, Redpath TW, Smith FW, Dean J, Gray J, et al. Aortic distensibility and stiffness index measured by magnetic resonance imaging in patients with Marfan’s syndrome. Br Heart J 1995;73(3):265–9.

    Google Scholar 

  30. Groenink M, de Roos A, Mulder BJ, Verbeeten Jr B, Timmermans J, Zwinderman AH, et al. Biophysical properties of the normal-sized aorta in patients with Marfan syndrome: evaluation with MR flow mapping. Radiology 2001;219(2):535–40.

    Google Scholar 

  31. Hirata K, Triposkiadis F, Sparks E, Bowen J, Boudoulas H, Wooley CF. The Marfan syndrome: cardiovascular physical findings and diagnostic correlates. Am Heart J 1992;123(3): 743–52.

    Google Scholar 

  32. Jeremy RW, Huang H, Hwa J, McCarron H, Hughes CF, Richards JG. Relation between age, arterial distensibility, and aortic dilatation in the Marfan syndrome. Am J Cardiol 1994; 74(4):369–73.

    Google Scholar 

  33. Baumgartner D, Baumgartner C, Matyas G, Steinmann B, Lof-fler-Ragg J, Schermer E, et al. Diagnostic power of aortic elastic properties in young patients with Marfan syndrome. J Thorac Cardiovasc Surg 2005 Apr;129(4):730–9.

    Google Scholar 

  34. Pyeritz RE, Wappel MA. Mitral valve dysfunction in the Marfan syndrome. Clinical and echocardiographic study of prevalence and natural history. Am J Med 1983 May;74(5):797–807.

    Google Scholar 

  35. De Backer J, Loeys B, Devos D, Dietz H, De Sutter J, De Paepe A. A critical analysis of minor cardiovascular criteria in the diagnostic evaluation of patients with Marfan syndrome. Genet Med 2006 Jul;8(7):401–8.

    Google Scholar 

  36. Nollen GJ, van Schijndel KE, Timmermans J, Groenink M, Barentsz JO, van der Wall EE, et al. Pulmonary artery root dilatation in Marfan syndrome: quantitative assessment of an unknown criterion. Heart 2002 May;87(5):470–1.

    Google Scholar 

  37. Dietz HC, Pyeritz RE. Marfan syndrome and related disorders. In: Scriver CR, Beaudet A, Sly WS, Valle D, editors. The metabolic and molecular bases of inherited diseases; 1995. p. 5287–311.

  38. Finkbohner R, Johnston D, Crawford ES, Coselli J, Milewicz DM. Marfan syndrome: long-term survival and complications after aortic aneurysm repair. Circulation 1995 February 1;91(3): 728–33.

  39. Engelfriet PM, Boersma E, Tijssen JG, Bouma BJ, Mulder BJ. Beyond the root: dilatation of the distal aorta in the Marfan syndrome. Heart; 2006 Feb 17.

  40. van Ooijen B. Marfan’s syndrome and isolated aneurysm of the abdominal aorta. Br Heart J 1988 Jan;59(1):81–4.

    Google Scholar 

  41. Pruzinsky MS, Katz NM, Green CE, Satler LF. Isolated descending thoracic aortic aneurysm in Marfan’s syndrome. Am J Cardiol 1988 May 1;61(13):1159–60.

    Google Scholar 

  42. Nollen GJ, Groenink M, Tijssen JG, Van Der Wall EE, Mulder BJ. Aortic stiffness and diameter predict progressive aortic dilatation in patients with Marfan syndrome. Eur Heart J 2004 Jul; 25(13):1146–52.

    Google Scholar 

  43. Kawamoto S, Bluemke DA, Traill TA, Zerhouni EA. Thor-acoabdominal aorta in Marfan syndrome: MR imaging findings of progression of vasculopathy after surgical repair. Radiology 1997 Jun;203(3):727–32.

    Google Scholar 

  44. Nollen GJ, Meijboom LJ, Groenink M, Timmermans J, Barentsz JO, Merchant N, et al. Comparison of aortic elasticity in patients with the Marfan syndrome with and without aortic root replacement. Am J Cardiol 2003 Mar 1;91(5):637–40.

    Google Scholar 

  45. Chatrath R, Beauchesne LM, Connolly HM, Michels VV, Driscoll DJ. Left ventricular function in the Marfan syndrome without significant valvular regurgitation. Am J Cardiol 2003 Apr 1;91(7):914–6.

    Google Scholar 

  46. Savolainen A, Nisula L, Keto P, Hekali P, Viitasalo M, Kaitila I, et al. Left ventricular function in children with the Marfan syndrome. Eur Heart J 1994;15(5):625–30.

    Google Scholar 

  47. Porciani MC, Giurlani L, Chelucci A, Pepe G, Giusti BH, Brunelli T, et al. Diastolic subclinical primary alterations in Marfan syndrome and Marfan-related disorders. Clin Cardiol 2002 Sep;25(9):416–20.

    Google Scholar 

  48. Das BB, Taylor AL, Yetman AT. Left ventricular diastolic dysfunction in children and young adults with Marfan syndrome. Pediatr Cardiol 2006 Mar–Apr;27(2):256–8.

    Google Scholar 

  49. De Backer JF, Devos D, Segers P, Matthys D, Francois K, Gillebert TC, et al. Primary impairment of left ventricular function in Marfan syndrome. Int J Cardiol; 2005 Nov 25.

  50. Rossi-Foulkes R, Roman MJ, Rosen SE, Kramer-Fox R, Ehlers KH, O’Loughlin JE, et al. Phenotypic features and impact of beta blocker or calcium antagonist therapy on aortic lumen size in the Marfan syndrome. Am J Cardiol 1999;83(9):1364–8.

    Google Scholar 

  51. Shores J, Berger KR, Murphy EA, Pyeritz RE. Progression of aortic dilatation and the benefitoflong-term beta-adrenergic blockade in Marfan’s syndrome. N Engl J Med 1994;330(19):1335–41.

    Google Scholar 

  52. Habashi JP, Judge DP, Holm TM, Cohn RD, Loeys BL, Cooper TK, et al. Losartan, an AT1 antagonist, prevents aortic aneurysm in a mouse model of Marfan syndrome. Science 2006 Apr 7; 312(5770):117–21.

  53. Brooke BS, Habashi JP, Judge DP, Patel N, Loeys B, Dietz 3rd HC. Angiotensin II blockade and aortic-root dilation in Marfan’s syndrome. N Engl J Med 2008 Jun 26;358(26):2787–95.

    Google Scholar 

  54. Lacro RV, Dietz HC, Wruck LM, Bradley TJ, Colan SD, Devereux RB, et al. Rationale and design of a randomized clinical trial of beta-blocker therapy (atenolol) versus angio-tensin II receptor blocker therapy (losartan) in individuals with Marfan syndrome. Am Heart J 2007 Oct;154(4):624–31.

    Google Scholar 

  55. Loeys BL, Chen J, Neptune ER, Judge DP, Podowski M, Holm T, et al. A syndrome of altered cardiovascular, craniofacial, neurocognitive and skeletal development caused by mutations in TGFBR1 or TGFBR2. Nat Genet 2005 Mar;37(3):275–81.

    Google Scholar 

  56. Loeys BL, Schwarze U, Holm T, Callewaert BL, Thomas GH, Pannu H, et al. Aneurysm syndromes caused by mutations in the TGF-beta receptor. N Engl J Med 2006 Aug 24;355(8):788–98.

    Google Scholar 

  57. Williams JA, Loeys BL, Nwakanma LU, Dietz HC, Spevak PJ, Patel ND, et al. Early surgical experience with Loeys–Dietz: a new syndrome of aggressive thoracic aortic aneurysm disease. Ann Thorac Surg 2007 Feb;83(2):S757–63 [discussion S85–90].

  58. Pepin M, Schwarze U, Superti-Furga A, Byers PH. Clinical and genetic features of Ehlers–Danlos syndrome type IV, the vascular type. N Engl J Med 2000;342(10):673–80.

    Google Scholar 

  59. Oderich GS, Panneton JM, Bower TC, Lindor NM, Cherry KJ, Noel AA, et al. The spectrum, management and clinical outcome of Ehlers–Danlos syndrome type IV: a 30-year experience. J Vasc Surg 2005 Jul;42(1):98–106.

    Google Scholar 

  60. Boutouyrie P, Germain DP, Fiessinger JN, Laloux B, Perdu J, Laurent S. Increased carotid wall stress in vascular Ehlers– Danlos syndrome. Circulation 2004 Mar 30;109(12):1530–5.

    Google Scholar 

  61. Coucke PJ, Willaert A, Wessels MW, Callewaert B, Zoppi N, De Backer J, et al. Mutations in the facilitative glucose transporter GLUT10 alter angiogenesis and cause arterial tortuosity syndrome. Nat Genet; 2006 Mar 19.

  62. Pannu H, Fadulu VT, Chang J, Lafont A, Hasham SN, Sparks E, et al. Mutations in transforming growth factor-{beta} receptor type II cause familial thoracic aortic aneurysms and dissections. Circulation 2005 July 26;112(4):513–20.

    Google Scholar 

  63. Zhu L, Vranckx R, Van Kien PK, Lalande A, Boisset N, Mathieu F, et al. Mutations in myosin heavy chain 11 cause a syndrome associating thoracic aortic aneurysm/aortic dissection and patent ductus arteriosus. Nat Genet 2006 Mar;38(3):343–9.

    Google Scholar 

  64. Guo DC, Pannu H, Tran-Fadulu V, Papke CL, Yu RK, Avidan N, et al. Mutations in smooth muscle alpha-actin (ACTA2) lead to thoracic aortic aneurysms and dissections. Nat Genet 2007 Dec;39(12):1488–93.

    Google Scholar 

  65. Lalande A, Khau Van Kien P, Walker PM, Zhu L, Legrand L, Claustres M, et al. Compliance and pulse wave velocity assessed by MRI detect early aortic impairment in young patients with mutation of the smooth muscle myosin heavy chain. J Magn Reson Imaging 2008 Nov;28(5):1180–7.

    Google Scholar 

  66. Laurent S, Boutouyrie P, Lacolley P. Structural and genetic bases of arterial stiffness. Hypertension 2005 Jun;45(6):1050–5.

    Google Scholar 

  67. Mills P, Leech G, Davies M, Leathan A. The natural history of a non-stenotic bicuspid aortic valve. Br Heart J 1978 Sep; 40(9):951–7.

    Google Scholar 

  68. de Sa M, Moshkovitz Y, Butany J, David TE. Histologic abnormalities of the ascending aorta and pulmonary trunk in patients with bicuspid aortic valve disease: clinical relevance to the Ross procedure. J Thorac Cardiovasc Surg 1999 Oct; 118(4):588–94.

    Google Scholar 

  69. Fedak PW, Verma S, David TE, Leask RL, Weisel RD, Butany J. Clinical and pathophysiological implications of a bicuspid aortic valve. Circulation 2002 Aug 20;106(8):900–4.

    Google Scholar 

  70. Hahn RT, Roman MJ, Mogtader AH, Devereux RB. Association of aortic dilation with regurgitant, stenotic and functionally normal bicuspid aortic valves. J Am Coll Cardiol 1992 Feb;19(2):283–8.

    Google Scholar 

  71. Cecconi M, Manfrin M, Moraca A, Zanoli R, Colonna PL, Bettuzzi MG, et al. Aortic dimensions in patients with bicuspid aortic valve without significant valve dysfunction. Am J Cardiol 2005 Jan 15;95(2):292–4.

    Google Scholar 

  72. Gurvitz M, Chang RK, Drant S, Allada V. Frequency of aortic root dilation in children with a bicuspid aortic valve. Am J Cardiol 2004 Nov 15;94(10):1337–40.

    Google Scholar 

  73. Basso C, Boschello M, Perrone C, Mecenero A, Cera A, Bicego D, et al. An echocardiographic survey of primary school children for bicuspid aortic valve. Am J Cardiol 2004 Mar 1;93(5):661–3.

    Google Scholar 

  74. Huntington K, Hunter AG, Chan KL. A prospective study to assess the frequency of familial clustering of congenital bicuspid aortic valve. J Am Coll Cardiol 1997 Dec;30(7):1809–12.

    Google Scholar 

  75. Emanuel R, Withers R, O’Brien K, Ross P, Feizi O. Congenitally bicuspid aortic valves. Clinicogenetic study of 41 families. Br Heart J 1978 Dec;40(12):1402–7.

    Google Scholar 

  76. Goh D, Han L, Judge DP, Dietz H. Linkage of familial bicuspid aortic valve with aortic aneurysm to chromosome 15q. Am Soc Hum Genet 2002;71:A239.

    Google Scholar 

  77. Loscalzo M, Goh D, Spevak PJ. A prospective analysis of the inheritance, pathogenesis and natural history of bicuspid aortic valve with thoracic aortic aneurysm. Am Soc Hum Genet; 2004.

  78. Beighton P. The dominant and recessive forms of cutis laxa. J Med Genet 1972 Jun;9(2):216–21.

    Google Scholar 

  79. Szabo Z, Crepeau MW, Mitchell AL, Stephan MJ, Puntel RA, Yin Loke K, et al. Aortic aneurysmal disease and cutis laxa caused by defects in the elastin gene. J Med Genet 2006 Mar;43(3): 255–8.

    Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to J. De Backer.

Rights and permissions

This is an open access article distributed under the CC BY-NC license. https://doi.org/creativecommons.org/licenses/by/4.0/

Reprints and permissions

About this article

Cite this article

De Backer, J., Loeys, B. & De Paepe, A. Marfan and Marfan-like syndromes. Artery Res 3, 9–16 (2009). https://doi.org/10.1016/j.artres.2009.01.003

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1016/j.artres.2009.01.003

Key words