Synonyms: Marfan syndrome, MFS1
This is an inherited connective tissue disorder with characteristic skeletal, dermatological, cardiac, aortic, ocular and dura mater malformations. Although it is a severe, chronic and life-threatening disease, most patients with Marfan's syndrome (MFS) who receive optimal medical care now have a near-normal life expectancy.
MFS is caused by a variety of mis-sense mutations in gene encoding for fibrillin 1, an elastin-matrix glycoprotein essential for the formation of cellular microfibrils and regulation of transforming growth factor beta (TGF-ß), dysregulation of which leads to the morphological changes seen in MFS.The gene is located on chromosome 15q21. The pattern of transmission is autosomal dominant with complete penetrance. There are over 1,000 genetic mutations, almost all unique to an affected family. Phenotype varies within and between families with the same genetic abnormality, leading to protean and variable manifestations of the condition in given individuals.
This is 2-3 per 10,000 of population, affecting both sexes equally. The prevalence is similar worldwide, regardless of geography or ethnicity.It is the most common inherited disorder of connective tissue. Prior to the availability of treatment, life expectancy was severely curtailed: 50% of men died by the age of 40 and 50% of women by the age of 48; the average age of death was 32.Despite medical advances, the leading cause of death remains cardiovascular disease, primarily progressive aortic root dilation and dissection, which still occurs in about 1 in 10 patients and carries a high mortality.
Around two thirds of cases are due to familial transmission. In the remainder there are sporadic mutations, associated with advanced paternal age.
The diagnosis is usually established using the Ghent criteria, which were revised in 2010. The clinical diagnostic criteria are family history and systemic features, particularly the presence of ectopia lentis and an increased diameter of the aortic root, plus molecular genetic testing.Basing diagnosis solely on molecular data is not possible, as mutation detection is far from perfect and some mutations of fibrillin do not cause the syndrome.
The condition can be asymptomatic. Patients are disproportionately tall and thin with unusually long arms and legs compared to their trunk (dolichostenomelia) and a 'cadaverous' physique. They often have long 'spidery' fingers and toes (arachnodactyly).
The main clinical features are:
- Skin - striae, especially thoracolumbar and sacral.
- Cardiovascular - thoracic aortic dilatation/rupture/dissection (usually asymptomatic), aortic regurgitation, mitral valve prolapse, mitral regurgitation, abdominal aortic aneurysm, cardiac dysrhythmia.
- Lungs - pleural rupture causing pneumothorax
- Eyes - lens dislocation, closed-angle glaucoma, high myopia.
- Skeleton - arachnodactyly, hypermobility, arthralgia, joint instability, finger contractures, pectus excavatum or carinatum deformities, misshapen chest, kyphoscoliosis, protrusio acetabuli and hindfoot deformity.
- Nervous system - dural ectasia hernias presenting with low back pain and symptoms akin to cauda equina syndrome or chronic postural headache due to CSF leakage
- Facial characteristics - maxillary/mandibular retrognathia, long face (dolichocephaly) and high, arched palate, enophthalmos, downslanting palpebral fissures and malar hypoplasia.
Arachnodactyly - the following signs may be used to demonstrate this:
- Walker's (wrist) sign - the patient encircles the wrist of their opposite hand with the little finger and thumb, which overlap.
- Steinberg's thumb sign - a flexed thumb grasped within a clenched palm protrudes beyond the ulnar border of that hand.
- Echocardiography: repeated annually, with careful monitoring of aortic root width and the function of the heart valves is recommended. Echocardiography is also being used to evaluate the function of the myocardium which is also thought to be affected.
- Cardiovascular magnetic resonance (CMR) or computerised tomography (CT): should be performed in every patient, showing the entire aorta. This should be repeated every five years, or annually if there is aneurysmal formation beyond the aortic root.
- Ambulatory ECG monitoring: in symptomatic patients.
- MRI scanning of the spinal column: consider this if headache/sacral pain is potentially attributable to dural ectasia.
- Pelvic X-ray: this may demonstrate protrusion of the acetabulum into the pelvic cavity (protrusio acetabula). It is present in about 50% of cases.
- Ehlers-Danlos syndrome.
- Fragile X syndrome.
- Gigantism and acromegaly.
- Klinefelter's syndrome.
- Loeys-Dietz aortic aneurysm syndrome.
- Sphrintzen-Goldberg syndrome.
- Other causes of arachnodactyly, aortic dissection, ectopic lentis and mitral valve prolapse.
Management requires a multidisciplinary team which should include a geneticist, an ophthalmologist, a cardiologist and an orthopaedic surgeon.
- Psychological support may be required in order to help patients cope with the fact that they have a chronic disease which may shorten their life and affect offspring. Many patients also have poor self-esteem and impaired relationships/sex lives due to concerns about their bodily appearance.
- The patient should be advised to avoid exertion at maximal capacity, vigorously competitive or contact sports (fatal aortic dissection and rupture in young adults is often due to MFS). Scuba diving, weightlifting, climbing steep inclines and gymnastics should be avoided due to dangers of raised intra-thoracic/intra-aortic pressures.
Prophylactic beta-blockers are used to reduce mean arterial pressure and pulse rate significantly.Studies have suggested that introducing them at an early age under the supervision of a paediatrician or cardiologist lowers the risk of aortic rupture and slowed aortic root dilatation. However, two meta-analyses have found conflicting results regarding the value of long-term beta-blockers.[13, 14]
The TGF-ß pathway is stimulated by angiotensin. The angiotensin-II receptor antagonist losartan has been shown to prevent and possibly reverse aortic root dilatation, mitral valve prolapse, lung disease and skeletal muscle dysfunction in a mouse model of MFS.In the same model losartan has also been shown to slow aortic root enlargement more effectively than propranolol.
A randomised controlled trial of 608 children and young adults under the age of 25 with MFS, compared losartan with atenolol over a three-year period.The primary outcome was the rate of aortic root dilation. Somewhat unexpectedly the study found no advantage of losartan over atenolol. There are several other similar trials underway and, to clarify what the effects are of angiotensin-II receptor antagonists and beta-blockers on patients with MFS, a prospective, collaborative meta-analysis based on individual patient data from these trials has been proposed.It is expected to include individual patient data from over 2,000 people.
With progressive aortic disease (dilatation of the ascending aorta and valve ring), composite valve conduit/aortic root graft replacement is the 'gold standard'. Some advocate medical therapy and aortic valve-sparing surgery where possible, due to the risks of having to anticoagulate after valve replacement.Indications for surgery are based primarily on the diameter of the aorta: repair advised if diameter ≥50mm (≥45 mm if there are other risk factors - for example, a family history of aortic dissection or a desire for pregnancy). Repair of a descending aortic aneurysm is generally recommended if the diameter is ≥55 mm but may be considered at lower diameters. Endovascular aortic repair in in MFS is not recommended.
Dislocated optic lens often occurs in early childhood. Removal of the lens is only indicated if cataract or secondary glaucoma intervenes or there is greatly reduced visual acuity which cannot be corrected with glasses. Anterior chamber intraocular lens placement is a technique often used following lens removal.
Surgery may be indicated for associated orthopaedic problems, including scoliosis.
Orthodontic treatment may be required to prevent or manage periodontal disease.
Expert input is required, as the risk of aortic rupture is vastly increased. There is also a 50% chance that the baby will be affected. Regular echocardiography (every 6-10 weeks) is recommended, along with adaptations of anaesthetic and intrapartum care. Where aortic root dilatation does occur, highly specialised surgical care and caesarean delivery are advocated.
Prognosis and complications
The main cause of death is cardiovascular disease and other vascular complications. Early use of propranolol and new surgical procedures have improved life expectancy substantially. Patients with MFS requiring surgery during childhood have a relatively favorable long-term outcome.Prophylactic surgery carries 5- and 10-year survival rates of 84% and 75% respectively but is significantly safer than emergency repair.
Further reading and references
; NICE Interventional Procedure Guidance, May 2011
; The Marfan Foundation (US)
; Marfan syndrome: 30 years of research equals 30 years of additional life expectancy. Heart. 2009 Mar95(3):173-5. doi: 10.1136/hrt.2008.160515. Epub 2008 Nov 10.
; European Society of Cardiology (2010)
; Online Mendelian Inheritance in Man (OMIM)
; Perspectives on the revised Ghent criteria for the diagnosis of Marfan syndrome. Appl Clin Genet. 2015 Jun 168:137-55. doi: 10.2147/TACG.S60472. eCollection 2015.
; Epidemiological profile of Marfan syndrome in a general population: a national database study. Mayo Clin Proc. 2014 Jan89(1):34-42. doi: 10.1016/j.mayocp.2013.08.022.
; Craniofacial structure in Marfan syndrome: a cephalometric study. Am J Med Genet A. 2004 Dec 15131(3):240-8.
; The unravelling of primary myocardial impairment in Marfan syndrome by modern echocardiography. Heart. 2009 Feb 17.
; Postural headache in a child with Marfan syndrome: case report and review of the literature. J Child Neurol. 2005 Feb20(2):153-5.
; Marfan's syndrome. Lancet. 2005 Dec 3366(9501):1965-76.
; The multidisciplinary approach to the Marfan patient. Isr Med Assoc J. 2008 Mar10(3):171-4.
; Determinants of quality of life in Marfan syndrome. Psychosomatics. 2008 May-Jun49(3):243-8.
; Medical treatment of Marfan syndrome: a time for change. Heart. 2008 Apr94(4):414-21.
; The effect of beta-blocker therapy on clinical outcome in patients with Marfan's syndrome: a meta-analysis. Int J Cardiol. 2007 Jan 18114(3):303-8. Epub 2006 Jul 10.
; The effect of beta-blocker therapy on progressive aortic dilatation in children and adolescents with Marfan's syndrome: a meta-analysis. Acta Paediatr. 2011 Sep100(9):e101-5. doi: 10.1111/j.1651-2227.2011.02293.x. Epub 2011 May 5.
; Recent advances in understanding Marfan syndrome: should we now treat surgical patients with losartan? J Thorac Cardiovasc Surg. 2008 Feb135(2):389-94.
; Atenolol versus losartan in children and young adults with Marfan's syndrome. N Engl J Med. 2014 Nov 27371(22):2061-71. doi: 10.1056/NEJMoa1404731. Epub 2014 Nov 18.
; Design and rationale of a prospective, collaborative meta-analysis of all randomized controlled trials of angiotensin receptor antagonists in Marfan syndrome, based on individual patient data: A report from the Marfan Treatment Trialists' Collaboration. Am Heart J. 2015 May169(5):605-12. doi: 10.1016/j.ahj.2015.01.011. Epub 2015 Feb 12.
; Surgical management of the aortic root in patients with Marfan syndrome. J Heart Valve Dis. 2005 Jan14(1):121-8
; Management of aortic disease in Marfan Syndrome: a decision analysis. Arch Intern Med. 2005 Apr 11165(7):749-55.
; The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (Aug 2014)
; Anterior chamber intraocular lens (ACIOL) placement after pars plana lensectomy in pediatric Marfan syndrome. J AAPOS. 2005 Jun9(3):240-2.
; Surgical treatment for scoliosis in Marfan syndrome. Spine (Phila Pa 1976). 2005 Oct 1530(20):E597-604.
; Marfan syndrome-an orthodontic perspective. Angle Orthod. 2009 Mar79(2):394-400.
; Surgery for acute type A aortic dissection in pregnant patients with Marfan syndrome. Eur J Cardiothorac Surg. 2005 Aug28(2):280-3
; Cardiovascular surgery in children with Marfan syndrome or Loeys-Dietz syndrome. J Thorac Cardiovasc Surg. 2009 Jun137(6):1327-32
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