This naming convention has also been adopted by The Ehlers Danlos Society (EDS, 2017), who previously used Villefranche nosology to classify EDS types. Unfortunately, no cure for EDS currently exists, and treatments may include physical therapy, braces, counseling, and pain medication.

Vascular EDS (vEDS) is characterized by “arterial aneurysm, dissection and rupture, bowel rupture, and rupture of the gravid uterus” and affects 1 in 50,000 to 200,000 individuals. These arterial aneurysms may be life threatening. As noted in the table above, this disorder is due to mutations in the COL3A1 or COL1A1 genes, with a sequence analysis of COL3A1 thought to identify approximately 98% of vEDS cases. A diagnosis depends on clinical features, including family history. Aneurysms occur in other types of EDS, including classical EDS (cEDS), due to vascular fragility. Johansen, et al. (2020) published a recent cross-sectional study with data collected from 18 patients with genetically verified vEDS and 34 patients with genetically verified LDS. The median age at diagnosis was 34 years. “Most respondents (87%) had cardiovascular surveillance visits, 58% yearly or more often, and still 29% had no antihypertensive medications.”

Loeys-Dietz syndrome

Loeys-Dietz syndrome (LDS) was first described in 2005 and is now considered an autosomal dominant connective tissue disorder characterized by “aortic aneurysms and generalized arterial tortuosity, hypertelorism, and bifid/broad uvula or cleft palate.” LDS was initially characterized by mutations in the transforming growth factor β receptor I (TGFBR1) and transforming growth factor β receptor II (TGFBR2) genes; however, additional genes have been identified, including the mothers against decapentaplegic homolog 3 (SMAD3) gene, the transforming growth factor β 2 ligand (TGFB2) gene, and the transforming growth factor β 3 ligand (TGFB3) gene. If a mutation is identified in all three genes, transforming growth factor-β (TGF-β) signaling is affected and patients typically exhibit similar craniofacial, cutaneous, cardiovascular, and skeletal features. Vascular involvement in LDS has recently been studied by Jud and Hafner (2019) who published a case study which followed a woman with a history of ectasias of the aortic arch, abdominal aorta, carotid bulbs, and common femoral arteries, as well as an asymptomatic aneurysm in superior mesenteric artery. In comparing surgical outcomes between those with LDS versus MFS, it was found that LDS patients had a greater likelihood of reoperation for aortic arch aneurysms than MFS patients, and that those with mutations in TGFBR1 had higher rates of reoperation than those with TGFBR2 mutations.

Epidermolysis bullosa

Epidermolysis bullosa (EB) is a group of hereditary diseases characterized by mucosa and skin fragility due to mutations that affect skin structural proteins, causing the skin to easily blister. Four major types of EB have been identified and include EB simplex, junctional EB, dystrophic EB, and Kindler syndrome. Unfortunately, there is currently no effective therapeutic option for this disorder, and treatment largely focuses on wound management. All the major EB types may result from mutations in the keratin 5 (KRT5) or keratin 14 (KRT14) gene. These two genes work together to encourage strength in the epidermis. Mutations prevent the keratin from assembling in necessary networks, leading to fragility. Further, a rare type of EB, known as Ogna, has been associated with mutations in the PLEC gene, leading to issues in the attachment of the epidermis to other layers of the skin. Ryan, et al. (2016) note that ventricular dysfunction and aortic dilation have been identified in patients with recessive dystrophic EB.

Clinical Utility and Validity

More than 90% of patients with the typical Marfan phenotype have mutations involving the gene encoding the connective tissue protein fibrillin-1 (FBN1). Out of a sample of 93 patients with MFS, 85 (91%) were found to have a FBN1 mutation. The eight remaining patients did not display any drastically different clinical features or family history, and the authors suggest that FBN1 mutations that go undetected are due to technical limitations. Most patients have a family history of MFS, but up to 25% have a mutation de novo. Mutations are in one of five categories: nonsense, frameshift (deletion, insertion), splicing errors, a missense mutation that substitutes or creates cysteine residues, or a missense mutation affecting a conserved EGF sequence. Although the phenotypic variability is wide, mutations involving exon skipping tend to result in more severe disease. Genetic findings have importance in the diagnosis, risk stratification, and clinical management of patients, as well as identifying potentially affected relatives.

Becerra-Munoz et al. (2018) conducted a prospective cohort study to summarize variants in FBN1 and establish a genotype-phenotype correlation. Genotype-phenotype correlations have identified that patients with MFS and truncating variants in FBN1 presented a higher proportion of aortic events compared to a more benign course in patients with missense mutations. A total of 84 patients fulfilled the Ghent diagnostic criteria, and of these 84, 44 had missense mutations and 35 had truncating mutations. However, of the 44 with missense mutations, only six had suffered an aortic event (such as aortic aneurysm) whereas 20 of the 35 with a truncating mutation had suffered an aortic event. Up to 10% of patients with the Marfan phenotype have no identifiable mutation in the FBN1 gene. Rather, mutations are identified in TGF-beta receptor 1 (TGFBR1) and TGFBR2 genes. It has been proposed that patients with the Marfan phenotype and TGFBR1 or TGFBR2 mutations be classified as having LDS to properly address the potential for more aggressive vascular disease than seen in MFS.

The diagnosis of MFS is now established by an FBN1 pathogenic variant known to be associated with Marfan syndrome AND one of the following: aortic root enlargement (Z-score ≥2.0), ectopia lentis, demonstration of aortic root enlargement (Z-score ≥2.0) and ectopia lentis OR a defined combination of features throughout the body yielding a systemic score ≥7. These features are summarized in the 2010 Ghent nosology, which is slightly altered for patients under 20 years old. Due to the identification of FBN1 as the genetic basis for MFS and its subsequent effects, the understanding of MFS as a structural disorder has become one of a developmental abnormality with broad effects on the morphogenesis and function of multiple organ systems. Importantly, this also introduced new biological targets for treatment strategies in MFS. 

Current clinical studies have elucidated a medical regimen for patients with MFS to help control the progression of cardiovascular manifestations and resulting mortality. The standard of care for medical management includes the use of β-blockers with supplementation or replacement by angiotensin receptor blockers (ARBs). However, the best course of treatment is a subject of ongoing research. However, a Cochrane review concluded, “Based on only one, low-quality RCT comparing long-term propranolol to no treatment in people with Marfan Syndrome, we could draw no definitive conclusions for clinical practice.” The authors concluded that further, high-quality, randomized trials were needed to evaluate the long-term efficacy of beta-blocker treatment in people with Marfan syndrome. Sellers, et al. (2018) recently reported, “Despite promising preclinical and pilot clinical data, a recent large-scale study using antihypertensive angiotensin II (AngII) receptor type 1 (ATR1) blocker losartan has failed to meet expectations at preventing MFS-associated aortic root dilation, casting doubts about optimal therapy.” Their mouse study suggested that “increased protective endothelial function, rather than ATR1 inhibition or blood pressure lowering, might be of therapeutic significance in preventing aortic root disease in.”

Johansen, et al. (2020); Ritelli et al. (2020); Shalhub, et al. (2020) analyzed vEDS data from 11 institutions between the year 2000 and 2015. Data used for this study included family history, clinical features, diagnostic criteria, demographics, and molecular testing results. A total of 173 individuals were identified for the purposes of this study, with 11 excluded because pathogenic COL3A1 variants were not identified. Of the remaining individuals, 86 had been diagnosed with a pathogenic COL3A1 variants, and 76 were diagnosed with only clinical criteria. “Compared with the cohort with pathogenic COL3A1 variants, the clinical diagnosis only cohort had a higher number of females (80.3% vs 52.3%; P < .001), mitral valve prolapses (10.5% vs 1.2%; P = .009), and joint hypermobility (68.4% vs 40.7%; P < .001). Additionally, they had a lower frequency of easy bruising (23.7% vs 64%; P < .001), thin translucent skin (17.1% vs 48.8%; P < .001), intestinal perforation (3.9% vs 16.3%; P = .01), spontaneous pneumothorax/hemothorax (3.9% vs 14%, P.03), and arterial rupture (9.2% vs 17.4%; P = .13).  .” This study highlights the importance of genetic testing for a vEDS diagnosis as the symptoms of vEDS overlap with many other disorders and a correct diagnosis is necessary for efficient disease treatment. Further, not all COL3A1 variants are pathogenic, meaning that genetic results must be interpreted by a trained professional.

Using a next-generation sequencing (NGS) multigene panel, Mariath, et al. (2019) identified 11 disease-causing variants of EB in a Brazilian population with an efficiency of 94.3%. Other studies that they have included have calculated efficiencies of 83.5% for a panel with 21 genes, 90% with 49 genes, and 97.7% in 21 genes, where all identified mutations were only in five genes. This conveys the clinical utility of gene variants in EB that could be translated to other connective tissue disorder mutations. In a study done with children with inherited EB, the accuracy of several diagnostic techniques, which included electron microscopy (EM), immunofluorescence mapping (IFM), and clinical provisional diagnosis (CPD) was evaluated. It was found that IFM, EM, and CPD yielded an accuracy of 75%, 75%, and 81.5%, respectively. All genetic components, tissue specimen, and clinical history are all necessary for a confirmed EB diagnosis.

Li, et al. (2021) conducted a study in northwestern China to determine the genotype-phenotype correlation for thoracic aortic aneurysm and dissection via NGS. They screened 15 genes from 212 patients to find that 67 (31.60%) patients in this cohort had a (likely) pathogenic variant, “42 (19.81%) had a variant of uncertain significance (VUS), and 103 (48.58%) had no variant (likely benign/benign/negative),” with 135 reportable variants. With FBN1, a gene implicated in MFS, they found that “patients with truncating and splicing mutations are more prone to developing severe aortic dissection than those with missense mutations, especially frameshift mutations (82.76% vs. 42.86%),” and “the positive rate of genetic testing was higher in TAAD [thoracic aortic aneurysm and dissection] patients with family history than in those without (76.74% vs. 18.94%)”.

Chen, et al. (2021) investigated how genetic testing could aid in avoiding the occurrence of MFS among Chinese families. Using data from 11 families, as well as variant classification and interpretation through pedigree analysis, the researchers were able to support two families who agreed to pre-implantation genetic testing for monogenic diseases (PGT-M) as part of the in vitro fertilization process. They were able to identify 11 potential-disease causing FBN1 variants and found that “nine variants were classified as likely pathogenic/pathogenic variants. Among 11 variants, eight variants were missense and seven of them were located in the Ca-binding EGF-like motifs. Moreover, half of them substituted conserved Cysteine residues.” They also found one splice site variant, one frameshift variant, one synonymous variant, and two de novo variants. All variants were detected by polymerase chain reaction (PCR). Ultimately, the two MFS families were able to give birth to a baby without the FBN1 mutation, as the healthy embryo was selected using haplotype analysis “to deduce the embryo’s genotype by using single nucleotide polymorphisms.” This demonstrated the tangible benefits of genetic testing for eliminating MFS and the development of comorbid conditions among future generations.

Damseh, et al. (2022) conducted a retrospective study using the 2017 EDS classification criteria on 72 pediatric patients who were referred for evaluation of EDS. From this initial cohort, 18 patients met the clinical criteria for an EDS subtype diagnosis, and 15 were confirmed molecularly. 75% (n=54) of the patients also had clinical features that belonged to EDS and other joint hypermobility syndromes, but not a complete qualification of EDS clinical criteria. From those 54 patients, it was discovered that 12 patients (22%) had a molecular genetic diagnosis of EDS. An EDS genetic panel, microarray, whole exome sequencing, single gene sequencing, familial variant testing, and other genetic panels were utilized to confirm genetic based diagnoses of EDS. Of the 15 patients who met clinical criteria and had a positive molecular diagnosis and 12 that did not meet clinical criteria but had a positive molecular diagnosis, 41% had classical EDS, 26% had arthrochalasia EDS, 11% had kyphoscoliotic EDS, and 22% had vascular EDS. The researchers ultimately “observed a correlation between generalized joint hypermobility, poor healing, easy bruising, atrophic scars, skin hyperextensibility, and developmental dysplasia of the hip with a positive molecular result.” This study aided in expanding the scope of the 2017 EDS classifications into the pediatric population and effecting changes to clinical decision making and treatment.

Veatch, et al. (2022) utilized clinical exam data and genetic testing results to understand the phenotypic and genotypic correlation for hereditary connective tissue diseases from 2016-2020. From a cohort of 100 unrelated individuals, the researchers isolated six likely pathogenic, and 35 classified “potentially pathogenic variants of unknown clinical significance.” They found that those with potentially pathogenic variants and pathogenic/likely pathogenic variants of the same genes exhibited similar symptoms, as those with “connective tissue symptoms had suggestive evidence of increased odds of having skin (odds ratio 2.18, 95% confidence interval 1.12 to 4.24) and eye symptoms (odds ratio 1.89, 95% confidence interval 0.98 to 3.66) requiring further studies.” Ultimately, the symptoms were broken up into classes of minimal skeletal symptoms (e.g., limb asymmetry, scoliosis, pes planus), more skeletal than connective tissue (e.g., joint hypermobility, dental defects, repeated ligament and cartilage disease), nervous, or gastrointestinal (e.g., irritable bowel syndrome, food intolerance) symptoms, and more nervous system (e.g., migraines, neuropathy) symptoms. Comprehending the spectrum of phenotypic heterogeneity could guide consequential clinical decision making for surveilling and counseling patients with hereditary connective tissue disorders and their current and future families.

Guidelines and Recommendations

American College of Cardiology (ACC)/American Heart Association (AHA)

The ACC 2022 released guidelines on thoracic aortic disease jointly with the American Heart Association:

Regarding heritable TAD:

• In patients with aortic root/ascending aortic aneurysms or aortic dissection and risk factors for heritable TAD, it is recommended that genetic testing be used to identify pathogenic/likely pathogenic variants.
• In patients with heritable TAD who have a pathogenic/likely pathogenic variant, genetic testing of at-risk biological relatives is recommended.

In the evaluation and genetic testing protocol for patients suspected of having TAD, the authors note these risk factors:

• “Features of MFS, LDS, or vEDS
• Family history of TAD, intracranial or peripheral aneurysm
• TAD < 60 y of age”

The following risk factors for familial TAD are identified in the guideline:

• “TAD and syndromic features of Marfan syndrome, Loeys-Dietz syndrome, or vascular Ehlers-Danlos syndrome.
• TAD presenting at age < 60 y
• A family history of either TAD or peripheral/intracranial aneurysms in a first- or second-degree relative.
• A history of unexplained sudden death at a relatively young age in a first- or second-degree relative.”

Regarding multigene pane testing, the ACC/AHA recommends, “Although the recommendations focus on individuals with a high risk for a single gene mutation, genetic testing may have a role in many TAD patients. A multigene panel comprising all genes suspected to cause HTAD is the most cost-effective and clinically useful approach to testing. Only pathogenic or likely pathogenic variants are disease-causing and should be used for cascade genetic testing all relatives at risk for inheriting the disease-causing variant.”

Genetic testing panels for heritable thoracic aortic disease may include 11 genes that are confirmed to have a highly penetrant risk for TAD: FBN1, LOX, COL3A1, TGFBR1, TGFBR2, SMAD3, TGFB2, ACTA2, MYH11, MYLK, and PRKG1. These panels also include genes that increase the risk for genetically triggered thoracic aortic disease and/or lead to features related to Marfan syndrome, Loeys-Dietz syndrome, or vascular Ehlers-Danlos syndrome. Lastly, in patients who meet clinical diagnostic criteria for Marfan syndrome but do not have the clinical feature of a dislocated lens, genetic testing should be considered to exclude an alternative diagnosis of Loeys-Dietz syndrome.

American Heart Association

The AHA published a guideline regarding genetic testing for inherited cardiovascular diseases. The AHA notes that genetic testing plays a major role in diagnosing both Loeys-Dietz Syndrome and Marfan Syndrome, as well as confirming diagnoses of familial thoracic aortic aneurysm and dissection. A confirmed diagnosis may then affect timing of treatment or extent of screening for family members of the proband.

The AHA cites an ACMG list of “Genes Associated With Cardiovascular Disorders in Which Secondary/Incidental Findings Are Reportable”. COL3A1 is listed for Ehlers-Danlos Syndrome and FBN1, TGFBR1, TGFBR2, SMAD3, ACTA2, MYH11 are listed for Marfan syndrome, Loeys-Dietz syndromes, and familial thoracic aortic aneurysms and dissections.

The AHA then lists another ACMG list of “Lists of Genes to Be Considered for Testing From Guidelines and Statements”. Regarding heritable thoracic aortic aneurysm(s) or dissection(s), the genes ACTA2, COL3A1, FBN1, MYH11, SMAD3, TGFB2, TGFBR1, TGFBR2, MYLK, LOX, PRKG1 are listed as having “definitive or strong evidence”, and the genes EFEMP2, ELN, FBN2, FLNA, NOTCH1, SLC2A10, SMAD4, SKI, are considered as “potentially diagnostic.”

American College of Medical Genetics (ACMG)

The ACMG recommends the following diagnostic evaluations for a MFS diagnosis: a physical exam, family history, echocardiogram, dilated eye exam, CT or MRI, and the consideration of FBN1 gene sequencing. The ACMG notes that, since FBN1 mutations may cause conditions other than MFS (such as EDS and LDS), clinical features must be used to diagnose MFS properly. The ACMG further notes SMAD3, ACTA2, and MYH11 as potential genes of interest in identifying MFS, in addition to FBN1, TGFBR1, and TGFBR2.

Regarding LDS, the ACMG notes that “LDS strongly resembles the vascular form of Ehlers–Danlos syndrome, especially in terms of thin skin.” Further, a diagnostic evaluation of LDS includes the following: a “physical exam, family history, echocardiogram, dilated eye exam (to exclude MFS), magnetic resonance angiography of the head, neck thorax, abdomen and pelvis, and TGFBR1 and TGFBR2 gene sequencing (Pyeritz, 2012).” Specifically, the ACMG states that “In a patient found to have consistent facial features, bifid uvula, and arterial tortuosity, the diagnosis [of LDS] can be confirmed with TGFBR testing.”

Regarding EDS hypermobile type, the ACMG recommends the following diagnostic evaluation: a physical exam, family history, echocardiogram, and dilated eye exam (to exclude MFS). The guidelines also specifically state that “Diagnosis is based on clinical evaluation and family history. A small subset of individuals with the hypermobile form of EDS have an insertion or deletion in the TNXB gene.”

ACMG also published a statement titled “Recommendations for reporting of secondary findings in clinical exome and genome sequencing.” In it, COL3A1 is listed for Ehlers-Danlos Syndrome, vascular type, and FBN1, TGFBR1, TGFBR2, SMAD3, ACTA2, and MYH11 were listed as relevant genes for aortopathies.

American Academy of Pediatrics (AAP)

The AAP released an updated guideline in 2023 on the medical management of children with MFS:

• When clinical features suggest Marfan syndrome, but do not fully meet diagnostic criteria, genetic testing for FBN1 mutations is recommended to clarify the diagnosis. 
• Genetic testing of FBN1 should be considered for those children suspected of having Marfan syndrome (but who may not meet full clinical criteria) after physical, cardiac, and ophthalmic evaluation. 
• Asymptomatic individuals with a first-degree relative diagnosed with MS should consider genetic testing to determine their risk and guide surveillance strategies. 
• Additionally, patients who “fit clinical criteria for Marfan syndrome in whom no pathogenic variant is found in the FBN1 gene should continue to be followed…In addition, broader genomic testing should be considered in these individuals.”

The Marfan Foundation

The Marfan Foundation has released recommendations on certain aspects of testing for MFS. The Foundation mentions several situations in which genetic testing may be useful, such as patients with features of multiple disorders, patients with a clinical symptom characteristic of MFS (such as ectopia lentis), children of parents affected by MFS, or adults with MFS that are considering having children. Prenatal testing may be performed, either a chorionic villus sampling (CVS) at 10-11 weeks or amniocentesis at 16-18 weeks. However, the parent’s mutation must be confirmed before proceeding with either prenatal test.

Screening of first-degree relatives of patients with MFS is also warranted. Aortic imaging may be performed if the mutation has not been identified.

The Ehlers Danlos Society and the International Consortium on the Ehlers-Danlos Syndromes

These guidelines state that Ehlers-Danlos syndrome “Molecular diagnostic strategies should rely on NGS technologies, which offer the potential for parallel sequencing of multiple genes. Targeted resequencing of a panel of genes, for example, COL5A1, COL5A2, COL1A1 and COL1A2, is a time‐ and cost‐effective approach for the molecular diagnosis of the genetically heterogeneous EDS. When no mutation (or in case of an autosomal recessive condition only one mutation) is identified, this approach should be complemented with a copy number variant (CNV) detection strategy to identify large deletions or duplications, for example Multiplex Ligation‐dependent Probe Amplification (MLPA), qPCR, or targeted array analysis. Alternatively, or in a second phase, whole exome sequencing or whole genome sequencing (WGS) and RNA sequencing techniques can be used, with data‐analysis initially focusing on the genes of interest for a given EDS subtype. In absence of the identification of a causal mutation, this approach allows to expand the analysis to other genes within the genome. This is particularly interesting in view of the clinical overlap between EDS subtypes and with other HCTDs, and the observation that in an important proportion of EDS‐patients, no pathogenic variants are identified in any of the known EDS‐associated genes.”

For cEDS, the following guidelines were given:

• "Molecular screening by means of targeted resequencing of a gene panel that includes at least the COL5A1, COL5A2, COL1A1, and COL1A2 genes, or by WES or WGS, is indicated. When no mutation is identified, this approach should be complemented with a CNV detection strategy to identify large deletions or duplications.
  Absence of these confirmatory findings does not exclude the diagnosis, as specific types of mutations (e.g., deep intronic mutations) may go undetected by standard diagnostic molecular techniques; however, alternative diagnoses should be considered in the absence of (a) COL5A1, COL5A2, COL1A1, or COL1A2 mutation(s).”

For classical-like EDS (clEDS), the following guidelines were given:

• “Molecular analysis of the TNXB gene should be used as the standard confirmatory test. Difficulties in DNA testing are related to the presence of a pseudogene (TNXA), which is more than 97% identical to the 3′ end of TNXB (exons 32–44). With the only exception of exon 35, which partially shows a TNXB‐specific sequence, exon and intron sequences in this region are identical or almost identical in both the gene and the pseudogene. This has implications both for sequencing and deletion/duplication analysis.
• For sequence analysis of TNXB, two approaches are recommended.
  • Sanger sequencing of the entire TNXB gene.
  • Next‐generation sequencing of TNXB + Sanger sequencing of the pseudogene region.”
• If no or only one causative mutation is identified by classic sequencing, additional methods that allow detection of large deletions/duplications should be added. So far no method is able to specifically detect TNXB CNVs in the highly homologous exons 32–34 and 36–44. CNV analysis of exon 35 is currently used to detect deletions in this region, including the 30 kb deletion.
• Absence of these confirmatory findings does not exclude the diagnosis, as specific types of mutations (e.g., deep intronic mutations) may go undetected by standard diagnostic molecular techniques; however, alternative diagnoses should be considered in the absence of a TNXB mutation.”

For cardiac-valvular EDS (cvEDS), the following recommendations were given:

• "Molecular screening by Sanger sequencing of COL1A2, or targeted resequencing of a gene panel that includes COL1A2 is indicated. When no mutation is identified, this approach should be complemented with a CNV detection strategy to identify large deletions or duplications.
• In case of unavailability of genetic testing, SDS PAGE demonstrates total absence of (pro‐) α2(I) collagen chains.
  Whereas absence of these confirmatory biochemical findings allows to exclude the diagnosis of cvEDS, absence of these confirmatory genetic findings does not exclude the diagnosis, as specific types of mutations (e.g., deep intronic mutations) may go undetected by standard diagnostic molecular techniques.”

For vEDS, the following guidelines were given:

• "Molecular screening by Sanger sequencing of COL3A1, or targeted resequencing of a gene panel that includes COL3A1 and COL1A1 (the latter to identify the above‐listed arginine‐to‐cysteine substitution mutations) is indicated. When no mutation is identified, this approach should be complemented with a CNV detection strategy to identify large deletions or duplications.
  Absence of these confirmatory findings does not exclude the diagnosis, as specific types of mutations (e.g., deep intronic mutations) may go undetected by standard diagnostic molecular techniques; however, alternative diagnoses should be considered in the absence of a COL3A1 or COL1A1 mutation.”

For hypermobile EDS (hEDS), the following guidelines were given:

“The diagnosis of hEDS remains clinical as there is yet no reliable or appreciable genetic etiology to test for in the vast majority of patients.”

For arthrochalasia EDS (aEDS), the following guideline were given:

• "Molecular screening by Sanger sequencing of COL1A1 and COL1A2, or targeted resequencing of a gene panel that includes these genes, is indicated. When no mutation is identified, this approach should be complemented with a CNV detection strategy to identify large deletions or duplications.
• In case of unavailability of genetic testing, SDS PAGE of the pepsin‐digested collagen in the medium or cell layer of cultured dermal fibroblasts demonstrates the presence of a mutant pNα1(I) or pNα2(I) chain (precursor procollagen chains in which the carboxy (C)‐but not the amino (N)‐propetide is cleaved off).
• TEM of skin specimens shows loosely and randomly organized collagen fibrils with a smaller and more variable diameter, and an irregular outline. These findings may support the diagnosis but cannot confirm it.
• Absence of a causative mutation in COL1A1 or COL1A2 that leads to complete or partial deletion of the exon 6 of either gene excludes the diagnosis of aEDS.”

For dermatosparaxis EDS (dEDS), the following guidelines were given:

• "Molecular screening by Sanger sequencing of targeted resequencing of a gene panel that includes ADAMTS2 is indicated. When no, or only one, causative mutation is identified, this approach should be complemented with a CNV detection strategy to identify large deletions or duplications.
• In case of unavailability of genetic testing, SDS, PAGE demonstrates presence of pNα1(I) and pNα2(I) chains of type I procollagen extracted from dermis in the presence of protease inhibitors or detected in fibroblast cultures.
• TEM shows collagen fibrils in affected skin specimens with a hieroglyphic pattern. These ultrastructural findings are usually typical but may be almost indistinguishable from those observed in aEDS. As such, they are not sufficient to confirm the diagnosis.
• Absence of these confirmatory findings does not exclude the diagnosis of dEDS, as specific types of mutations (e.g., deep intronic mutations) may go undetected by standard diagnostic molecular techniques; however, alternative diagnoses should be considered in the absence of ADAMTS2 mutations.”

For kyphoscoliotic (kEDS), the following recommendations were given:

• Laboratory confirmation of kEDS should start with the quantification of deoxypyridinoline (Dpyr or LP for lysyl‐pyridinoline) and pyridinoline (Pyr or HP for hydroxylysyl‐pyridinoline) cross‐links in urine quantitated by means of high‐performance liquid chromatography (HPLC). An increased Dpyr/Pyr ratio is a highly sensitive and specific test for kEDS caused by biallelic PLOD1 mutations (kEDS‐PLOD1) but is normal for biallelic FKBP14 mutations (kEDS‐FKBP14).
• The normal ratio of Dpyr/Pyr cross‐links is approximately 0.2, whereas in kEDS‐PLOD1 the ratio is significantly increased (approximately 10–40 times increase, range 2–9). This method is fast and cost‐effective, and it can also be used to determine the pathogenic status of a VUS in PLOD1.
• SDS–PAGE may detect faster migration of under hydroxylated collagen chains and their derivatives in kEDS‐PLOD1 but not in kEDS‐FKBP14. However, abnormalities in migration can be subtle.
• Molecular analysis for kEDS‐PLOD1 may start with MLPA analysis of PLOD1, for the evaluation of the common intragenic duplication in PLOD1 caused by an Alu‐Alu recombination between introns 9 and 16 (the most common mutant allele). 
• Molecular screening by means of targeted resequencing of a gene panel that includes PLOD1 and FKBP14, is indicated when MLPA of PLOD1 fails to identify the common duplication. Such a gene panel my also include other genes associated with phenotypes that clinically overlap with kEDS, such as ZNF469, PRDM5, B4GALT7, B3GALT6, SLC39A13, CHST14 and DSE. Alternatively, WES may be performed. When no, or only one, causative mutation is identified, this approach should be complemented with a CNV detection strategy to identify large deletions or duplications in these genes.
• TEM on skin specimens has shown variable diameters and abnormal contours of the collagen fibrils and irregular interfibrillar space, but these abnormalities are not unique to this condition. As such, whereas TEM on a skin biopsy can support diagnosis, it cannot confirm it.
• Whereas absence of an abnormal urinary LP/HP ratio excludes the diagnosis of kEDS‐PLOD1, absence of the confirmatory genetic findings does not exclude the diagnosis of kEDS, as specific types of mutations (e.g., deep intronic mutations) may go undetected by standard diagnostic molecular techniques and/or other, yet to be discovered, genes, may be associated with this phenotype; however, alternative diagnoses should be considered in the absence of PLOD1 or FKBP14 mutations.”

For brittle cornea syndrome (BCS), the following guidelines were given:

• "Molecular screening by means of targeted resequencing of a gene panel that includes ZNF469 and PRDM5 is indicated. Such a gene panel my also include other genes associated with phenotypes that clinically overlap with BCS, such as PLOD1, FKBP14, B4GALT7, B3GALT6, SLC39A13, CHST14, and DSE. Alternatively, WES may be performed. When no, or only one, causative mutation is identified, this approach should be complemented with a CNV detection strategy to identify large deletions or duplications in these genes.
• Absence of these confirmatory findings does not exclude the diagnosis, as specific types of mutations (e.g., deep intronic mutations) may go undetected by standard diagnostic molecular techniques, and other, yet unknown genes, might be associated with BCS.”

For spondylodysplastic EDS (spEDS), the following guidelines were given:

• Molecular screening by means of targeted resequencing of a gene panel that includes B4GALT7, B3GALT6, and SLC39A13 is indicated. Such a gene panel my also include other genes associated with phenotypes that clinically overlap with spEDS, such as PLOD1, FKBP14, ZNF469, PRDM5, CHST14, and DSE. Alternatively, WES may be performed. When no, or only one, causative mutation is identified, this approach should be complemented with a CNV detection strategy to identify large deletions or duplications in these genes.
• For definite proof of GAG deficiency (B4GALT7 and B3GALT6 mutations), biochemical methods to assess GAG synthesis in patients’ cultured fibroblasts are currently available in many specialized laboratories.
• The laboratory measurement of urinary pyridinolines, lysyl‐pyridinoline (LP) and hydroxylysyl‐pyridinoline (HP) quantitated by HPLC allows the detection of an increased ratio LP/HP to approximately 1, (compared to a normal value of approximately 0.2) in patients with mutations in SLC39A13. This fast and cost‐effective method can also be used to determine the pathogenic status of a VUS (see also “verification of diagnosis” in kEDS‐PLOD1).
• Absence of confirmatory genetic findings does not exclude the diagnosis of spEDS, as specific types of mutations (eg deep intronic mutations) may go undetected by standard diagnostic molecular techniques, and still other, yet to be discovered, genes may be associated with these phenotypes. In case no B4GALT7, B3GALT6, or SCL39A13 mutations are identified, alternative diagnoses should however be considered.”

For musculocontractural EDS (mcEDS), the following guidelines were given:

• "Molecular screening by means of targeted resequencing of a gene panel that includes CHST14 and DSE is indicated. Such a gene panel my also include other genes associated with phenotypes that clinically overlap with mcEDS, such as PLOD1, FKBP14, ZNF469, PRDM5, B4GALT7, B3GALT6 and SLC39A13. Alternatively, WES may be performed. When no, or only one, causative mutation is identified, this approach should be complemented with a CNV detection strategy to identify large deletions or duplications in these genes.
• Absence of these confirmatory genetic findings does not exclude the diagnosis of mcEDS, as specific types of mutations (e.g., deep intronic mutations) may go undetected by standard diagnostic molecular techniques. In case no CHST14 or DSE mutations are identified, alternative diagnoses should be considered.”

For myopathic EDS (mEDS), the following guidelines were given:

• "Molecular screening by means of targeted resequencing of a gene panel that includes COL12A1 is indicated. Such a gene panel my also include other genes associated with phenotypes that clinically overlap with mEDS, such as COL6A1, COL6A2, COL6A3. Alternatively, WES may be performed. When no, or only one, causative mutation is identified, this approach should be complemented with a CNV detection strategy to identify large deletions or duplications in these genes.
• Absence of these confirmatory findings does not exclude the diagnosis, as specific types of mutations (eg deep intronic mutations) may go undetected by standard diagnostic molecular techniques, and other, yet to be discovered, genes may be associated with this phenotype.”

For periodontal EDS (pEDS), the following guidelines were given:

• "Identification of known or compatible mutations by sequence analysis of C1R and C1S. Large deletions or null mutations that completely remove C1r or C1s protein function do not cause pEDS.
• At present it cannot be stated whether absence of a C1R or C1S mutations excludes the diagnosis because the experience with the molecular diagnosis is limited.”

Canadian Cardiovascular Society (CCS)

The CCS has published recommendations for MFS stating a strong recommendation for clinical and genetic screening for anyone with suspected MFS “to clarify the nature of the disease and provide a basis for individual genetic counseling.”

The CCS also published recommendations for non-Marfan genetic forms of aortic disease such as thoracic aortic disease (TAD). These guidelines state that “We recommend screening for TAD-associated genes in non-BAV aortopathy index cases to clarify the origin of disease and improve clinical and genetic counselling.” These guidelines also state that individuals with a known LDS mutation (such as TGFBR1/2, TGFB, SMAD3, ACTA2, or MYH11) should receive complete aortic imaging when diagnosed and six months after diagnosis.

International Group of Specialists with a Broad Aggregate Experience in the Care of Individuals with Vascular EDS

Recommendations made by this group of vEDS specialists recommend to “identify causative variants in COL3A1 prior to [the] application of diagnosis” of vEDS.

National Organization for Rare Disorders (NORD)

NORD has posted recommendations on EB stating that “When EB is suspected, a skin biopsy should be obtained and sent to an appropriate laboratory to confirm the diagnosis with transmission electron microscopy (TEM) and/or immunofluorescent antibody/antigen mapping. Molecular genetic testing for mutations in most of the genes known to be associated with the various types of EB is clinically available.”

On the diagnosis of EDS, the NORD has stated that diagnosis is generally made using patient histories and clinical findings, and that genetic testing can help in the diagnosis of some subtypes. Electron microscopic analysis could also aid in revealing the collagen abnormalities seen in EDS. “The clinical evaluation of individuals with suspected or diagnosed EDS typically includes assessments to detect and determine the extent of skin and joint hyperextensibility.” The NORD also posted recommendations of utilizing computerized tomography  scanning, magnetic resonance imaging (MRI), and echocardiography to observe any mitral valve prolapse and aortic dilatation. On kEDS, NORD has written of confirmatory tests using “either a urine sample and extrapolated ratio of deoxypyridinoline to pyridinoline cross-links, or on a skin biopsy sample and measurement of lysyl hydroxylase enzyme activity from skin fibroblast cells.”

Dystrophic Epidermolysis Bullosa Research Association (DEBRA) International

An international group was convened to develop a clinical practice guideline on laboratory testing for epidermolysis bullosa (EB). The following recommendations apply:

• A strong recommendation that EB lab diagnosis be performed with the first clinical suspicion of EB (Grade C).
• Early diagnosis by immunofluorescence antigen mapping (IFM) and genetic testing to provide prognosis and help aid in decision making in most cases (Grade B/C).
• A consideration that DNA-based prenatal diagnosis can be considered for all EB subtypes and be performed upon family request (Grade B).
• A strong recommendation that EB laboratory diagnosis be performed in accredited laboratories that have the necessary expertise (Grade D).
• The individual in question and the biological parents should be genetically tested to provide accurate genetic counseling and a risk assessment (Grade B).
• The methods listed for genetic testing include: NGS with a targeted EB gene panel, Whole Exome Sequencing, and Sanger Sequencing. Other methods can be considered in certain cases: SNP arrays for segregation analysis, MLPA, qPCR, and RNA-Seq, as well as homozygosity mapping in case of consanguinity. Hotspot and recurrent pathogenic variants can be tested in targeted situations (Grade B)
• IFM is recommended to help attain a rapid diagnosis and prognosis (Grade C)

The following prioritization strategies of EB laboratory diagnosis should be considered:

• “In neonates, IFM should be the first diagnostic step as it delivers rapid results. In parallel, genetic testing should always be performed.”
• “In cases with characteristic clinical features, including localized dominant EBS or DEB, for which IFM will frequently not deliver a useful result, genetic testing by NGS or SS can deliver a final diagnosis.”
• In EB (sub)types with genetic heterogeneity or in cases with uncharacteristic findings, without a clear candidate gene, genetic testing by NGS is recommended.”

Additionally, “In EB (sub)types with genetic heterogeneity, in cases with-out a clear candidate gene, where candidate genes have been ruled out, or in cases when SS was the first chosen method and did not identify the pathogenic variant, targeted NGS with the 21 known EB genes [CD151, COL17A1, COL7A1, DSP, DST, EXPH5, FERMT1, ITGA3, ITGA6, ITGB4, JUP, KLHL24, KRT14, KRT5, LAMA3, LAMA3A, LAMB3, LAMC2, PKP1, PLEC, and TGM5]⁷or WES with targeted filtering for laboratory diagnosis of EB is recommended (level of evidence 2++, grade of recommendation B) Subsequently, confirmation of novel pathogenic variants found this way should be performed by SS (level of evidence 4, grade of recommendation D). Recent data showed that in clinically unaffected parents, mosaicism may be detected by NGS more often than expected (depending on the coverage of the NGS platform), which has important impacts on genetic counselling. The advantage of targeted EB gene panels is that they obviously have a much higher coverage per gene and base. However, current WES platforms should also provide sufficient coverage per gene and base to provide accurate results, but it is recommended to confirm this in individual laboratories.”

State and Federal Regulations, as applicable

Food and Drug Administration (FDA)

Many labs have developed specific tests that they must validate and perform in house. These laboratory-developed tests (LDTs) are regulated by the Centers for Medicare and Medicaid (CMS) as high-complexity tests under the Clinical Laboratory Improvement Amendments of 1988 (CLIA ’88). As an LDT, the U. S. Food and Drug Administration has not approved or cleared this test; however, FDA clearance or approval is not currently required for clinical use.

VYJUVEK (beremagene geperpavec) is an FDA approved therapy for certain individuals with epidermolysis bullosa. “Indications and usage: VYJUVEK is a herpes-simplex virus type 1 (HSV-1) vector-based gene therapy indicated for the treatment of wounds in patients 6 months of age and older with dystrophic epidermolysis bullosa with mutation(s) in the collagen type VII alpha 1 chain (COL7A1) gene. . . VYJUVEK is a biological suspension, mixed into excipient gel, for topical application.”

Billing/Coding/Physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

Applicable service codes: 81403, 81405, 81408, 81410, 81411, 81479

BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.

Scientific Background and Reference Sources

For policy titled: Marfan Syndrome AHS – M2144

Becerra-Munoz, V. M., Gomez-Doblas, J. J., Porras-Martin, C., Such-Martinez, M., Crespo-Leiro, M. G., Barriales-Villa, R., . . . Cabrera-Bueno, F. (2018). The importance of genotype-phenotype correlation in the clinical management of Marfan syndrome. Orphanet J Rare Dis, 13(1), 16. doi:10.1186/s13023-017-0754-6

Bin Mahmood, S. U., Velasquez, C. A., Zafar, M. A., Saeyeldin, A. A., Brownstein, A. J., Ziganshin, B. A., . . . Mukherjee, S. K. (2017). Medical management of aortic disease in Marfan syndrome. Ann Cardiothorac Surg, 6(6), 654-661. doi:10.21037/acs.2017.11.09

Dale, M., Fitzgerald, M. P., Liu, Z., Meisinger, T., Karpisek, A., Purcell, L. N., . . . Xiong, W. (2017). Premature aortic smooth muscle cell differentiation contributes to matrix dysregulation in Marfan Syndrome. PLoS One, 12(10), e0186603. doi:10.1371/journal.pone.0186603

Davis, M. R., & Summers, K. M. (2012). Structure and function of the mammalian fibrillin gene family: implications for human connective tissue diseases. Mol Genet Metab, 107(4), 635-647. doi:10.1016/j.ymgme.2012.07.023

Dietz, H. (2017). Marfan Syndrome. In M. P. Adam, H. H. Ardinger, R. A. Pagon, S. E. Wallace, L. J. H. Bean, K. Stephens, & A. Amemiya (Eds.), GeneReviews((R)). Seattle (WA): University of Washington, Seattle University of Washington, Seattle. GeneReviews is a registered trademark of the University of Washington, Seattle. All rights reserved. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/20301510.

Dietz, H. C., Loeys, B., Carta, L., & Ramirez, F. (2005). Recent progress towards a molecular understanding of Marfan syndrome. Am J Med Genet C Semin Med Genet, 139c(1), 4-9. doi:10.1002/ajmg.c.30068

Faivre, L., Collod-Beroud, G., Loeys, B., Child, A., Binquet, C., Gautier, E., . . . Boileau, C. (2007). Effect of Mutation Type and Location on Clinical Outcome in 1,013 Probands with Marfan Syndrome or Related Phenotypes and FBN1 Mutations: An International Study. Am J Hum Genet, 81(3), 454-466.

FDA. (2018).

Foundation, M. (2013a). GENETIC TESTING AND MARFAN SYNDROME.

Foundation, M. (2013b). OVERVIEW OF CARDIAC MANAGEMENT IN MARFAN SYNDROME.

Grewal, N., & Gittenberger-de Groot, A. C. (2018). Pathogenesis of aortic wall complications in Marfan syndrome. Cardiovasc Pathol, 33, 62-69. doi:10.1016/j.carpath.2018.01.005

Hilhorst-Hofstee, Y., Rijlaarsdam, M. E., Scholte, A. J., Swart-van den Berg, M., Versteegh, M. I., van der Schoot-van Velzen, I., . . . Pals, G. (2010). The clinical spectrum of missense mutations of the first aspartic acid of cbEGF-like domains in fibrillin-1 including a recessive family. Hum Mutat, 31(12), E1915-1927. doi:10.1002/humu.21372

Hiratzka, L. F., Bakris, G. L., Beckman, J. A., Bersin, R. M., Carr, V. F., Casey, D. E., Jr., . . . Williams, D. M. (2010). 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation, 121(13), e266-369. doi:10.1161/CIR.0b013e3181d4739e

Jensen, S. A., & Handford, P. A. (2016). New insights into the structure, assembly and biological roles of 10-12 nm connective tissue microfibrils from fibrillin-1 studies. Biochem J, 473(7), 827-838. doi:10.1042/bj20151108

Judge, D. P., & Dietz, H. C. (2005). Marfan's syndrome. Lancet, 366(9501), 1965-1976. doi:10.1016/s0140-6736(05)67789-6

Kalia, S. S., Adelman, K., Bale, S. J., Chung, W. K., Eng, C., Evans, J. P., . . . Miller, D. T. (2017). Recommendations for reporting of secondary findings in clinical exome and genome sequencing, 2016 update (ACMG SF v2.0): a policy statement of the American College of Medical Genetics and Genomics. Genet Med, 19(2), 249-255. doi:10.1038/gim.2016.190

Koo, H. K., Lawrence, K. A., & Musini, V. M. (2017). Beta-blockers for preventing aortic dissection in Marfan syndrome. Cochrane Database Syst Rev, 11, Cd011103. doi:10.1002/14651858.CD011103.pub2

Loeys, B., De Backer, J., Van Acker, P., Wettinck, K., Pals, G., Nuytinck, L., . . . De Paepe, A. (2004). Comprehensive molecular screening of the FBN1 gene favors locus homogeneity of classical Marfan syndrome. Hum Mutat, 24(2), 140-146. doi:10.1002/humu.20070

Loeys, B., & Dietz, H. (2018, 03/01/2018). Loeys-Dietz Syndrome. GGeneReviews (R). Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK1133/

Loeys, B. L., Dietz, H. C., Braverman, A. C., Callewaert, B. L., De Backer, J., Devereux, R. B., . . . De Paepe, A. M. (2010). The revised Ghent nosology for the Marfan syndrome. Journal of Medical Genetics, 47(7), 476. doi:10.1136/jmg.2009.072785

Nataatmadja, M., West, M., West, J., Summers, K., Walker, P., Nagata, M., & Watanabe, T. (2003). Abnormal extracellular matrix protein transport associated with increased apoptosis of vascular smooth muscle cells in marfan syndrome and bicuspid aortic valve thoracic aortic aneurysm. Circulation, 108 Suppl 1, Ii329-334. doi:10.1161/01.cir.0000087660.82721.15

Neptune, E. R., Frischmeyer, P. A., Arking, D. E., Myers, L., Bunton, T. E., Gayraud, B., . . . Dietz, H. C. (2003). Dysregulation of TGF-beta activation contributes to pathogenesis in Marfan syndrome. Nat Genet, 33(3), 407-411. doi:10.1038/ng1116

Pyeritz, R. E. (2012). Evaluation of the adolescent or adult with some features of Marfan syndrome. Genet Med, 14(1), 171-177. doi:10.1038/gim.2011.48

Pyeritz, R. E. (2017). Etiology and pathogenesis of the Marfan syndrome: current understanding. Ann Cardiothorac Surg, 6(6), 595-598. doi:10.21037/acs.2017.10.04

Radke, R. M., & Baumgartner, H. (2014). Diagnosis and treatment of Marfan syndrome: an update. Heart, 100(17), 1382-1391. doi:10.1136/heartjnl-2013-304709

Sellers, S. L., Milad, N., Chan, R., Mielnik, M., Jermilova, U., Huang, P. L., . . . Bernatchez, P. (2018). Inhibition of Marfan Syndrome Aortic Root Dilation by Losartan: Role of Angiotensin II Receptor Type 1-Independent Activation of Endothelial Function. Am J Pathol, 188(3), 574-585. doi:10.1016/j.ajpath.2017.11.006

Tinkle, B. T., & Saal, H. M. (2013). Health Supervision for Children With Marfan Syndrome. Pediatrics, 132(4), e1059. doi:10.1542/peds.2013-2063

Wright, M., & Connolly, H. (2018). Genetics, clinical features, and diagnosis of Marfan syndrome and related disorders - UpToDate. In H. Dietz (Ed.), UpToDate. Retrieved from https://www.uptodate.com/contents/genetics-clinical-features-and-diagnosis-of-marfan-syndrome-and-related-disorders?search=marfan&source=search_result&selectedTitle=1~125&usage_type=default&display_rank=1#H559172.

For policy titled: Genetic Testing for Connective Tissue Disorder

Galante N, Bedeschi MF, Beltrami B, Bailo P, Silva Palomino LA, Piccinini A. Reviewing hereditary connective tissue disorders: Proposals of harmonic medicolegal assessments. Int J Legal Med. Nov 2024;138(6):2507-2522. doi:10.1007/s00414-024-03290-4

Loeys BL, Dietz HC, Braverman AC, et al. The revised Ghent nosology for the Marfan syndrome. Journal of Medical Genetics. 2010;47(7):476. doi:10.1136/jmg.2009.072785

Wright MJ, Connolly HM. Genetics, clinical features, and diagnosis of Marfan syndrome and related disorders. Updated October 1, 2024. https://www.uptodate.com/contents/genetics-clinical-features-and-diagnosis-of-marfan-syndrome-and-related-disorders

Loeys B, Dietz H. Loeys-Dietz Syndrome. GeneReviews [Internet]. University of Washington, Seattle; 2018. https://www.ncbi.nlm.nih.gov/books/NBK1133/

Malfait F, Francomano C, Byers P, et al. The 2017 international classification of the Ehlers-Danlos syndromes. Am J Med Genet C Semin Med Genet. Mar 2017;175(1):8-26. doi:10.1002/ajmg.c.31552

Isselbacher EM, Preventza O, Hamilton Black Iii J, et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology. 2022/12/13/ 2022;80(24):e223-e393. doi:10.1016/j.jacc.2022.08.004

Pfender EG, Lucky AW. Dystrophic Epidermolysis Bullosa. In: Adam MP, Feldman J, Mirzaa GM, et. al, eds. Gene Reviews^® [Internet]. University of Washington, Seattle; 1993-2025. https://www.ncbi.nlm.nih.gov/books/NBK1304/

Wedge RA. Overview of Hereditary Disorders of Connective Tissue. In: Cartaxo T SC, et al., editors.,, ed. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Care Services; Committee on Selected Heritable Disorders of Connective Tissue and Disability; ; 2022. https://www.ncbi.nlm.nih.gov/books/NBK584965/

Burke CR. Clinical manifestations and diagnosis of thoracic aortic aneurysm. Updated July 13, 2023. https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-thoracic-aortic-aneurysm

Ambry Genetics. TAADNext. https://www.ambrygen.com/providers/genetic-testing/12/cardiology/taadnext

Prevention Genetics. Marfan Syndrome and Related Aortopathies Panel. https://www.preventiongenetics.com/testInfo?val=Marfan-Syndrome-and-Related-Aortopathies-Panel

GeneDx. Marfan TAAD Panel. https://providers.genedx.com/tests/detail/marfan-taad-panel-814

Invitae. Invitae Aortopathy Comprehensive Panel. https://www.invitae.com/us/providers/test-catalog/test-02301

Labcorp. GeneSeq^® Cardio: Familial Aortopathy Panel,. https://www.labcorp.com/tests/482189/geneseq-cardio-familial-aortopathy-panel

Fulgent Genetics. Marfan Syndrome and Thoracic Aortic Aneurysm and Dissection NGS Panel. https://fulgentgenetics.com/Marfan-TAAD

Radke RM, Baumgartner H. Diagnosis and treatment of Marfan syndrome: an update. Heart (British Cardiac Society). Sep 2014;100(17):1382-91. doi:10.1136/heartjnl-2013-304709

Faivre L, Collod-Beroud G, Loeys B, et al. Effect of Mutation Type and Location on Clinical Outcome in 1,013 Probands with Marfan Syndrome or Related Phenotypes and FBN1 Mutations: An International Study. Am J Hum Genet. 2007;81(3):454-66.

Dietz H. Marfan Syndrome. In: Adam MP, Ardinger HH, Pagon RA, et al, eds. GeneReviews((R)). University of Washington, SeattleUniversity of Washington, Seattle. GeneReviews is a registered trademark of the University of Washington, Seattle. All rights reserved.; 2017. https://www.ncbi.nlm.nih.gov/pubmed/20301510

Pyeritz RE. Etiology and pathogenesis of the Marfan syndrome: current understanding. Annals of cardiothoracic surgery. Nov 2017;6(6):595-598. doi:10.21037/acs.2017.10.04

Grewal N, Gittenberger-de Groot AC. Pathogenesis of aortic wall complications in Marfan syndrome. Cardiovascular pathology : the official journal of the Society for Cardiovascular Pathology. Feb 2 2018;33:62-69. doi:10.1016/j.carpath.2018.01.005

Davis MR, Summers KM. Structure and function of the mammalian fibrillin gene family: implications for human connective tissue diseases. Molecular genetics and metabolism. Dec 2012;107(4):635-47. doi:10.1016/j.ymgme.2012.07.023

Nataatmadja M, West M, West J, et al. Abnormal extracellular matrix protein transport associated with increased apoptosis of vascular smooth muscle cells in marfan syndrome and bicuspid aortic valve thoracic aortic aneurysm. Circulation. Sep 9 2003;108 Suppl 1:Ii329-34. doi:10.1161/01.cir.0000087660.82721.15

Dale M, Fitzgerald MP, Liu Z, et al. Premature aortic smooth muscle cell differentiation contributes to matrix dysregulation in Marfan Syndrome. PloS one. 2017;12(10):e0186603. doi:10.1371/journal.pone.0186603

Neptune ER, Frischmeyer PA, Arking DE, et al. Dysregulation of TGF-beta activation contributes to pathogenesis in Marfan syndrome. Nature genetics. Mar 2003;33(3):407-11. doi:10.1038/ng1116

Bin Mahmood SU, Velasquez CA, Zafar MA, et al. Medical management of aortic disease in Marfan syndrome. Annals of cardiothoracic surgery. 2017;6(6):654-61. doi:10.21037/acs.2017.11.09

Pauker S, Stoler J. Ehlers-Danlos syndromes: Clinical manifestations and diagnosis. Updated September 23, 2024. https://www.uptodate.com/contents/ehlers-danlos-syndromes-clinical-manifestations-and-diagnosis

Byers PH, Belmont J, Black J, et al. Diagnosis, natural history, and management in vascular Ehlers-Danlos syndrome. Am J Med Genet C Semin Med Genet. Mar 2017;175(1):40-47. doi:10.1002/ajmg.c.31553

Malfait F. Vascular aspects of the Ehlers-Danlos Syndromes. Matrix Biol. Oct 2018;71-72:380-395. doi:10.1016/j.matbio.2018.04.013

Johansen H, Velvin G, Lidal I. Adults with Loeys-Dietz syndrome and vascular Ehlers-Danlos syndrome: A cross-sectional study of health burden perspectives. Am J Med Genet A. Jan 2020;182(1):137-145. doi:10.1002/ajmg.a.61396

MacCarrick G, Black JH, 3rd, Bowdin S, et al. Loeys-Dietz syndrome: a primer for diagnosis and management. Genet Med. Aug 2014;16(8):576-87. doi:10.1038/gim.2014.11

Jud P, Hafner F. Vascular Involvement in Loeys-Dietz Syndrome. Mayo Clin Proc. Jun 2019;94(6):1117-1119. doi:10.1016/j.mayocp.2018.12.030

Seike Y, Matsuda H, Inoue Y, et al. The differences in surgical long-term outcomes between Marfan syndrome and Loeys-Dietz syndrome. J Thorac Cardiovasc Surg. Aug 7 2020;doi:10.1016/j.jtcvs.2020.07.089

Murrell DF. Overview of the management of epidermolysis bullosa. Updated November 13, 2024. https://www.uptodate.com/contents/overview-of-the-management-of-epidermolysis-bullosa

Coulombe PA, Hutton ME, Letai A, Hebert A, Paller AS, Fuchs E. Point mutations in human keratin 14 genes of epidermolysis bullosa simplex patients: genetic and functional analyses. Cell. Sep 20 1991;66(6):1301-11. doi:10.1016/0092-8674(91)90051-y

NIH. Epidermolysis bullosa simplex. https://ghr.nlm.nih.gov/condition/epidermolysis-bullosa-simplex#genes

Ryan TD, Lucky AW, King EC, Huang G, Towbin JA, Jefferies JL. Ventricular dysfunction and aortic dilation in patients with recessive dystrophic epidermolysis bullosa. Br J Dermatol. Mar 2016;174(3):671-3. doi:10.1111/bjd.14168

Loeys B, De Backer J, Van Acker P, et al. Comprehensive molecular screening of the FBN1 gene favors locus homogeneity of classical Marfan syndrome. Human mutation. Aug 2004;24(2):140-6. doi:10.1002/humu.20070

Becerra-Munoz VM, Gomez-Doblas JJ, Porras-Martin C, et al. The importance of genotype-phenotype correlation in the clinical management of Marfan syndrome. Orphanet journal of rare diseases. Jan 22 2018;13(1):16. doi:10.1186/s13023-017-0754-6

Jensen SA, Handford PA. New insights into the structure, assembly and biological roles of 10-12 nm connective tissue microfibrils from fibrillin-1 studies. The Biochemical journal. Apr 1 2016;473(7):827-38. doi:10.1042/bj20151108

Dietz HC, Loeys B, Carta L, Ramirez F. Recent progress towards a molecular understanding of Marfan syndrome. Am J Med Genet C Semin Med Genet. Nov 15 2005;139c(1):4-9. doi:10.1002/ajmg.c.30068

Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease. Circulation. Apr 6 2010;121(13):e266-369. doi:10.1161/CIR.0b013e3181d4739e

Koo HK, Lawrence KA, Musini VM. Beta-blockers for preventing aortic dissection in Marfan syndrome. The Cochrane database of systematic reviews. Nov 7 2017;11:Cd011103. doi:10.1002/14651858.CD011103.pub2

Sellers SL, Milad N, Chan R, et al. Inhibition of Marfan Syndrome Aortic Root Dilation by Losartan: Role of Angiotensin II Receptor Type 1-Independent Activation of Endothelial Function. The American journal of pathology. Mar 2018;188(3):574-585. doi:10.1016/j.ajpath.2017.11.006

Shalhub S, Byers PH, Hicks KL, et al. A multi-institutional experience in vascular Ehlers-Danlos syndrome diagnosis. J Vasc Surg. Jan 2020;71(1):149-157. doi:10.1016/j.jvs.2019.04.487

Ritelli M, Rovati C, Venturini M, et al. Application of the 2017 criteria for vascular Ehlers-Danlos syndrome in 50 patients ascertained according to the Villefranche nosology. Clin Genet. Feb 2020;97(2):287-295. doi:10.1111/cge.13653

Mariath LM, Santin JT, Frantz JA, Doriqui MJR, Kiszewski AE, Schuler-Faccini L. An overview of the genetic basis of epidermolysis bullosa in Brazil: discovery of novel and recurrent disease-causing variants. Clin Genet. Sep 2019;96(3):189-198. doi:10.1111/cge.13555

Saunderson RB, Vekic DA, Mallitt K, Mahon C, Robertson SJ, Wargon O. A retrospective cohort study evaluating the accuracy of clinical diagnosis compared with immunofluorescence and electron microscopy in children with inherited epidermolysis bullosa. Br J Dermatol. May 2019;180(5):1258-1259. doi:10.1111/bjd.17648

Li J, Yang L, Diao Y, et al. Genetic testing and clinical relevance of patients with thoracic aortic aneurysm and dissection in northwestern China. Mol Genet Genomic Med. Oct 2021;9(10):e1800. doi:10.1002/mgg3.1800

Chen S, Fei H, Zhang J, et al. Classification and Interpretation for 11 FBN1 Variants Responsible for Marfan Syndrome and Pre-implantation Genetic Testing (PGT) for Two Families Successfully Blocked Transmission of the Pathogenic Mutations. Front Mol Biosci. 2021;8:749842. doi:10.3389/fmolb.2021.749842

Damseh N, Dupuis L, O'Connor C, et al. Diagnostic outcomes for molecular genetic testing in children with suspected Ehlers-Danlos syndrome. Am J Med Genet A. May 2022;188(5):1376-1383. doi:10.1002/ajmg.a.62672

Veatch OJ, Steinle J, Hossain WA, Butler MG. Clinical genetics evaluation and testing of connective tissue disorders: a cross-sectional study. BMC Med Genomics. Aug 2 2022;15(1):169. doi:10.1186/s12920-022-01321-w

Musunuru K, Hershberger Ray E, Day Sharlene M, et al. Genetic Testing for Inherited Cardiovascular Diseases: A Scientific Statement From the American Heart Association. Circulation: Genomic and Precision Medicine. 2020/08/01 2020;13(4):e000067. doi:10.1161/HCG.0000000000000067

Pyeritz RE. Evaluation of the adolescent or adult with some features of Marfan syndrome. Genet Med. Jan 2012;14(1):171-7. doi:10.1038/gim.2011.48

Miller DT, Lee K, Abul-Husn NS, et al. ACMG SF v3.1 list for reporting of secondary findings in clinical exome and genome sequencing: A policy statement of the American College of Medical Genetics and Genomics (ACMG). Genet Med. Jul 2022;24(7):1407-1414. doi:10.1016/j.gim.2022.04.006

Miller DT, Lee K, Gordon AS, et al. Recommendations for reporting of secondary findings in clinical exome and genome sequencing, 2021 update: a policy statement of the American College of Medical Genetics and Genomics (ACMG). Genet Med. Aug 2021;23(8):1391-1398. doi:10.1038/s41436-021-01171-4

Tinkle BT, Lacro RV, Burke LW, GENETICS TCO. Health Supervision for Children and Adolescents With Marfan Syndrome. Pediatrics. 2023;151(4)doi:10.1542/peds.2023-061450

Foundation M. Genetic Testing and Marfan Syndrome. The Marfan Foundation,. https://marfan.org/wp-content/uploads/2021/04/Genetic_Testing_and_Marfan_Syndrome.pdf

Foundation M. Overview of Cardiac Management in Marfan Syndrome. The Marfan Foundation. https://marfan.org/wp-content/uploads/2021/10/Cardiac-Management-2015.pdf

Boodhwani M, Andelfinger G, Leipsic J, et al. Canadian Cardiovascular Society position statement on the management of thoracic aortic disease. Can J Cardiol. Jun 2014;30(6):577-89. doi:10.1016/j.cjca.2014.02.018

NORD. Epidermolysis Bullosa. Updated January 22, 2024. https://rarediseases.org/rare-diseases/epidermolysis-bullosa/

NORD. Ehlers Danlos Syndromes. Updated September 27, 2021. https://rarediseases.org/rare-diseases/ehlers-danlos-syndrome/

Has C, Liu L, Bolling MC, et al. Clinical practice guidelines for laboratory diagnosis of epidermolysis bullosa. British Journal of Dermatology. 2020;182(3):574-592. doi:10.1111/bjd.18128

FDA. Package Insert - VYJUVEK. 2023. https://www.fda.gov/media/168350/download

Specialty Matched Consultant Advisory Panel review 3/2020

Medical Director review 3/2020

Specialty Matched Consultant Advisory Panel review 3/2021

Medical Director review 3/2021

Medical Director review 11/2022

Medical Director review 4/2023

Medical Director review 4/2024

Medical Director review 4/2025

Policy Implementation/Update Information

1/1/2019 BCBSNC will provide coverage for genetic testing for marfan syndrome when it is determined to be medically necessary because criteria and guidelines are met. Medical Director review 1/1/2019. Policy noticed 1/1/2019 for effective date 4/1/2019. (jd)

5/14/19 Reviewed by Avalon 1st Quarter 2019 CAB. Minor revisions to Description and When Covered sections, no change to policy intent. Policy guidelines extensively revised. Referenced updated. Medical Director review 5/2019. (jd) 

10/29/19 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.

For policy titled: Genetic Testing for Connective Tissue Disorders

5/12/20 Policy title changed from “Marfan Syndrome” to “Genetic Testing for Connective Tissue Disorders. Reviewed by Avalon 1st Quarter 2020 CAB. Added items #3 and #4 to the When Covered section. Under the When Not Covered section, added “All others” to the not medically necessary statement. Added Related Policies section. Description, policy guidelines, and references updated. Specialty Matched Consultant Advisory Panel review 3/2020. Medical Director review 3/2020. (jd)

4/20/21 Specialty Matched Consultant Advisory Panel review 3/2021. Medical Director review 3/2021. (jd)

5/4/21 Reviewed by Avalon 1st Quarter 2021 CAB. Added the following statement to item 1 under the When Covered section: “the individual needs to consult cardiology specialist prior to genetic testing” for clarity; removed the following from item 2 “If FBN1 mutation testing is negative”; item 3 reworded about genetic testing (COL3A1 and COL1A1) for vascular Ehlers-Danlos syndrome (vEDS); reworded item 4 for clarity. Note 3 updated. Added 2nd statement to When Not Covered section: “Reimbursement is not allowed for genetic testing to confirm or establish a diagnosis of hypermobile Ehlers-Danlos syndrome (hEDS) in individuals with characteristics of hEDS (see Note 5).; and added Note 5. Description section, policy guidelines and references updated. Medical Director review 4/2021. (jd)

5/17/22 Reviewed by Avalon 1st Quarter 2022 CAB. Updated policy guidelines; adding Table of Terminology and references. Medical Director review 4/2022. (jd)

12/13/22 Off-cycle review by Avalon 3rd Quarter 2022 CAB. Policy Guidelines and References updated. When Covered section edited for clarity and consistency. Added coverage criteria 2c “For individuals suspected of having Marfan Syndrome who have tested negative for FBN1”, removed coverage criteria 4 related to multi-gene testing outside of vEDS. Medical Director review 11/2022. (tm)

5/16/23 Reviewed by Avalon 1st Quarter 2023 CAB. Removed Related Policies section, edited Note 4 under When Covered section for clarity. Updated policy guidelines and References. No change to policy statement. Medical Director review 4/2023. (tm)

5/15/24 Reviewed by Avalon 1st Quarter 2024 CAB. Updated Description, Policy Guidelines and References. Related Policies added to Description section. Removed Table of Terminology. Minor edits to Notes under When Covered and When Not Covered sections, no change to policy statement. Medical Director review 4/2024. (tm)

7/1/25 Reviewed by Avalon 2^nd Quarter 2025 CAB. Updated Description, Policy Guidelines and References. Updates to the When Covered section: replaced “mutation” with pathogenic or likely pathogenic variant” in CC1.b. and CC2.b., with “variant” in CC3. New CC4 and 5. CC4. The following genetic testing for heritable thoracic aortic disease (HTAD) (see Note 5) is considered medically necessary: a. Multigene panel testing (see Note 6, Note 7) in the following situations: i. For individuals with thoracic aortic disease (TAD) and syndromic features of Marfan syndrome, Loeys-Dietz syndrome, or vascular Ehlers-Danlos syndrome. ii. For individuals presenting with TAD before 60 years of age. iii. For individuals with a family history of either TAD or peripheral/intracranial aneurysms in a first- or second-degree relative (see Note 2). iv. For individuals with a first- or second-degree relative (see Note 2) who had an unexplained sudden death at a relatively young age. b. Testing restricted to the known variant for individuals with a close blood relative (see Note 2) with a known pathogenic or likely pathogenic variant. CC5. The following genetic testing for epidermolysis bullosa (EB) are considered medically necessary: a. Single gene or multigene panel testing (see Note 6, Note 8) for individuals for whom there is a clinical suspicion of EB. b. Testing restricted to the known pathogenic or likely pathogenic variant in the following situations: i. For the biological parents of an individual who has been identified to have a pathogenic or likely pathogenic variant for EB. ii. For the prenatal diagnosis or PGD of EB in the offspring of individuals with known pathogenic or likely pathogenic variants. iii. COL7A1 testing for individuals being considered for beremagene geperpavec. Notes section updated with new notes added. New Note 2, defining first-degree relatives: “Note 2: First-degree relatives include parents, full siblings, and children of the individual.” “(see Note 2)” replaces description of first-degree relatives in CC1.b. and CC2.b. New Note 5, 7, and 8, to define HTAD and EB and to define rules for multigene panel testing. Note 2-5 numbers shifted with addition of new notes, adjusted within criterion to align. Former Note 4, now Note 6, edited to change “5” to “two” to align with guidance in R2162: “Note 6: For two or more gene tests being run on the same platform, please refer to Laboratory Procedures Medical Policy AHS-R2162.” Added codes 81403 and 81479 to the Billing/Coding section. Medical Director review 4/2025. (tm)