Case Reports1. A Late Presentation of Loeys-Dietz Syndrome: Beware of TGFβ Receptor Mutations in Benign Joint Hypermobility

Background: Thoracic aortic aneurysms (TAA) and dissections are not uncommon causes of sudden death in young adults. Loeys-Dietz syndrome (LDS) is a rare, recently described, autosomal dominant, connective tissue disease characterized by aggressive arterial aneurysms, resulting from mutations in the transforming growth factor beta (TGFβ) receptor genes TGFBR1 and TGFBR2. Mean age at death is 26.1 years, most often due to aortic dissection. We report an unusually late presentation of LDS, diagnosed following elective surgery in a female with a long history of joint hypermobility. Methods: A 51-year-old Caucasian lady complained of chest pain and headache following a dural leak from spinal anaesthesia for an elective ankle arthroscopy. CT scan and echocardiography demonstrated a dilated aortic root and significant aortic regurgitation. MRA demonstrated aortic tortuosity, an infrarenal aortic aneurysm and aneurysms in the left renal and right internal mammary arteries. She underwent aortic root repair and aortic valve replacement. She had a background of long-standing joint pains secondary to hypermobility, easy bruising, unusual fracture susceptibility and mild bronchiectasis. She had one healthy child age 32, after which she suffered a uterine prolapse. Examination revealed mild Marfanoid features. Uvula, skin and ophthalmological examination was normal. Results: Fibrillin-1 testing for Marfan syndrome (MFS) was negative. Detection of a c.1270G > C (p.Gly424Arg) TGFBR2 mutation confirmed the diagnosis of LDS. Losartan was started for vascular protection. Conclusions: LDS is a severe inherited vasculopathy that usually presents in childhood. It is characterized by aortic root dilatation and ascending aneurysms. There is a higher risk of aortic dissection compared with MFS. Clinical features overlap with MFS and Ehlers Danlos syndrome Type IV, but differentiating dysmorphogenic features include ocular hypertelorism, bifid uvula and cleft palate. Echocardiography and MRA or CT scanning from head to pelvis is recommended to establish the extent of vascular involvement. Management involves early surgical intervention, including early valve-sparing aortic root replacement, genetic counselling and close monitoring in pregnancy. Despite being caused by loss of function mutations in either TGFβ receptor, paradoxical activation of TGFβ signalling is seen, suggesting that TGFβ antagonism may confer disease modifying effects similar to those observed in MFS. TGFβ antagonism can be achieved with angiotensin antagonists, such as Losartan, which is able to delay aortic aneurysm development in preclinical models and in patients with MFS. Our case emphasizes the importance of timely recognition of vasculopathy syndromes in patients with hypermobility and the need for early surgical intervention. It also highlights their heterogeneity and the potential for late presentation. Disclosures: The authors have declared no conflicts of interes

Digital microfluidic processing of mammalian embryos for vitrification.

Cryopreservation is a key technology in biology and clinical practice. This paper presents a digital microfluidic device that automates sample preparation for mammalian embryo vitrification. Individual micro droplets manipulated on the microfluidic device were used as micro-vessels to transport a single mouse embryo through a complete vitrification procedure. Advantages of this approach, compared to manual operation and channel-based microfluidic vitrification, include automated operation, cryoprotectant concentration gradient generation, and feasibility of loading and retrieval of embryos

Vitrification protocol implementation on digital microfluidic chip.

<p>Implementation of common vitrification protocols on a digital microfluidic chip with a single dispensing reservoir. Timings and concentrations are shown in (A), and the generalized mixing curve is shown in (B).</p

Summary of vitrification results.

<p>Summary of vitrification results.</p

Key device design elements and fabrication layers.

<p>(A) Device structure and fabrication. Electrodes (1 mm×1 mm) were separated by a 20 µm gap. (B) Regions for vitrification medium dispensing and for embryo loading/extraction. The top ITO slide is placed on the device in a manner that exposes portions of the top electrodes in the dispensing reservoir and exposes portions of the leg of the T-shaped electrodes, for medium and embryo loading, respectively. (C) Embryo is input and extracted by actuating electrodes at edge of top glass slide.</p

Droplet mixing protocol and resulting concentration profile.

<p>(A) 1: Embryo (red circle) contained in culture medium (CM) droplet. 2: Embryo droplet mixed with VS droplet. 3: Droplet split into two droplets (left contains embryo). 4: Droplet containing embryo is kept and other droplet is sent to waste. Process is repeated to increase VS concentration. (B) Mixing profile showing the generation of ES medium and VS medium. Droplet volumes were calculated by imaging droplet boundaries and modeling as cylinders. Concentrations were then calculated using these volumes before and after each mixing step.</p