Genetic Basis For Congenital Heart Disease: Revisited: Circulation

Circulation
AHA SCIENTIFIC STATEMENT
Genetic Basis for Congenital Heart Disease:

Revisited
A Scientific Statement From the American Heart Association
Endorsed by the American Academy of Pediatrics
ABSTRACT: This review provides an updated summary of the state of Mary Ella Pierpont, MD,
our knowledge of the genetic contributions to the pathogenesis of PhD, Chair
congenital heart disease. Since 2007, when the initial American Heart Martina Brueckner, MD
Association scientific statement on the genetic basis of congenital heart Wendy K. Chung, MD,
disease was published, new genomic techniques have become widely PhD
available that have dramatically changed our understanding of the Vidu Garg, MD, FAHA
causes of congenital heart disease and, clinically, have allowed more Ronald V. Lacro, MD
accurate definition of the pathogeneses of congenital heart disease in Amy L. McGuire, JD, PhD
Seema Mital, MD, FAHA
patients of all ages and even prenatally. Information is presented on
James R. Priest, MD
new molecular testing techniques and their application to congenital William T. Pu, MD
heart disease, both isolated and associated with other congenital Amy Roberts, MD
anomalies or syndromes. Recent advances in the understanding of copy Stephanie M. Ware, MD,
Downloaded from http://ahajournals.org by on January 7, 2019
number variants, syndromes, RASopathies, and heterotaxy/ciliopathies PhD

are provided. Insights into new research with congenital heart disease Bruce D. Gelb, MD, Vice
models, including genetically manipulated animals such as mice, chicks, Chair*
and zebrafish, as well as human induced pluripotent stem cell–based Mark W. Russell, MD, Vice
approaches are provided to allow an understanding of how future Chair*
research breakthroughs for congenital heart disease are likely to happen. On behalf of the American
It is anticipated that this review will provide a large range of health Heart Association Council
care–related personnel, including pediatric cardiologists, pediatricians, on Cardiovascular
Disease in the Young;
adult cardiologists, thoracic surgeons, obstetricians, geneticists, genetic
Council on Cardiovascu-
counselors, and other related clinicians, timely information on the lar and Stroke Nursing;
genetic aspects of congenital heart disease. The objective is to provide a and Council on Genomic
comprehensive basis for interdisciplinary care for those with congenital and Precision Medicine
heart disease.
*Equal contributions.
Key Words: AHA Scientific Statements

◼ heart defects, congenital ◼ genetics
© 2018 American Heart Association, Inc.
https://www.ahajournals.org/journal/circ
Circulation. 2018;138:e653–e711. DOI: 10.1161/CIR.0000000000000606 November 20, 2018 e653

Pierpont et al Genetic Basis for Congenital HD: Revisited
T
his review has been compiled to provide infor- part of a syndrome, and in 3% to 10% among those
CLINICAL STATEMENTS
mation for clinicians about new developments in with isolated congenital HD. The largest genetic study
AND GUIDELINES
our understanding of the genetic contributions of congenital HD with NGS suggested that 8% and
to the pathogenesis of congenital heart disease (HD), 2% of cases are attributable to de novo autosomal
providing an update of the 2007 American Heart As- dominant and inherited autosomal recessive variation,
sociation scientific statement on this subject.1 Not in- respectively.14 Environmental causes are identifiable in
cluded in this review that is intended to cover genetic 2% of congenital HD cases. The unexplained remain-
aspects of structural heart defects are the aortopathies, der of congenital HD is presumed to be multifactorial
arrhythmia/channelopathies, and isolated cardiomy- (oligogenetic or some combination of genetic and en-
opathies for which there are recent reviews.2–5 At the vironmental factors).13
time the previous scientific statement was published, Uncovering a genetic pathogenesis for congenital
genetic testing techniques such as chromosomal micro- HD is increasingly clinically relevant, in part because of
array and next-generation sequencing (NGS) were not the aforementioned improved survival. For the clinician
in wide use. Since the rapid dissemination of these test- caring for a child or adult with congenital HD, impor-
ing modalities and others described in this review, distant reasons for determining the genetic cause can in-
coveries of numerous pathogenic copy number variants clude (1) assessing recurrence risks for the offspring of
(CNVs) and gene mutations have significantly advanced the congenital HD survivor, additional offspring of the
our understanding of the causes of congenital HD. Be- parents, or other close relatives; (2) evaluating for as-
cause of the availability of new genomic technologies, sociated extracardiac involvement; (3) assessing risk for
the pace of discovery of new genes for congenital HD neurodevelopmental delays for newborns and infants;
is now very rapid. and (4) providing more accurate prognosis for the con-
genital HD and outcomes for congenital HD–related
interventions.
CONGENITAL HD EPIDEMIOLOGY
AND IMPORTANCE OF IDENTIFYING A
MOLECULAR TECHNIQUES AND
GENETIC BASIS FOR CONGENITAL HD
DIAGNOSIS
Current research indicates that congenital HD is the
most common birth defect, affecting nearly 10 to 12 Human Genetic Variation
per 1000 liveborn infants (1%–1.2%).6–8 Not all indi- In addition to aneuploidies and large chromosomal re-
viduals with congenital HD are diagnosed early, so the arrangements, the past 10 years of genetics research
actual prevalence has been difficult to determine, but has advanced a contemporary understanding of normal
one estimate from Canada suggested that the over- and pathogenic human genetic variation based on the
all prevalence is 13.1 per 1000 children and 6.1 per concept of detecting individual differences relative to a
1000 adults.9 Their data also suggested that congeni- reference sequence defined as normal. The human ref-
tal HD prevalence increased 11% in children and 57% erence sequence for both medical and research use was
in adults from 2000 to 2010. The impact of successful released by the Human Genome Project in 2000 and
medical and surgical management of congenital HD on has been corrected and refined in subsequent years.15,16
the survival of individuals with congenital HD is likely Multiple individuals were included in the creation of the
contributing to a large extent to its increased preva- reference, which can be thought of not as the genome
lence among older children and adults. More and more of a single person but as being composed of genetic
patients with severe types of congenital HD are surviv- information from as many as 20 to 25 individuals.17 A
ing into their 30s and beyond. Of note, estimates of single-nucleotide polymorphism (SNP) is a change in a
congenital HD incidence and prevalence have not in- single nucleotide of DNA (eg, reference GGTCTC, al-
cluded cases of isolated bicuspid aortic valve (BAV), un- ternative GGTGTC). An insertion or deletion (INDEL) is
arguably a form of congenital HD. Because the popula- a change in multiple nucleotides that results in a dif-
tion prevalence of BAV is 1% to 2% (based on studies ference in length relative to the reference sequence
at autopsy and of liveborn infants and healthy adoles- (eg, reference GGTCTC, alternatives GGTGCGTC or
cents), the total prevalence of congenital HD is closer to GGTTC). CNVs constitute large insertions or deletions
2% to 3%.10–12 of DNA, frequently defined as >1000 nucleotides in
Epidemiological studies have suggested that a ge- length, and can occur anywhere throughout the ge-
netic or environmental cause can be identified in 20% nome (these lesions can also be referred to as micro-
to 30% of congenital HD cases.13 Single-gene disor- deletions or microduplications). Each of these types of
ders are found in 3% to 5%, gross chromosomal genetic variation has well-described causal roles in a
anomalies/aneuploidy in 8% to 10%, and pathogenic variety of different diseases, including congenital HD,
CNVs in 3% to 25% of those with congenital HD as to be discussed in later sections.
e654 November 20, 2018 Circulation. 2018;138:e653–e711. DOI: 10.1161/CIR.0000000000000606

Table 1. Clinical Tests
CLINICAL STATEMENTS
Aneuploidies and
AND GUIDELINES
Genomic vs Chromosomal Copy Number SNPs and
Targeted Rearrangements Variation INDELS Example of Clinical Use
Karyotype Genomic +++ + – Confirmation of trisomy 21
Array CGH Genomic ++ +++ – Multiple congenital anomalies without obvious
syndromic association
FISH Targeted + + – Suspected 22q11.2 deletion syndrome
Gene panel testing Targeted – + +++ Suspected monogenic disease with a small
differential diagnosis
Exome sequencing Genomic – – +++ Broad genetic differential diagnosis without
obvious syndromic association, or previous negative
panel testing
Genome sequencing Genomic + + +++ Broad genetic differential diagnosis without
obvious syndromic association, or previous negative
panel testing and need for rapid turnaround time
Sensitivity of tests for the types of genetic variation are indicated as not detected (-), low (+), medium (++), or high (+++). Array CGH indicates comparative
genomic hybridization using arrays; FISH, fluorescence in situ hybridization; INDEL, insertion or deletion; and SNP, single-nucleotide polymorphism.
Technologies and Testing Paradigms of the commercial platform used, it can detect a lower
size limit of ≈100 000 nucleotides.19 Fluorescence in situ
Genetic testing can be divided into 2 categories; ge-
hybridization (FISH) is a targeted test in which a probe
nomic tests capture ≥1 types of variation at all locations
for a specific region of the genome is hybridized against
within the human genome, whereas targeted tests
metaphase chromosomes from the patient to detect for
capture information about ≥1 select genetic locations
CNVs at a specific genetic locus. At many institutions,
(Table 1). There is now significant overlap between
FISH and karyotypes are falling out of common usage,
the types of variation detectable by different testing
being largely supplanted by array CGH or SNP genotyp-
technologies. Genomic tests can offer an unbiased ap-
ing arrays (collectively referred to as chromosome mi-
proach to detecting clinically relevant genetic variation,
croarrays or CMAs).20
whereas targeted assays test a specific hypothesis about
≥1 genes or loci involved in disease.18 Many tests use, in

some form, the principle of DNA hybridization by which Small Genetic Variation
a sequence of DNA can be separated into 2 comple- The detection of SNPs and INDELs for clinical genetic
mentary strands (eg, ATCGGTC binding to TAGCCAG), testing now almost universally uses NGS technologies,
and these individual strands will bind very specifically to also known as sequencing by synthesis or short-read se-
a synthetic complementary strand (for a specific region quencing. Gene panel tests are targeted tests and rely
of the genome, genetic sequence, or series of genes) on either hybridization or polymerase chain reaction to
under appropriately controlled chemical conditions. capture the regions of genes (typically 1 to 100 genes)
that encode for protein sequences. Whole exome se-
quencing (WES) is a genomic test that captures (by
Large Genetic Variation hybridization) the protein coding regions of all 18 000
Karyotyping, a genomic test, is the gold standard for human genes (≈1.5% of the entire genome), followed
detecting aneuploidies and large chromosomal rear- by NGS. Whole genome sequencing is a genomic test
rangements that occur throughout the genome; it is that obtains genetic information from the entire human
performed on metaphase chromosomes in an auto- genome without a complex capture process followed
mated or semiautomated process before review by a by NGS, although functionally the analysis of the data
cytogeneticist. In comparative genomic hybridization obtained is usually limited to the protein-coding regions
(CGH), the copy number of DNA sequences from a of the genome.21 After generation of the sequencing
subject is compared to those DNA from a control or information by NGS, gene panel tests, exome sequenc-
reference by hybridizing both to DNA probes spaced ing, and genome sequencing all require a subsequent
throughout the human genome. Most commercially bioinformatic analysis to detect and classify SNPs and
available CGH tests (which use arrays and thus are INDELs in genes relevant to the disease under consid-
called array CGH) also test for common (not disease- eration.22,23 Most gene panel tests now offer concur-
related) SNPs to provide additional information regard- rent detection of deletion or duplication (arising from a
ing unusual conditions, such as uniparental disomy. As CNV) of the small number of genes on the panel test,24
indicated by the name, an array CGH is a genomic test and this is an emerging offering from some providers of
and is used to detect CNVs; depending on the specifics clinical exome-sequencing services.

Practical Considerations include trisomy 21, 18, and 13 and sex chromosome an-
CLINICAL STATEMENTS
euploidies such as Turner syndrome (Appendix). There is

In contemporary practice, genetic counselors and other
AND GUIDELINES
an increased risk of many aneuploidies with increasing

qualified clinicians are essential for the appropriate and
maternal age. Increasingly, aneuploidies are detected
ethical application of any genetic test in the clinical set-
prenatally with noninvasive prenatal diagnostic screen-
ting. Genetic counselors with extensive disease- and
ing, and in this section, aneuploidies commonly associ-
gene-specific domain knowledge are often the primary
ated with congenital HD such as Down syndrome and
interpreters of genetic information detected on panel,
Turner syndrome are presented. Information on other
exome, and genome tests in subspecialty clinics that
aneuploidies is present in the Appendix. Less common
do not include a medical geneticist.25,26 Just as with all
aneuploidies such as trisomy 8 and 9 survive to term
other medical tests, each technique in modern genetic
only when they are mosaic. Fetal echocardiograms
testing can display false-positive and false-negative re-
allow for early and accurate diagnosis of the cardiac
sults for specific types of genetic variation, which can
anatomy when aneuploidies are detected.
often be linked to the fundamental technical aspects
of the sequencing chemistries and bioinformatics used
in processing a specific test.27,28 In addition, the genetic Down Syndrome
testing will not always yield a “yes” or “no” result; vari- Down syndrome is the most common aneuploidy and
ants of unknown significance are commonly identified, is usually caused by trisomy 21. It is also the most com-
and the communication of results to the family is best mon chromosome abnormality associated with con-
accomplished by genetic counselors, geneticists, and genital HD.32
qualified clinicians with expertise in congenital HD.
Common Features
The common features of Down syndrome include
Emerging Technologies characteristic facial features; short stature; hypotonia;
There are a number of additional technologies that have intellectual disability ranging from mild to moderate;
entered or will shortly enter clinical use, of which 2 will behavioral issues including problems with attention, ob-
be discussed here. The sequencing of fetal cell-free DNA sessive/compulsive behavior, and tantrums; and a range
(fcfDNA) is commonly used in the prenatal setting as a of congenital anomalies, including ≈40% to 50% with
screening tool for aneuploidies. Whole blood from a preg- congenital HD. Individuals with Down syndrome often
nant woman contains DNA from the fetal trophoblastic experience a gradual decline in cognition and have an
cells that can be separated by centrifugation. Once the increased risk of Alzheimer disease. Health supervision
fcfDNA is separated, the ratio of genetic information can guidelines are available and treatment is based on spe-
be sampled and compared between different chromo- cific clinical manifestations.33
somes to detect aneuploidies,29 and in the future, clinical
Cardiac Features
testing could also be expanded to include detection of
Congenital HD is frequently diagnosed in infants and
specific subchromosomal deletions or duplications such
children with Down syndrome (40%–50%). The most
as the 22q11.2 deletion. However, current implemen-
common congenital HDs include atrioventricular sep-
tations of fcfDNA technology display measurably lower
tal defect (AVSD), ventricular septal defect (VSD), atrial
sensitivity and specificity for aneuploidy relative to gold
septal defect (ASD), patent ductus arteriosus (PDA), and
standard tests such as FISH testing of amniotic fluid.30
tetralogy of Fallot.34 Congenital HD and cardiac com-
Additional advances in sequencing technology that
plications are common causes of mortality in patients
effectively increase the length of sampling for DNA
with Down syndrome, contributing to 13% of deaths
(current NGS sample size is ≈100–250 nucleotides;
in childhood and 23% of deaths in adulthood.35 Indi-
long-read sequencing is often >10 000 nucleotides) are
viduals with Down syndrome have increased risk of pul-
more robust for detecting structural variation. Once
monary hypertension, as well as congenital respiratory
perfected and when cost-effective, long-read sequenc-
tract anomalies, pulmonary abnormalities, and hypoto-
ing will allow for the robust detection of SNPs/INDELs
nia, each of which can lead to worse outcomes after
and CNVs simultaneously with a single clinical test.31
surgery.36 One subset of patients with Down syndrome
that has a higher surgical risk is those undergoing
CHROMOSOMAL ANEUPLOIDIES single-ventricle palliation. Among those patients un-
dergoing staged single-ventricle palliation, individuals
AND CNVs ASSOCIATED WITH
with Down syndrome had higher in-hospital mortality
CONGENITAL HD rates.37
Aneuploidies Prevalence
Aneuploidy is an abnormal number of chromosomes, Down syndrome occurs in ≈1 in 800 newborns. Ap-
and aneuploidies that most commonly survive to term proximately 5300 babies with Down syndrome are born

in the United States each year, and ≈200 000 people adolescents should be performed every 5 years if there
CLINICAL STATEMENTS
in the United States have Down syndrome. The risk of is no history of aortic dilation, BAV, or hypertension,
AND GUIDELINES
having a child with Down syndrome increases with ad- and more frequent screening can be beneficial for in-
vanced maternal age. dividuals with risk factors for aortic dissection.41 Up to
40% of girls with Turner syndrome have hypertension,
Molecular Genetics
which should be treated aggressively.38 A cardiovascu-
Most individuals with Down syndrome have trisomy
lar and renal evaluation should be completed when
21, but rarely, Down syndrome results from a translo-
hypertension is identified.
cation of chromosome 21 with another chromosome
(commonly 21, 14, or 13) or mosaicism in a subset Prevalence
of cells. Turner syndrome occurs in ≈1 in 2000 to 1 in 2500 live
female births.42
Cardiovascular Genotype/Phenotype
Correlations Molecular Genetics
The vast majority of individuals with Down syndrome The exact genetic abnormality found on karyotype
have trisomy 21, so there is little genotype/phenotype analysis varies and can include classic 45,X but also in-
correlation. However, in general for individuals with dividuals who are mosaic 45,X with another cell line,
mosaicism, the lower the level of mosaicism for trisomy including 46,XX, 47,XXX, or 46,XY, as well as individu-
21, the less severe the cognitive deficits are. als with structural abnormalities of the X chromosome,
including deletions and translocations of the X chromo-
some. Array CGH is useful to define precisely the extent
Turner Syndrome
of the deletions or translocation. For mosaic individuals,
Turner syndrome is another common chromosomal the phenotype is generally less severe as the percent-
condition, caused by loss of part or all of an X chromo- age of 45,X cells decreases. It is important to determine
some in females. whether there are any cells with a Y chromosome us-
Common Features ing an SRY polymerase chain reaction test, because this
The most common features of Turner syndrome include can be associated with gonadal dysgenesis that might
short stature, early loss of ovarian function manifesting require surgical removal of gonadal tissue to prevent
as delayed puberty and delayed menarche (and in adult the increased risk of cancer.
women, anovulation and infertility), lymphedema, Cardiovascular Genotype/Phenotype

webbed neck, low posterior hairline, cubitus valgus, Correlations
congenital HD, skeletal anomalies, renal anomalies, and The prevalence of cardiovascular abnormalities in in-
developmental delays, nonverbal learning disabilities, dividuals with Turner syndrome varies between 20%
and behavioral problems in some girls. and 40% and is higher with monosomy X relative to
Treatment with growth hormone is often beneficial, those with structural abnormalities of the X chromo-
ideally beginning in early childhood, and can increase some and in girls with a more pronounced clinical phe-
final adult height by 8 to 10 cm. Estrogen replacement notype.38,39,43,44
therapy is usually started at the time of normal puberty,
around 12 years of age, to initiate normal timing of
breast development and to help prevent osteoporosis.
Estrogen and progesterone are given to support men-
COPY NUMBER VARIANTS
struation. Review of Types of CNVs
Cardiac Features CNVs range widely in size from single genes to large
Cardiac structural anomalies usually involve the left segmental deletions or duplications of millions of base
side of the heart and most commonly include BAV pairs. In general, deletions are more deleterious than
and coarctation of the aorta and less commonly partial duplications because of the sensitivity in gene dosage
anomalous pulmonary venous return and hypoplastic for many genes that do not tolerate haploinsufficiency.
left heart syndrome (HLHS). All patients with Turner CNVs that encompass multiple genes can have a wide
syndrome should have a baseline echocardiogram and range of phenotypic effects because of the additive
cardiac evaluation and follow-up as necessary based impact of individual genes on individual phenotypes
on the baseline evaluation. Aortic root dilatation is or the pleiotropic effects of single genes on multiple
present in 3% to 8% and can lead to dissecting an- phenotypes. Identification of the relevant gene for con-
eurysms and rupture. BAV, coarctation of the aorta, genital HD within a CNV interval requires mapping of
and systemic hypertension are associated with aortic multiple patients with overlapping CNVs to identify a
dilatation and dissection.38–40 Serial aortic arch imaging critical interval and ultimately a single gene within the
by echocardiogram or magnetic resonance imaging for critical interval that is associated consistently with con-

genital HD. Additional supportive evidence for the con- certain single genes within the interval have pleiotropic
CLINICAL STATEMENTS
genital HD gene is provided by examples of patients effects on multiple aspects of the phenotype. For each
AND GUIDELINES
with point mutations within that single gene within the of the CNVs discussed below, the associated congeni-
critical region who have congenital HD. tal HD is incompletely penetrant. It is usually unclear
what the other determinants of congenital HD are, but
it is likely that they are interacting with genetic factors
Association of Pathogenic CNVs as a either on the opposite allele or genetic variants in cis
Class With Clinical Outcome on the same chromosome or in trans on other chro-
On average as a group, children with pathogenic CNVs mosomes, as well as nongenetic factors. Most CNVs
associated with congenital HD have poorer outcomes are associated with effects on behavior and cognition,
than children without pathogenic CNVs. At least part and many are associated with growth effects that are
of the explanation for the worse outcome could be an independent of the congenital HD and are important to
association with extracardiac manifestations that im- appreciate when assessing clinical outcomes.
pact medical care. In one series of 58 patients with
congenital HD and other dysmorphic features or oth-
er anomalies, 20.7% of the patients had potentially DESCRIPTIONS OF SPECIFIC CNVs
pathogenic CNVs that ranged in size from 240 kb to ASSOCIATED WITH CONGENITAL HD
9.6 Mb.45 In another series of 422 children with non-
In this section, several CNVs are highlighted. The Ap-
syndromic, isolated congenital HD followed up pro-
pendix provides information on other less frequent
spectively from before their first surgery, there was an
CNVs.
increased frequency of potentially pathogenic CNVs in
12.1% of congenital HD subjects compared with 5%
of control subjects, and in this series, the presence 22q11.2 Deletion Syndrome
of a CNV was associated with significantly decreased The 22q11.2 deletion syndrome (22q11.2DS) is the
transplant-free survival after surgery, with an adjusted most common microdeletion syndrome, with a preva-
2.6-fold increased risk of death or transplantation.46 lence estimated at 1 per 5950 live births.49 The clini-
Beyond survival, putatively pathogenic CNVs that were cal features of the 22q11.2DS are those described for
more frequent in congenital HD patients with single- the DiGeorge and velocardiofacial syndromes and the
ventricle physiology (13.9% of 223 affected individuals Takao conotruncal anomaly face syndrome, although
compared with 4.4% of control subjects) were associ- the phenotype can vary, even within a family.50 Al-
ated with worse linear growth and worse neurocogni- though highly overlapping, the 22q11.2DS and Di-
tive outcomes.47 There is undoubtedly heterogeneity in George and velocardiofacial syndromes are not synon-
outcomes across CNVs, and future studies will require ymous, because nearly 10% of patients with DiGeorge
refined analyses specific to the individual CNV to deter- and velocardiofacial syndromes do not have a 22q11.2
mine which ones are associated with differential prog- deletion, and not all patients with 22q11.2 deletion
nosis when controlling for the cardiac anatomy, as well will demonstrate classic features of DiGeorge and velo-
as studying the other associated anomalies, ventricular cardiofacial syndromes.
function, and arrhythmias that could account for dif-
ferential outcomes. Common Features
Many new CNVs associated with congenital HD have Frequent clinical features include dysmorphic facies,
been identified over the past 10 years and now have congenital HD (especially conotruncal malformations
been observed in sufficient numbers of patients to de- and aortic arch anomalies), palatal malformations,
fine the clinical features associated with them.48 Most learning difficulties, and immunodeficiency. Facial fea-
of the CNVs are flanked by repeat sequences that lead tures are characteristic but can be relatively subtle, espe-
to nonallelic homologous recombination and recurrent cially in infants. Facial dysmorphisms include myopathic
de novo deletions or duplications of the same interval, facies, tubular nose with bulbous nasal tip, hypoplas-
although a minority of patients have smaller or larger tic alae nasi, and low-set or dysplastic ears. Additional
CNVs associated with less or more severe phenotypes, findings include hypocalcemia, significant feeding and
respectively. There are several common principles that swallowing problems (including regurgitation through
apply across the CNVs. Each of the CNVs includes con- the nose), constipation, renal anomalies, hearing loss,
tiguous gene deletions or duplications, and generally laryngotracheoesophageal anomalies, growth hor-
deletions are associated with greater severity of neu- mone deficiency, autoimmune disorders, seizures, cen-
rocognitive phenotype. Because each of the CNVs in- tral nervous system anomalies, skeletal abnormalities,
cludes multiple genes, it is not always clear whether the ophthalmologic abnormalities, enamel hypoplasia, and
overall phenotype is caused by the effects of multiple malignancies (rare). Behavioral and learning disabilities
genes on multiple aspects of the phenotype or whether become more evident in school-aged children, whereas

Table 2. Common Clinical Features of 22q11.2DS and Most Common Table 3. Suggested Patients With Congenital HD to Test for a 22q11.2
CLINICAL STATEMENTS
Age at Presentation Deletion
AND GUIDELINES
Toddler/ Adolescent/ All fetuses with interrupted aortic arch, truncus arteriosus, tetralogy of
Clinical Feature Infancy School Age Adult Fallot, VSD,* or aortic arch anomaly (if amniocentesis performed for
diagnostic purposes)
Congenital HD (conotruncal X X
defects and interrupted All newborns/infants/children/adolescents/adults with:
aortic arch)
Interruption of aortic arch
Characteristic facial features X X
Truncus arteriosus
Palatal abnormalities X X
Tetralogy of Fallot
(velopharyngeal insufficiency,
hypernasal speech) VSD* with aortic arch anomaly
Feeding problems/nasal X Isolated aortic arch anomaly
regurgitation of feeds
Congenital HD and additional feature of 22q11.2DS
Hypocalcemia X
22q11.2DS indicates 22q11.2 deletion syndrome; HD, heart disease; and
Immune deficiency/thymus X X VSD, ventricular septal defect.
anomalies *Malalignment, conoseptal hypoplasia, perimembranous.
Learning difficulties X
(nonverbal learning disability)
ic counseling and familial screening and to allow for
Psychiatric disease (autism, X
schizophrenia in adults)
identification of associated noncardiac features that
require specific management. For example, there is
22q11.2DS indicates 22q11.2 deletion syndrome; and HD, heart disease.
a higher operative mortality in some patients with
22q11.2 deletion.58,59 It is important for clinicians to
psychiatric disorders often become manifest in adoles- be aware of a 22q11.2 deletion to plan surgery and
cence and adulthood (Table 2). Delays in emergence of postoperative care, particularly with respect to im-
language, intellectual disability, and learning differences munologic issues and calcium metabolism. Affected
(nonverbal learning disability with verbal IQ significantly individuals should receive leukocyte-depleted and
greater than the performance IQ) are common. Autism cytomegalovirus-negative blood products to prevent
or autism spectrum disorder is found in ≈20% of chil- serious graft-versus-host disease or overwhelming
dren, and psychiatric illness (schizophrenia) is present infection.
in 25% of adults. Attention deficit disorder, anxiety, Given the frequency of 22q11.2 deletions in the
perseveration, and difficulty with social interactions are congenital HD population, it is reasonable to test all
also common.51 individuals with IAA type B, truncus arteriosus, tetral-
ogy of Fallot, VSD (malalignment, conoseptal hypopla-
Cardiovascular Features
sia, or perimembranous) with aortic arch anomaly, or
Conotruncal malformations account for 70% of the
isolated aortic arch anomaly (Table 3). Clinical assess-
heart defects associated with a 22q11.2 deletion.52 The
ment for syndromic features alone might not consis-
most common cardiovascular defects include tetralogy
tently identify the infant carrying a 22q11 deletion,
of Fallot (20%), truncus arteriosus (6%), conoventricu-
because facial features can evolve with time. There-
lar VSD (14%), type B interruption of the aortic arch
fore, routine screening of individuals with selected
(IAA), and other aortic arch anomalies (13%).53–56 ASDs,
types of congenital HD using CMA is warranted either
pulmonary valve stenosis (PVS), HLHS, double-outlet
prenatally or postnatally.
right ventricle, transposition of the great arteries (TGA),
vascular rings, and heterotaxy syndrome are less com- Cardiovascular Genotype/Phenotype Correlations
mon but have also been reported. The estimated 22q11.2 deletion frequency is particu-
larly high for IAA (22%–48%),42,60 truncus arteriosus
Prevalence
(12%–35%), tetralogy of Fallot (8%–13%), and iso-
The estimated prevalence of the 22q11.2 deletion
lated aortic arch anomalies (24%).42,60,61 In patients
among various cardiovascular malformations is 1.9%.52
with VSDs, the deletion frequency is low overall42 (2%)
Molecular Genetics but higher when associated with aortic arch anomaly
The majority of 22q11.2 deletions are de novo, but they (right aortic arch, cervical location or abnormal branch-
are inherited from a parent in an autosomal dominant ing pattern, and discontinuous branch pulmonary ar-
fashion in 6% to 28% of cases.50 It is not unusual in teries).60 For IAA, 22q11.2 deletions are specifically
familial cases for one of the parents to be diagnosed associated with type B (accounting for more than half
with the 22q11.2 deletion only after their child is diag- of the cases of type B interruption) and not commonly
nosed.50,57 associated with type A. Among those with tetralogy
It is important to identify the cardiac patient with of Fallot, the strongest association with 22q11.2 dele-
a 22q11.2 deletion by CMA to offer accurate genet- tions is for those with pulmonary atresia.60 A 22q11.2

deletion is infrequent in children with double-outlet a distinct genomic disorder.68 Other clinical features
CLINICAL STATEMENTS
right ventricle (2%)42 and those with TGA. Aortic include prematurity, problems with growth, cleft pal-
AND GUIDELINES
root dilation has been described with 22q11.2 dele- ate, skeletal anomalies, and congenital HD including
tions either in association with a conotruncal defect truncus arteriosus and BAV.68 CRKL and MAPK1 are the
or other cardiac defect or as an isolated finding.62,63 genes in this region that might play a role in cardiac
Tetralogy of Fallot with aortic arch abnormalities is the development.69
most frequent congenital HD with aortic dilation in A recent study compared rare CNVs outside the
22q11.2DS.62 common 22q11.2 deletion region in 607 22q11.2DS
subjects with congenital HD compared with 339
Phenotypic Variability and Related Conditions 22q11.2DS subjects with normal cardiac anatomy. Al-
22q11.2DS is a contiguous gene deletion syndrome, though there was no significant difference in the overall
and >40 genes are deleted in the most common dele- burden of rare CNVs, an overabundance of CNVs affect-
tion. Deletion of several genes within this region con- ing cardiac-related genes was detected in 22q11.2DS
tributes to the cardiac and noncardiac features. The size individuals with congenital HDs, which suggests that
of the deletion can be precisely determined by CMA. CNVs outside the 22q11.2 region might contain genes
The vast majority (97%) of affected individuals will that modify risk for congenital HDs in some 22q11.2DS
have either a common recurrent ≈3-Mb deletion or a patients.70 Finally, another recent study has shown that
smaller, less common ≈1.5-Mb nested deletion. Smaller the phenotypic variability observed in a subset of indi-
or larger deletions can contribute to atypical clinical viduals with 22q11.2DS is attributable to other muta-
phenotypes. Mutations outside the interval or on the tions on the nondeleted chromosome.71
nondeleted 22q11.2 allele are also known to modify
the phenotype. An example of this is Bernard-Soulier
syndrome, an autosomal recessive trait, which includes Williams-Beuren Syndrome
giant platelets, thrombocytopenia, and a prolonged Williams-Beuren syndrome or Williams syndrome (WS)
bleeding time. One cause of Bernard-Soulier syndrome is a contiguous gene deletion syndrome caused by dele-
is biallelic loss-of-function mutations in the gene en- tion at 7q11.23.
coding the β-subunit of the platelet glycoprotein GPIb
(GPIBB), which resides in the 22q11.2 critical region. Common Features
Several cases of Bernard-Soulier syndrome have been Clinical manifestations (Table 4) include dysmorphic
reported in which a 22q11.2del was combined with a features, characteristic cardiovascular defects (vascu-
loss-of-function GP1BB mutation on the nondeleted lar stenoses, elastin arteriopathy), a specific cognitive
allele. Although rare, the occurrence of these 2 con- profile, unique personality characteristics (“social per-
ditions together can potentially place the 22q11.2 in- sonality”), growth abnormalities, connective tissue
dividual at risk for life-threatening bleeding in conjunc- and skeletal abnormalities, and endocrine abnormali-
tion with surgeries and procedures.64 ties (infantile hypercalcemia, hypercalciuria, hypothy-
Duplication of the same 22q11.2 CNV region causes roidism, and early puberty). Feeding difficulties during
an extremely variable disorder with a phenotype that infancy often lead to poor weight gain. Adults have
ranges from normal to learning disability and, infre- short stature (less than third percentile) and tend to
quently, congenital defects including heart defects. be overweight or obese and to have complications of
Generally, the duplication is associated with milder and systemic hypertension, diabetes mellitus, and diver-
more variable manifestations than the deletion. The du- ticulosis.72
plication can be either de novo or inherited from a phe- Cardiovascular Features
notypically normal parent.65 Congenital HD occurs in Frequent cardiovascular anomalies include supravalvu-
15% with similar defects as 22q11.2DS.66 The associat- lar aortic stenosis (SVAS), often in combination with
ed features are largely neurobehavioral and range from supravalvular pulmonary artery stenosis and branch
apparently normal to intellectual disability/learning dis- pulmonary artery stenosis. The SVAS can progress dur-
ability, delayed development, or hypotonia. Many of ing childhood and is the most common abnormality
the reported series likely suffer from ascertainment bias requiring surgical intervention. In contrast, the branch
compared with phenotypes in unselected population- pulmonary artery stenosis often regresses with time.73,74
based cohorts.65,67 These arterial abnormalities constitute an elastin arteri-
A small number of individuals have distal deletions opathy or vasculopathy caused by deletion of the ELN
of 1.4 to 2.1 Mb of 22q11.2 that do not overlap with gene. Any artery can be narrowed, including the as-
the DiGeorge proximal 22q11.2 deletion. Patients with cending aorta, aortic arch, and descending thoracic and
the distal deletion share some overlapping neurobehav- abdominal aorta, as well as central and peripheral arter-
ioral features, including speech delay and learning dis- ies including the coronary arteries, carotid and cerebral
abilities, with proximal 22q11.2DS, but this represents arteries, mesenteric arteries, renal arteries, and pulmo-

Table 4. Clinical Features of Williams Syndrome death. Risk factors include myocardial ischemia attrib-
CLINICAL STATEMENTS
Cardiovascular utable to coronary stenosis or severe biventricular out-
AND GUIDELINES
Elastin arteriopathy: any artery may be narrowed; can be multiple
flow tract obstruction, but the causative mechanisms
have not been fully delineated.75–79
Supravalvular aortic stenosis: most common (75%) and most clinically
significant
Prevalence
Pulmonary arterial stenosis: common in infancy WS occurs in 1 per 7500 to 20 000 births.
Aortic/mitral valve defects
Systemic hypertension
Molecular Genetics
The vast majority of affected individuals with a clinical
Distinctive facies
diagnosis of WS have been found by FISH or deletion/
Stellate iris pattern
duplication testing to have a microdeletion at chromo-
Broad forehead, bitemporal narrowing some 7q11.23, typically a recurrent 1.5- to 1.8-Mb de-
Periorbital fullness letion of the Williams-Beuren syndrome critical region
Malar flattening that encompasses ELN, the gene encoding elastin.80
Short nose, broad nasal tip, long philtrum Most cases arise de novo, although parent-to-child
Full lips/wide mouth/small, widely spaced teeth
transmission with an autosomal dominant pattern of
inheritance has been reported. As with other contigu-
Craniofacial
ous gene deletion syndromes, WS has a broad range of
Recurrent otitis media
phenotypic variability. The size of the deletion can be
Malocclusion precisely determined by CMA. Although there is wide
Ophthalmologic phenotypic variability even among individuals with the
Strabismus typical deletion, smaller or larger deletions might con-
Hyperopia tribute to atypical clinical phenotypes.
Neurological
Given the clinical variability of WS and the fact that
the physical and developmental signs can be relatively
Cognitive disability: strength in language; extreme weakness in visuospatial
subtle during infancy, it is not unusual for the diagnosis
Unique personality: overfriendliness, empathy, generalized anxiety,
to be confirmed only after identification of a charac-
specific phobias
teristic cardiovascular defect such as SVAS. The severity
Hyperacusis
of SVAS and other vascular defects tends to be greater
Connective tissue abnormalities in males, and infants and children with more severe
Hoarse voice vascular involvement tend to be diagnosed with WS at
Inguinal/umbilical hernia younger ages than those with trivial or no cardiovascu-
Bowel/bladder diverticulae lar involvement.81,82
Rectal prolapse
Because SVAS is very common in WS and uncommon
in the general population, it is appropriate to consider
Joint limitation or laxity/soft, lax skin
testing all patients with SVAS at the time of diagnosis
Growth abnormalities
of the cardiovascular defect. Furthermore, if peripheral
Prenatal growth deficiency pulmonary artery stenosis persists beyond infancy, it is
Infantile failure to thrive also appropriate to consider testing for WS. Similarly,
Constipation if any of the defects associated with the elastin arteri-
Adult height less than third percentile opathy, including coronary artery ostial stenosis, renal
Overweight/obese
artery stenosis, and middle aortic syndrome (abdominal
coarctation), are diagnosed at any age, testing for WS
Endocrine
should be considered.
Hypercalcemia/hypercalciuria
Hypothyroidism Cardiovascular Genotype/Phenotype Correlations
Adult diabetes mellitus Point mutations or small intragenic deletions of ELN
Renal/bladder disorders
have been found in the autosomal dominant disorder
familial SVAS without other characteristics of WS. The
Structural anomalies
vascular disease in the nonsyndromic familial SVAS is in-
Nephrocalcinosis
distinguishable from that seen in WS. Of note, CNVs in
Chronic urinary tract infections the 7q11.23 region have been found to be associated
with autism in a study of >4000 individuals who did not
nary arteries. Affected arteries typically have thickened have WS,83 and dilation of the ascending aorta occurs
walls and narrowed lumens. There is an increased risk in almost half of individuals with 7q11.23 duplication
of anesthesia-related complications and sudden cardiac syndrome.84,85

General Clinical Recommendations ative genes for a number of these clinical phenotypes,
CLINICAL STATEMENTS
Early diagnosis of WS is important to optimize manage- including heart defects (see Molecular Genetics).92
AND GUIDELINES
ment of other potential medical problems (Table 4).86

Renal anomalies are common, and a renal ultrasound is
More than half of affected individuals have congeni-
recommended at baseline and as needed.87 Endocrine
tal HD, most of whom require surgical intervention.
abnormalities include idiopathic hypercalcemia, hyper-
About one-third of patients with heart defects have
calciuria, hypothyroidism, subclinical hypothyroidism,
a membranous VSD, and another third have left ven-
and early puberty.72 Hypercalcemia and hypercalciuria
tricular outflow tract defects with various degrees of
can be treated with appropriate diet and medication.
hypoplasia or obstruction of the mitral valve, left ven-
Hypercalcemia occurs most commonly in the first year
tricle, aortic valve, or aorta. This spectrum includes mi-
of life, whereas hypercalciuria can persist and occur at
tral stenosis, BAV, aortic valve stenosis, coarctation of
any age. Hypercalcemia can lead to nephrocalcinosis
the aorta, Shone complex, and HLHS. HLHS is highly
and renal failure. Obesity, abnormal oral glucose toler-
overrepresented in patients with JS (5%–10%), an es-
ance tests, and diabetes mellitus are common, espe-
timated frequency that is 1000 to 2000 times that of
cially in adults.72 Systemic hypertension is also common
the general population. The other one-third of children
and often presents during childhood or adolescence.88
with congenital HD have a variety of heart defects in-
About half of adults with WS will have high blood pres-
cluding double-outlet right ventricle, TGA, AVSD, se-
sure. Intellectual disability is common and usually mild,
cundum ASD, dextrocardia, aberrant right subclavian
but with a specific cognitive profile with strengths in
artery, PDA, persistent left superior vena cava, tricuspid
verbal short-term memory and language and extreme
atresia, type B IAA, truncus arteriosus, and PVS.
weakness in visuospatial constructive cognition.89 An
early diagnosis of WS allows for enhancement of learn- Prevalence
ing and development in children with WS. Attention The prevalence of JS is estimated to be 1 in 50 000 to 1
deficit disorder and anxiety are common. Whereas dele- in 100 000 live births.
tion of ELN accounts for the cardiovascular and connec-
Molecular Genetics
tive tissue abnormalities in WS, deletion of additional
Diagnosis of JS is currently accomplished by CMA. Through
genes in the Williams-Beuren syndrome critical region
a combination of human genetic techniques and using
(LIMK1, GTF2I, STX1A, BAZ1B, CLIP2, GTF2IRD1, NCF1)
genetically engineered animal models, ETS1 has been
has been implicated in other manifestations of WS.72

identified as the causal gene for congenital HD in JS.92
Homozygous deletion of Ets1 caused VSDs and abnormal
Jacobsen Syndrome (11q Terminal ventricular morphology with nearly 100% penetrance
Deletion Disorder) in mice in a C57/B6 background but not in an FVBN-1
background.93 The fact that homozygous Ets1 knockout
Since Jacobsen’s initial report in 1973,90 >200 patients
mice do not have heart defects in at least 1 strain strongly
with Jacobsen syndrome (JS) have been reported. JS is
implies the presence of a genetic modifier. Most recently,
a clinically recognizable contiguous gene deletion syn-
a patient with a complex congenital HD including mitral
drome involving deletions from subband 11q23 to the
atresia and hypoplastic left ventricle was found to carry a
telomere, ranging in size from 7 to 16 Mb.
de novo frameshift mutation in ETS1, likely a loss-of-func-
Common Features tion mutation, providing further confirmation that loss of
Clinical manifestations include dysmorphic features, ETS1 is the cause of congenital HD in JS.94
growth retardation sometimes associated with IGF-1 (in-
Cardiovascular Genotype/Phenotype Correlations
sulin-like growth factor 1) deficiency, cognitive and be-
There is no correlation between the size of the dele-
havioral dysfunction, congenital HD, thrombocytopenia
tion and whether or not there is congenital HD or what
and platelet dysfunction (Paris-Trousseau syndrome), re-
the specific congenital HD is. Using FISH, Grossfeld and
current infections, immune deficiency, and ophthalmo-
colleagues91 found that the smallest terminal deletion
logic, gastrointestinal, and genitourinary problems.91,92
associated with a congenital HD (HLHS) was ≈7 Mb
A prospective study of 110 patients with the 11q ter-
(cardiac critical region).
minal deletion disorder, diagnosed by karyotype rather
than CMA, provided detailed delineation of the clinical Thombocytopenia and Platelet Dysfunction
manifestations, as well as a comprehensive set of recom- Nearly all patients with JS have Paris-Trousseau syn-
mendations for the clinical management of patients with drome, characterized by thrombocytopenia and plate-
this disorder. Molecular analysis of the deletion break- let dysfunction, and heterozygous loss of the FLI1 gene
points in 65 patients defined genetic “critical regions” has been identified as the cause.92 The thrombocyto-
for 14 clinical phenotypes, as well as for the neuropsychi- penia presents in the neonatal period. Platelet dysfunc-
atric profiles.91 Subsequent studies have implicated caus- tion persists in older individuals, despite normal platelet

counts. Risk for bleeding is one of the most common Among individuals with the 1p36 deletion, there is a
CLINICAL STATEMENTS
causes of mortality in JS and likely places these patients range of neurocognitive disability, but ≈90% of individu-
AND GUIDELINES
at increased risk for the development of brain hemor- als have severe to profound intellectual disability, and
rhages.91,92,95 Platelet transfusion or desmopressin may 75% are nonverbal. Behavioral disorders include autism,
be necessary for bleeding and high-risk procedures. tantrums, self-mutilation, stereotypies, and hyperphagia.
Structural brain abnormalities include dilation of the later-
Cognitive Function and Behavior
al ventricles, cortical atrophy, and hypoplasia or agenesis
Cognitive function ranges from normal intelligence to
of the corpus callosum. Seizures are present in approxi-
moderate cognitive disability. Nearly half of the patients
mately half of the individuals with the 1p36 deletion.
have mild cognitive disability, with a characteristic neu-
ropsychiatric profile demonstrating near-normal recep- Cardiac Features
tive language ability but mild to moderate impairment Structural heart defects include ASD, VSD, valvular ab-
in expressive language, with full-scale IQs typically in normalities, PDA, tetralogy of Fallot, coarctation of the
the 60s to 70s.91 The severity of intellectual disability aorta, infundibular stenosis of the right ventricle, and
correlates with the size of the deletion; those with the Ebstein’s anomaly.99,100 In addition, 27% of individu-
largest deletions (>12 Mb) have the most severe intel- als with the 1p36 deletion have cardiomyopathy, 23%
lectual disability (IQ <50).96 Approximately one-half of with left ventricular noncompaction and 4% with di-
all JS patients fulfill the diagnostic criteria for autism, lated cardiomyopathy.99
and candidate genes for autism (RICS) and intellectual
disability (BSX-1) have been identified.96,97 Prevalence
The prevalence of 1q36 deletion is 1 in 5000 to 10 000
General Clinical Recommendations births, with a 2:1 female-to-male ratio.99–101
Individuals with suspected or confirmed JS should have
a thorough genetics evaluation. The extent of the de- Molecular Genetics
letion can be precisely delineated by CMA in the pro- This condition is identified by CMA testing. The dele-
band. Most deletions are de novo, with only 8% re- tion varies in size and can extend to >5 Mb.
sulting from a parental translocation, or in rare cases
from a relatively mildly affected parent carrying an 11q
1q21.1 Deletion
deletion.91 Parents should be screened for a transloca-
Common Features
tion or deletion. Patients with JS require coordinated

multisystem care. A cardiac evaluation including an Recurrent 1.35-Mb deletions of 1q21.1 are typically
echocardiogram is recommended at baseline and as associated with microcephaly, mild intellectual dis-
needed. Careful monitoring of the platelet count is ability, mildly dysmorphic features, short stature,
necessary in infancy and early childhood, and once eye abnormalities (strabismus, chorioretinal and iris
the platelet count normalizes, platelet function studies colobomas, microphthalmia, hypermetropia, Duane
should be evaluated periodically. Neurocognitive and anomaly, and cataracts), and sensorineural hearing
behavioral difficulties are common. Baseline and ongo- loss.102,103 Less commonly, there are other associated
ing evaluations by a neuropsychologist and behavioral findings, including congenital HD, genitourinary al-
specialist are recommended, as well as brain imaging terations, skeletal malformations (craniosynostosis,
at baseline and as needed. Patients should be screened scoliosis), and seizures. The associated psychiatric and
for ophthalmologic issues including exotropia, amblyo- behavioral anomalies include autistic spectrum dis-
pia, refractive errors, ptosis, and retinal artery tortuos- order, attention deficit hyperactivity disorder, mood
ity. Common gastrointestinal issues include failure to disorder, and sleep disturbances.104 Neurocognitive is-
thrive, constipation, and pyloric stenosis. Genitourinary sues are generally global, with generalized learning
anomalies include cryptorchidism and renal anomalies. disabilities and challenges with gross motor develop-
A baseline renal ultrasound is recommended. ment and coordination.
Cardiac Features
1p36 Deletion The types of congenital HD include PDA, truncus arte-
The 1p36 deletion syndrome is the second most com- riosus, VSD, ASD, tetralogy of Fallot, BAV, dilation of
mon deletion syndrome. the ascending aorta, aortic insufficiency, coarctation of
the aorta, IAA, anomalous origin of the right coronary
Common Features artery, PVS, and TGA.105
Clinical features include dysmorphic facies, intellectual
disability ranging from mild to severe, hypotonia, sei- Prevalence
zures, structural brain abnormalities, congenital heart The prevalence of the 1q21.1 microdeletion is ≈0.2%
defects, ophthalmologic and vision issues, hearing loss, of individuals with developmental delays, intellectual
skeletal abnormalities, and genitourinary anomalies.98 disabilities, or congenital abnormalities.106

Molecular Genetics Alagille Syndrome

CLINICAL STATEMENTS
The condition is identified by CMA. The gene respon-

Alagille syndrome (ALGS) is an autosomal dominant
AND GUIDELINES
sible for congenital HD within the interval is possibly

syndromic disorder characterized by cardiovascular, he-
GJA5, which encodes for a cardiac gap junction protein
patic, orthopedic, and ophthalmologic complications.
connexin 40.107
Common Features
Recognizable Facial Features
1q21.1 Duplication
Children with ALGS have a prominent forehead, deeply
The reciprocal duplication of 1q21.1 is also associat- set eyes, hypertelorism, straight nose with a bulbous
ed with congenital HD, more commonly tetralogy of tip, and pointed chin.
Fallot but also including VSD, TGA, and PVS.106,108,109
Again, the gene responsible for congenital HD with- Development
in the interval is possibly GJA5.107 Other congeni- Mild gross motor delays are reported in 16% of indi-
tal malformations associated with the CNV include viduals,159 and mild intellectual disability is seen in only
hypospadias, clubbed feet, hemivertebrae, and hip 2%. Neurovascular accidents, likely secondary to pre-
dysplasia. There is a tendency toward larger head stenotic vessel aneurysms, occur in up to 15% of cases
size. Some individuals have neurobehavioral mani- and can cause significant neurological compromise.160
festations, including intellectual disabilities, devel- Hepatic
opmental delay, expressive language delay, learning There is considerable intrafamilial and interfamilial vari-
disabilities, features of autism, or attention deficit ability in the hepatic complications of ALGS, and some
hyperactivity disorder, but others have no neurobe- individuals have no detectable liver disease. The most
havioral problems.104,110 common complications are chronic cholestasis, elevated
liver enzymes, hypercholesterolemia, or liver failure.161 In-
8p23.1 Deletion fants with ALGS can present with jaundice, cholestasis,
and pruritis. The typical pathological finding is paucity of
Deletions of 8p23.1 are associated with congenital the bile ducts on liver biopsy. It is estimated that ≈15%
HD, congenital diaphragmatic hernia, growth impair- of affected individuals will require liver transplantation.160
ment, microcephaly, behavioral problems including
hyperactivity and impulsivity, mild to moderate in- Ophthalmologic

tellectual disability, and developmental delays.111,112 More than 80% will have posterior embryotoxon, an
Types of congenital HD typically associated include anterior chamber defect, by slit-lamp examination.160,162
ASD, AVSD, and PVS. There are also several reported Although not of any functional significance to vision, it
cases of more complex cardiac anatomy including hy- is a useful marker for diagnosis. Additional complica-
poplastic right ventricle, double-outlet right ventricle, tions include Axenfeld anomaly, Rieger anomaly, optic
and double-inlet left ventricle. The gene most likely disk drusen, and retinal pigmentary changes.163
responsible for the congenital HD is GATA binding
Orthopedic
protein 4 (GATA4) encoding a zinc finger transcrip-
It is estimated that 30% to 90% of individuals with
tion factor.113
ALGS have butterfly vertebrae by radiography.159 But-
terfly vertebrae are typically not of any clinical conse-
quence but are a useful marker for diagnosis. Less com-
WELL-CHARACTERIZED SYNDROMES monly reported skeletal features include hemivertebrae,
CAUSED BY SINGLE-GENE VARIATION spina bifida occulta, and rib anomalies.
During the past 10 to 15 years, a period of active gene Renal
discovery, the molecular basis of many syndromes Kidney complications including small hyperechoic kidneys,
has been identified. Numerous syndromes caused by uteropelvic obstruction, renal tubular acidosis, hyperten-
single-gene variants (traditionally referred to as mu-
sion, and renal artery stenosis are reported in ≈40%.164
tations) have additionally been found to be geneti-
cally heterogeneous, which means that an individu- Cardiovascular Features
al variant in >1 gene is capable of causing a similar Two-thirds of those with ALGS have peripheral or
condition (Table 5). Several selected syndromes are branch pulmonary stenosis or other arterial narrowing
discussed in more detail with regard to their cardiac (aortic coarctation, renal artery, middle aortic syndrome,
malformations, including Alagille, Holt-Oram, Char, Moya-moya, basilar, and middle cerebral arteries).159
Ellis-van Creveld, Adams-Oliver, Kabuki, and CHARGE Structural cardiac defects are also reported, including
syndromes. Table 5 can be consulted for details of tetralogy of Fallot (7%–15% of cases), aortic stenosis,
multiple other genetic syndromes. ASD, and VSD.160

Table 5. Genes and Loci Associated With Congenital HD
CLINICAL STATEMENTS
% Congenital
AND GUIDELINES
Syndrome Gene(s) Loci Cardiac Disease HD Other Clinical Findings References
Very commonly associated
Alagille JAG 1 20p12.2 PPS, TOF, PA >90 Bile duct paucity, posterior embryotoxon, 114, 115
NOTCH2 1p12-p11 butterfly vertebrae, renal defects
CFC BRAF 7q34 PVS, ASD, HCM 75 Curly hair, sparse eyebrows, feeding 116
KRAS 12p12.1 problems, developmental delay,
intellectual disability
MAP2K1 15q22.31
MAP2K2 19p13.3
Cantu ABCC9 12p12.1 PDA, BAV, HCM, 75 Hypertrichosis at birth, macrocephaly, 117, 118
CoA, PE, AS narrow thorax, coarse facies, macroglossia,
broad hands, advanced bone age
Char TFAP2B 6p12.3 PDA, VSD 58 Wide-set eyes, down-slanting palpebral 119, 120
fissures, thick lips, hand anomalies
CHARGE CHD7 8q12 TOF, PDA, DORV, 75–85 Coloboma, choanal atresia, genital 121
AVSD, VSD hypoplasia, ear anomalies, hearing loss,
developmental delay, growth retardation,
Costello HRAS 11p15.5 PVS, ASD, VSD, 44–52 Short stature, feeding problems, broad 122
HCM, arrhythmias facies, bitemporal narrowing, redundant
skin, intellectual disability
22q11.2DS TBX1 22q11.2 Conotruncal 74–85 Cleft palate, bifid uvula, velopharyngeal 54
deletion defects, VSD, IAA, insufficiency, microcephaly, hypocalcemia,
ASD, VR immune deficit, psychiatric disorder,
learning disability
Ellis-van Creveld EVC 4p16.2 Common atrium 60 Skeletal dysplasia, short limbs, polydactyly, 123, 124
EVC2 4p16.2 short ribs, dysplastic nails, respiratory
insufficiency
Holt-Oram TBX5 12q24.1 VSD, ASD, AVSD, 50 Absent, hypoplastic, or triphalangeal 125
conduction defects thumbs; phocomelia; defects of radius;
limb defects more prominent on left

Kabuki KMT2D 12q13 CoA, BAV, VSD, 50 Growth deficiency, wide palpebral fissures, 126, 127
KDM6A Xp11.3 TOF, TGA, HLHS large protuberant ears, fetal finger pads,
intellectual disability, clinodactyly
Noonan PTPN11 12q24.13 Dysplastic PVS, 75 Short stature, hypertelorism, down- 128
SOS1 2p22.1 ASD, TOF, AVSD, slanting palpebral fissures, ptosis, low
HCM, VSD, PDA posterior hairline, pectus deformity,
RAF1 3p25.2
bleeding disorder, chylothorax,
KRAS 12p12.1 cryptorchidism
NRAS 1p13.2
RIT1 1q22
SHOC2 10q25.2
SOS2 14q21.3
BRAF 7q34
VACTERL Unknown VSD, ASD, HLHS, 53–80 Vertebral anomalies, anal atresia, 129
association PDA, TGA, TOF, TA tracheoesophageal fistula, renal
anomalies, radial dysplasia, thumb
hypoplasia, single umbilical artery
Williams-Beuren 7q11.23 7q11.23 SVAS, PAS, VSD, 80 Unusual facies, thick lips, strabismus, 130
deletion (ELN) ASD stellate iris pattern, intellectual disability
Frequently associated
Carpenter RAB23 6p11.2 VSD, ASD, PDA, PS, 50 Craniosynostosis, brachydactyly, 131
TOF, TGA syndactyly, polydactyly, obesity
Coffin-Siris ARID1B 6q25 ASD, AVSD, VSD, 20–44 Developmental delay, coarse facies, 132, 133
SMARCB1 22q11 MR, PDA, PS, DEX, hypoplastic distal phalanges, short stature,
AS intellectual disability
ARID1A 1p36.1
SMARCB1 22q11.23
SMARCA4 19p13.2
SMARCE1 17q21.2
(Continued )

Table 5. Continued
CLINICAL STATEMENTS
% Congenital
AND GUIDELINES

Frequently associated (Continued)
Cornelia NIPBL 5p13 PVS, VSD, ASD, 33 Microbrachycephaly, synophrys, arching 134
deLange SMC1L1 Xp11.22 PDA eyebrows, growth retardation, intellectual
disability, micromelia
SMC3 10q25
Goldenhar Unknown VSD, PDA, TOF, 32 Hemifacial microsomia, epibulbar 135
CoA, conotruncal dermoids, microtia, hemivertebrae
defects
Mowat-Wilson ZEB2 2q22.3 VSD, CoA, ASD, 54 Short stature, microcephaly, Hirschsprung 136, 137
PDA, PAS disease, intellectual disability, seizures
Rubinstein-Taybi CBP 16p13.3 PDA, VSD, ASD, 33 Microcephaly, growth retardation, 138
EP300 22q13.2 HLHS, BAV down-slanting palpebral fissures, low-set
malformed ears, prominent or beaked
nose, intellectual disability, broad thumbs
and toes
Smith-Lemli-Opitz DHCR7 11q12-13 AVSD, HLHS, ASD, 50 Microcephaly, ptosis, genital anomalies, 139
PDA, VSD renal anomalies, broad nasal tip with
anteverted nostrils, intellectual disability,
syndactyly
Occasionally associated
Adams-Oliver ARHGAP31 3q13 ASD, VSD, CoA, 20 Aplasia cutis congenita, terminal 140, 141
DOCK6 19p13.2 HLHS, DORV transverse defects of hands, fingers, toes,
feet
RBPJ 4p15.2
EOGT 3p14.1
NOTCH1 9q34.3
DLL4 15q15.1
Baller-Gerold RECQL4 8q24.3 VSD, TOF, subaortic 25 Craniosynostosis, micrognathia, small 142
disease mouth, radial aplasia/hypoplasia,
imperforate anus, renal anomalies

Beckwith- CDKNIC 11p15.4 VSD, HLHS, PS 6.5 Macrosomia, macroglossia, omphalocele, 143
Wiedemann risk of malignancy
Coffin-Lowry RSK2 Xp22.2 LVNC, MVP, AVA 5–14 Growth deficiency, coarse facies, everted 144
lower lip, hypodontia, intellectual disability
Duane-radial ray SALL4 20q13.2 ASD, PVS, VSD <10 Unilateral or bilateral Duane anomaly, 145
(Okihiro) hypoplasia of thumbs, hypoplastic radius
and ulna, renal malformations, ear
anomalies
Fragile X FMR1 Xq27.3 MVP, aortic dilation <10 Macrocephaly, intellectual disability, hand 146
flapping, speech abnormality, autism
spectrum disorder, macroorchidism,
seizures, prominent forehead, large ears
Nance-Horan NHS Xp22.13 TOF, VSD, PDA <10 Congenital cataracts, strabismus, peg- 147
shaped supernumerary teeth, other
dental anomalies, prominent ears,
brachymetacarpalia
Peter’s Plus B3GALTL 13q12.3 ASD, VSD, PVS, <30 Short limb growth deficiency, intellectual 148,149
BPV, subvalvular AS disability, autism spectrum disorder,
prominent forehead, cupid’s bow upper
lip, cleft lip ± cleft palate, Peter’s anomaly,
cataracts, hydronephrosis
Roberts ESC02 8p21.1 ASD, AS <20 Growth deficiency of prenatal onset, 150
cleft lip ± cleft palate, hypertelorism,
sparse hair, hypomelia with variable limb
reduction defects, cryptorchidism
Robinow RDR2 (AR) 9q22 RVOTO 29 AD Macrocephaly, frontal bossing, 151, 152
WNT5A (AD) 13 AR prominent eyes, small upturned
nose, short forearms, hemivertebrae,
hypoplastic phalanges of hands and toes,
hypoplastic genitalia
(Continued )

Table 5. Continued
CLINICAL STATEMENTS
% Congenital
AND GUIDELINES
Occasionally associated (Continued)
Saethre-Chotzen TWIST 7p21p22 VSD <10 Craniosynostosis, brachycephaly, high flat 153
forehead, hypertelorism, ptosis, partial
cutaneous syndactyly, broad great toes,
strabismus
Short rib DYNC2H1 11q22.3 TGA, DORV, DOLV, <25 Short stature, postaxial polydactyly of 154
polydactyly type I AVSD, HRH hands or feet, short horizontal ribs, small
iliac bones, polycystic kidneys, early death
from respiratory insufficiency
Simpson-Golabi- GPC3 Xq26.2 TGA, VSD, PVS, 26 Macrosomia, coarse face, macroglossia, 155, 156
Behmel CoA, AS, PDA, hepatosplenomegaly, nephromegaly,
BAV, CM variable cognitive disability
Sotos NSD1 5q35.3 ASD, PDA, VSD 21 Excessive size, large hands and feet, 157
prominent forehead, hypotonia, variable
intellectual disability, scoliosis, advanced
bone age
Townes-Brocks SALL1 16p12.1 ASD, TOF, VSD, TA, 14–25 Auricular anomalies, preauricular tags, 158
PA, PDA hearing loss, thumb hypoplasia/polydactyly,
imperforate anus, renal agenesis,
multicystic kidney, microphthalmia
22q11.2DS indicates 22q11.2 deletion syndrome; AD, autosomal dominant; AR, autosomal recessive; AS, aortic stenosis; ASD, atrial septal defect; AVA, aortic
valve anomaly; AVSD, atrioventricular septal defect; BAV, bicuspid aortic valve; BPV, bicuspid pulmonary valve; CFC, cardiofaciocutaneous; CHARGE, coloboma,
heart defects, choanal atresia, retarded growth and development, genital anomalies, and ear anomalies; CM, cardiomyopathy; CoA, coarctation of the aorta; DEX,
dextrocardia; DOLV, double-outlet left ventricle; DORV, double-outlet right ventricle; HCM, hypertrophic cardiomyopathy; HD, heart disease; HLHS, hypoplastic left
heart; HRH, hypoplastic right heart; IAA, interruption of aortic arch; LVNC, left ventricular noncompaction; MR, mitral regurgitation; MVP, mitral valve prolapse;
OFD, oral-facial-digital; PA, pulmonary atresia; PAS, pulmonary artery stenosis; PDA, patent ductus arteriosus; PE, pericardial effusion; PPS, peripheral pulmonary
stenosis; PS, pulmonary stenosis; PVS, pulmonary stenosis; RVOTO, right ventricular outflow tract obstruction; SVAS, supravalvular aortic stenosis; TA, truncus
arteriosus; TGA, transposition of great arteries; TOF, tetralogy of Fallot; VACTERL, association of vertebral defects, anal atresia, cardiac defects, tracheoesophageal
fistula, renal and limb anomalies; VR, vascular ring; and VSD, ventricular septal defect.
Prevalence Holt-Oram Syndrome

There is no known racial or ethnic predilection for
Holt-Oram syndrome (HOS) is an autosomal dominant
ALGS. There is an estimated incidence of 1:30 000 to
disorder often referred to as heart-hand syndrome be-
1:50 000 live births.159,165
cause of the 2 most common features: congenital HD
Molecular Genetics and radial ray defects.
Pathogenic variants in JAG1 cause >90% of ALGS, with Common Features
89% attributable to sequence variants and 5% to 7%
Orthopedic
attributable to partial or complete gene deletions.159 An
Radial ray abnormalities can be unilateral or bilateral
estimated 1% to 2% of individuals who meet clinical
and, when bilateral, can be symmetrical or asymmetri-
criteria for ALGS and do not have a JAG1 mutation will
cal. The penetrance of upper limb anomalies in HOS is
have a NOTCH2 sequence variant.115 The Jagged1 and
complete but ranges from subtle carpal abnormalities
Notch proteins are part of the Notch signaling pathway,
without functional consequence only seen by radio-
which is important to regulation of cell fate in many cell
gram to complete phocomelia (the hand attached close
types during development.159
to the trunk). Other reported abnormalities include
Cardiovascular Genotype/Phenotype Correlations triphalangeal thumb, absent thumb, radius hypoplasia
Overall, there are no differences in the cardiovascular or aplasia, and radioulnar synostosis.167,168
phenotype based on causative gene or mutation type (se- Family History
quence variant versus deletion). However, there have been Because there is considerable intrafamilial phenotypic
2 variants reported for which affected individuals had car- variability, a family history of a first-degree relative with
diac but not liver disease, and further analysis demonstrat- a septal defect, cardiac conduction disease, or radial ray
ed that the amount of JAG1 protein produced was more abnormality can provide a clue to the diagnosis.
than in other ALGS variants but less than in wild type.166
Because the characteristic facial features can be subtle and Cardiac Features
the presentation variable, it is important to consider a di- Three quarters of those with HOS have congenital HD,
agnosis of ALGS in those with characteristic cardiovascular most commonly involving the atrial or ventricular sep-
findings, even in the absence of overt liver disease. tum. ASDs can present as common atrium, often with

atrial isomerism.169 Cardiac conduction disease is seen Molecular Genetics

CLINICAL STATEMENTS
in those with or without congenital HD. Sinus bradycar- Approximately half of families who have the diagnos-
AND GUIDELINES
dia, first-degree atrioventricular heart block, and com- tic triad of Char syndrome (recognizable facial features,
plete heart block with or without atrial fibrillation are all aplasia or hypoplasia of the middle phalanges of the
reported coincident with or subsequent to the time of fifth fingers, and PDA) will have a heterozygous patho-
congenital HD diagnosis (if present).167 This has led to genic variant in TFAP2B.119 The majority of mutations
the recommendation that all individuals with HOS have affect the highly conserved C-terminal half of the pro-
an annual screening ECG. tein’s basic domain that is essential for DNA binding.
Prevalence Cardiovascular Genotype/Phenotype
HOS has an estimated prevalence of between 0.7 and Correlations
1 per 100 000.169 There are no known genotype-phenotype correlations
with regard to cardiovascular complications. There have
Molecular Genetics been reports of TFAP2B pathogenic variants in cases of
Seventy percent of cases are caused by a heterozygous PDA without the facial or orthopedic findings of Char
pathogenic variant in TBX5, <1% by a partial or com- syndrome.173
plete gene deletion.125 Most variants result in a null
allele and haploinsufficiency. TBX5 is a transcription
factor and is an essential regulator of limb and cardiac Ellis-van Creveld Syndrome
development, particularly the cardiac septum and con- Ellis-van Creveld syndrome (EVC) is an autosomal reces-
duction system.168 sive skeletal dysplasia associated with a characteristic
Cardiovascular Genotype/Phenotype Correlations cardiac finding of a primary atrial septation defect re-
Pathogenic missense variants at the 5ʹend of the T-box sulting in a common atrium.123
are associated with more serious cardiac defects.170 Common Features
Recognizable Facial Features
Char Syndrome Individuals with EVC can have a characteristic appear-
ance of the mouth, with a short upper lip bound by
Char syndrome is an autosomal dominant familial PDA frenula to the alveolar ridge.
syndrome.
Dental
Common Features A variety of dental abnormalities are reported, including
Recognizable Facial Features natal teeth, partial adontia, small teeth, delayed tooth
Flat midface, flat nasal bridge, broad nasal tip, hyper- eruption, conical teeth, and enamel hypoplasia.174,175
telorism, down-slanting palpebral fissures, mild ptosis,
short philtrum, and everted lips are among the recog- Hair and Nails
nizable facial features.171 The nails are often hypoplastic, and hair can be scant
or fine.176
Orthopedic
Aplasia or hypoplasia of the middle phalanges of the Growth
fifth fingers is part of the diagnostic triad (along with There is prenatal-onset short stature; adult stature is in
typical facial features and PDA) of Char syndrome.172 the range of 43 to 60 inches.177
Other Orthopedic
Case reports indicate a number of additional features The characteristic skeletal findings include postaxial
can be seen in Char syndrome, including hypodontia, polydactyly, usually of the hands, short limbs (with in-
foot anomalies (joint fusion, clinodactyly, polydactyly, creasing severity from the proximal to distal portions
syndactyly), strabismus, and other hand anomalies (in- of the limbs), and short ribs. Hand radiographs often
terstitial polydactyly, distal symphalangism of the fifth show short, broad middle phalanges and hypoplastic
fingers, and third finger hypoplasia).172 distal phalanges, and sometimes carpal bone abnor-
malities.175 Bone age is usually delayed.
Cardiac Features
The primary cardiac finding is PDA. Other heart defects, Cardiac Features
It has been estimated that 50% to 60% of cases have
including VSD and more complex congenital HDs, have
congenital HD, characteristically common atrium. Ab-
been reported.172
normalities of the mitral and tricuspid valves, PDA, VSD,
Prevalence and HLHS are also reported.178 The severity of the con-
The prevalence has not been determined, but it is genital HD is the main determinant of morbidity and
thought to be quite rare. mortality.175

Prevalence Prevalence
CLINICAL STATEMENTS
The worldwide prevalence is not known. There is a There is an estimated incidence of 0.44 per 100 000 live
AND GUIDELINES
founder mutation among the Amish, and large kin- births.183 This could be a significant underestimate, be-
dreds from Mexico, Ecuador, and Brazil that have also cause not all clinical features are present in all affected
been reported.123 individuals.
Molecular Genetics Molecular Genetics
Two-thirds of cases of EVC are caused by homozy- Six genes are currently involved in the pathogenesis
gous or compound heterozygous mutations in EVC or of AOS. Two genes, ARHGAP31 (autosomal domi-
EVC2.123,179 These 2 genes are in a 5ʹ to 5ʹ (head-to- nant gain-of-function mutations) and DOCK6 (ho-
head) orientation in close proximity and are thought to mozygous loss-of-function mutations), are part of
share a common, bidirectional promoter.180 the CDC42/RAC1 pathway. The other 4 genes (RBPJ,
EGOT, NOTCH1, and DLL4) are part of the Notch sig-
Cardiovascular Genotype/Phenotype Correlations
naling pathway, which regulates cell fate in many
No cardiovascular genotype-phenotype correlations
cell types.140
have been reported.
Cardiovascular Genotype/Phenotype
Correlation
Adams-Oliver Syndrome
Pathogenic variants of NOTCH1 are associated with a
Adams-Oliver syndrome (AOS) is an inherited malforma- 42% occurrence of congenital HD and vasculopathy
tion syndrome in which cardiac, scalp, and limb defects in AOS.141,184 The other 5 genes associated with AOS
are present. There is genetic heterogeneity, with both do not have as frequent vasculopathies or cardiac mal-
autosomal dominant and autosomal recessive forms. formations. Additionally, NOTCH1 gene variants have
Common Features been associated with autosomal dominant left ventricu-
lar outflow defects (most commonly BAV and calcific
Skin and Scalp Defects
aortic stenosis) without evidence of AOS185 and familial
There is considerable variability in the extent of aplasia
BAV without evidence of AOS.186
cutis congenita in affected individuals, ranging from to-
tal absence of an area of scalp skin and skull to vertex
hairless patches. Kabuki Syndrome
Orthopedic Kabuki syndrome (KS) has both X-linked and autosomal

Limb defects can include terminal transverse reduction dominant pathogeneses. The syndrome is character-
defects of hands or feet, short distal phalanges, syndac- ized by specific facial features, skeletal anomalies, con-
tyly, ectrodactyly, and polydactyly. genital HD, renal anomalies, intellectual disability, and
Central Nervous System growth deficiency.
Brain anomalies occur in 35% of affected individu- Common Features
als, including microcephaly, encephalocele, neuronal Recognizable Facial Features
migration anomalies, thin or absent corpus callosum, Children with KS have long palpebral fissures, eversion
and enlarged ventricles. Some evidence of vascular se- of lateral one-third of the lower eyelid, arched eyebrows
quelae in the brain has been documented, with cal- with sparse lateral third, large dysplastic ears, cleft pal-
cification, periventricular leukomalacia, and stroke/ ate, and depressed nasal tip.187
thrombosis.140
Development
Ophthalmologic Mild to moderate intellectual disability is seen in 82%
Ophthalmologic findings are uncommon in AOS but do to 90% of individuals, with one-third having expressive
occur, including retinal folds/detachment, cataract, and and receptive language difficulties. There can be associ-
optic nerve hypoplasia.140 ated autism spectrum disorder, communication difficul-
Cardiovascular Features ties, and repetitive behavior.
One-fourth of individuals with AOS have congenital Orthopedic
HD, often left-sided obstructive malformations such
More than 80% have skeletal findings such as vertebral
as BAV, aortic stenosis, HLHS, coarctation of the aor-
anomalies, scoliosis, hip dislocation, short incurved fifth
ta, and parachute mitral valve. Other defects include
fingers, brachydactyly, and hyperextensible joints.188
VSD, ASD, tetralogy of Fallot, and other conotruncal
defects.181 Vascular lesions such as hepatic thrombosis, Urogenital Anomalies
PVS,141,182 intracranial vascular lesions, and limb vascular Cryptorchidism, duplicated collecting system, single
anomalies have also been described. fused kidney, and hypospadias have been reported.188

Other Common Features

CLINICAL STATEMENTS
Growth deficiency is present in 55% and hearing loss Recognizable Facial Features
AND GUIDELINES
in 28% to 40%, with immunodeficiency and persistent Characteristic facial features can include orofacial
fetal finger pads also common.189 clefts, unilateral or bilateral facial palsy, and malformed
Cardiovascular Features protruding ear pinnae.
Congenital HD occurs in 40% to 70% of individuals Development
with KS.126,127 There is a predominance of left-sided Marked developmental delay is usual. Motor skills are
obstructive defects, including coarctation of the aorta, delayed with hypotonia. Delayed language develop-
BAV, and HLHS.190 The most common cardiac malfor- ment can result from hearing loss and reduced vision.
mations are coarctation of the aorta, ASD, and VSD. The intellectual outcome is variable, with up to 50%
Other defects include double-outlet right ventricle, with good outcome.202 If microcephaly, brain malfor-
pulmonary stenosis, mitral atresia/stenosis, and partial mations, and extensive coloboma are present, these
anomalous pulmonary venous return.191–193 suggest a poorer intellectual outcome.
Prevalence Ophthalmologic
The prevalence in Japan was estimated at 1:32 000,194 More than 80% to 90% of individuals will have unilateral
as the initial patients described were Japanese. A mini- or bilateral colobomas variably affecting the iris, retina,
mum birth incidence of 1:86 000 in Australia and New choroid, or optic discs, sometimes associated with mi-
Zealand has been calculated.195 crophthalmia. Vision is variably affected by the colobomas.
Molecular Genetics Ears and Hearing
KS is caused mainly by pathogenic variants in the KM- Malformed external ear pinnae, anomalies of the os-
T2D (MLL2) and KDM6A genes. Only a few cases with sicles, Mondini cochlea defect, and absent or small
a Kabuki-like phenotype have been described with semicircular canals are present in >90% of affected in-
RAP1A and RAP1B and HNKRNPK variants.196 Germline dividuals. Hearing loss is extremely common and varies
dominant, usually truncating, variants in KMT2D cause from mild to profound.203,204
most cases of KS (75%).197 Pathogenic variants in the
X-linked gene KDM6A are found in ≈5% of individuals Respiratory
with KS, which are also generally truncating variants Bilateral or unilateral choanal atresia is present in
but with a few whole-gene deletions described.198 It has >50%, necessitating immediate evaluation and possi-
been noticed that KS and CHARGE have some overlap- bly tracheostomy.
ping clinical features. Additionally, there are a number Gastrointestinal
of patients with a Kabuki-like syndrome who are under Individuals can have severe swallowing difficulties, aspi-
investigation for related genes in the CHARGE/Kabuki ration problems, gastroesophageal reflux, and tracheo-
spectrum, as well as heterogeneous nuclear ribonucleo- esophageal fistula. Feeding problems are very common,
protein K (HNRNPK) haploinsufficiency.199 Furthermore, and gastrostomy feeding measures are often required.204
a KMT2D novel variant has been found in 2 generations
of a family with choanal atresia, which also suggests a Genital/Renal
connection to CHARGE syndrome.200 Males can have cryptorchidism and micropenis, and
both males and females can have hypogonadotropic
Cardiovascular Genotype/Phenotype Correlations hypogonadism.203 Occasional renal anomalies such as
A preponderance of males compared with females with horseshoe kidney and renal dysgenesis are found.
left-sided obstructive lesions has been described among
KMT2D patients.196 Those with KDM6A mutations have Orthopedic
a frequency of congenital HD of 45%, with a higher Hand anomalies including polydactyly and occasional
prevalence of right-sided congenital HD.196 scoliosis are possible.
CHARGE Syndrome Three-fourths of those with CHARGE have congeni-
tal HD, and these are often complex.205 These can
The acronymic name of this condition includes C for
be conotruncal defects, including tetralogy of Fallot,
coloboma, H for heart defects, A for choanal atresia,
IAA, truncus arteriosus, and double-outlet right ven-
R for retarded growth and development, G for genital
tricle. Multiple other abnormalities have been seen in
anomalies, and E for ear anomalies. CHARGE syndrome
CHARGE, including vascular rings, aortic arch anoma-
is inherited as an autosomal dominant condition, but it
lies, AVSD, septal defects, and PDA.206
is usually sporadic. Diagnostic criteria are helpful in de-
termining a clinical diagnosis for individuals suspected Prevalence
of having CHARGE syndrome.121,201 CHARGE syndrome occurs in 1 in 8500 births.207

Molecular Genetics Common Features
CLINICAL STATEMENTS
CHARGE syndrome is caused by pathogenic variants in Recognizable Facial Features
AND GUIDELINES
the CHD7 gene in the majority of individuals suspected The facial features of NS change with age.212 They can
clinically of having the syndrome.203 A few rare instances be subtle during infancy (tall forehead, widely spaced
of exon, whole gene, or large contiguous deletions have prominent eyes that slant down, depressed nasal bridge,
been found.208 Most affected individuals are the only fam- bulbous nasal tip, and low-set ears), more obvious dur-
ily member with clinical findings; however, some famil- ing childhood (ptosis and neck webbing also seen), and
ial cases of CHARGE syndrome have been described.209 change again during adolescence (eyes less prominent,
Many individuals with familial CHD7 variants are mildly nasal root pinched with a thin bridge, and the shape of
affected and do not completely fulfill the diagnostic crite- the face is that of an inverted triangle). In adulthood,
ria for CHARGE syndrome.210 Some of these more mildly the features are most often mild, although some adults
affected individuals were only recognized after a more retain significant, readily recognizable dysmorphisms.
seriously affected family member was found to have a
CHD7 pathogenic variant. Some families in which there Eye and Ear
are affected siblings and unaffected parents are likely An estimated 80% of those with NS have a structural
examples of gonadal mosaicism. In recent years, marked eye abnormality, including ptosis (50%), strabismus
overlap in clinical features with CHARGE syndrome has (40%), refractive error (60%), posterior segment ab-
been seen in individuals eventually discovered to have KS, normalities (6%), and anterior segment abnormalities
22q11.2 deletion, or Kallmann syndrome.200,210 (60%).213 A minority have conductive hearing loss at-
tributable to middle ear effusion (20%) or sensorineural
Cardiovascular Genotype/Phenotype hearing loss (10%).214
Correlations
Congenital HD is more commonly found in individuals Gastrointestinal
with truncating variants of CHD7 (80%) than with mis- Early feeding problems related to hypotonia and de-
sense or splice-site variants (58%).205 layed gastrointestinal motor development, gastro-
esophageal reflux, chronic constipation, and intestinal
malrotation respond well to medical management and
THE RASOPATHIES feeding therapy.215 It is not uncommon for early feed-
The RASopathies are a group of autosomal dominant dis- ing issues to be significant enough to require temporary
orders with overlapping cardiac, growth, facial, and neu- placement of a gastrostomy feeding tube.
rodevelopmental features. They are so named because Growth and Endocrine
they are caused by pathogenic variants in genes that en- The most common endocrine complications include
code proteins in or with close interaction with the RAS/ hypothyroidism, pubertal delay, and short stature. The
mitogen-activated protein kinase pathway, which plays pathogenesis for the short stature can be nutritional,
an important role in cellular programs, including apopto- attributable to growth hormone deficiency, or attribut-
sis, development, differentiation, proliferation, and trans- able to growth hormone insensitivity.216 Short stature
formation. Somatic mutations in genes in the pathway in NS is a Food and Drug Administration–approved in-
have long been known to cause hematologic cancers dication for growth hormone therapy. Looking across
and solid tumors. More recently, germline sequence vari- studies, there is a mean gain in height of 9.5 to 13 cm
ants have been found to cause Noonan syndrome (NS) for boys and 9 to 9.8 cm for girls with growth hormone
and other uncommon phenotypically related disorders, therapy.128 Treatment outcomes are best with earlier
including cardiofaciocutaneous syndrome (CFC), Costello initiation and longer duration.217 To date, there is no
syndrome (CS), and Noonan syndrome with multiple len- evidence that treatment with growth hormone exacer-
tigines (NSML). Collectively, these disorders are termed bates the cardiac complications of NS.128
the RASopathies. Although it has more unique features
than it has overlapping features to NS, CFC, CS, and Hematology
NSML, neurofibromatosis type 1 is often included as a Coagulation factor deficiencies, thrombocytopenia,
RASopathy. Because it infrequently presents with signifi- and platelet aggregation abnormalities have all been
cant cardiac complications (2% of cases), neurofibroma- reported218; however, only a small proportion of those
tosis type 1 will not be further discussed here.211 with abnormalities on coagulation testing have func-
tional bleeding problems. The observed rate of post-
operative bleeding complications in a cohort of 142
Noonan Syndrome individuals with NS was <2% (half of the cohort had
Individuals with NS have characteristic facial features been screened preoperatively for a coagulopathy and
and structural and functional abnormalities involving half had not).219
multiple organ syndromes and a high incidence of car- NS attributable to PTPN11 mutations is associated
diac abnormalities. with an increased risk of hematologic malignancies, in-

cluding acute lymphoblastic leukemia and juvenile my- Molecular Genetics

CLINICAL STATEMENTS
elomonocytic leukemia. Myeloproliferative disorders are NS is an autosomal dominant disorder with complete
AND GUIDELINES
also more common in NS than in the general pediatric penetrance and variable expressivity. Fifty percent of
population and are associated with a benign course in cases are explained by heterozygous PTPN11 missense
40% and an aggressive course in 15%.220 pathologic variants.233 PTPN11 encodes SHP2, a phos-
phatase that has an active and inactive conformation.
Lymphatic
Pathogenic variants alter residues that stabilize the in-
Lymphatic abnormalities are thought to affect ≈20%
active state, activating SHP2 and leading to increased
of individuals.221 Peripheral edema can be seen during
RAS/ERK (extracellular signal-regulated kinase)/MAPK
infancy and usually regresses during the first year. It can
(mitogen-activated protein kinase) activation.234 It is esti-
occur or recur in adolescence or adulthood. Chylous ef-
mated that an additional 30% of cases can be explained
fusion is a regularly reported complication of cardiac
by a variant in one of multiple genes in the RAS MAPK
surgery. Less commonly, pulmonary, intestinal, and tes-
ticular lymphangiectasia are reported.222 pathway including SOS1, RAF1, RIT1, KRAS, SHOC2,
NRAS, SOS2, and BRAF.212 Case reports or small case
Neurological, Cognitive, and Behavioral series implicate other genes in the pathway, including
Seizures are reported in a minority of cases (10%– A2ML1, LZTR1, MYST4, RASA2, RRAS, SPRY1, and SYN-
13%) and include generalized, temporal lobe, and GAP1.235 Approximately half of the cases are de novo,
febrile seizures.223 Structural brain abnormalities are and the other half are inherited. In the nonfamilial cases,
rare, but there are multiple case reports of symptom- there is an association with advanced paternal age.236
atic Chiari I malformation.224 There are highly variable
neurocognitive and behavioral outcomes that depend, Cardiovascular Genotype/Phenotype Correlations
in part, on the causative gene. Gross and fine motor PTPN11-associated NS is more likely to cause PVS and
development are often delayed because of hypotonia, less likely to cause HCM.234 Septal defects are more
congenital HD, or orthopedic issues.225 Although many common in those with SOS1-associated NS.237 Al-
school-aged children require individualized education though only ≈20% of patients with NS have HCM,
plans or special education instruction, intellectual dis- 95% of those with a RAF1 mutation and 75% with a
ability is uncommon (6%–23% across studies).226 RIT1 mutation have it.238,239
Orthopedic
The most commonly reported orthopedic complications Other RASopathies

include radioulnar synostosis, pectus carinatum and ex- CFC, CS, and NSML are among the other RASopathies.
cavatum, scoliosis, and pes planus.227 They share common features, including developmental
Renal and Genitourinary delays, short stature, ptosis, hypertelorism, macroceph-
Renal anomalies, including vesicoureteral reflux, hydro- aly, and cardiac involvement. There is such significant
nephrosis, and dysplastic kidney, are seen in 10% to phenotypic overlap that it can be challenging, particu-
20% of individuals.128 The majority of males have crypt- larly during infancy, to make the diagnosis based on
orchidism (80%). clinical features alone.
Cardiac Features Common Features

Cardiovascular involvement is observed in 80% to 90% Cardiofaciocutaneous Syndrome
of affected individuals, comprising congenital HD and In contrast to NS, CFC is characterized by more signifi-
hypertrophic cardiomyopathy (HCM).222,228 The most cant feeding issues (often requiring long-term gastros-
common congenital HD is PVS, seen in roughly 40% tomy tube use) and cognitive delays (with the major-
of patients and often with dysplastic valve leaflets, but ity of individuals in the mild to moderate intellectual
other prevalent lesions include aortic coarctation, mitral disability range) and by a variety of cutaneous abnor-
valve anomalies, ASDs, and tetralogy of Fallot. HCM, malities, including hyperkeratosis, ichthyosis, keratosis
seen in up to 20% of patients, can vary from a mild, pilaris, ulerythema ophryogenes, and xerosis.240 CFC is
stable form, typically presenting in toddlers, to a severe, considerably rarer than NS, with an estimated preva-
rapidly progressive form that presents in early infancy lence of 1 in 810 000.241
and is often life-threatening.229 Arterial defects such as
Costello Syndrome
aneurysms (coronary, aortic, pulmonary, intracranial)
Features most often seen in those with CS but not in
and coronary atresia have also been observed.230,231
NS include coarse facial features, loose and soft skin
Prevalence with deep creases of the palms and soles, bronzing of
Systematic epidemiological studies have not been com- the skin during childhood, papillomata of the face and
pleted, but a prevalence of 1:1000 to 1:2500 has been perianal region, and an increased risk for malignant tu-
estimated.232 mors.242 Like NS and CFC, feeding issues are common

and often require use of a gastrostomy tube. Intellec- the RASopathies. If no cardiac disease is detected, re-
CLINICAL STATEMENTS
tual disabilities are much more common than in NS but peat evaluation with a cardiologist is indicated every 5
AND GUIDELINES
less severe than those seen in CFC. CS has an estimated years throughout childhood and adulthood.128,222
birth prevalence of 1 in 300 000 to 1 in 1 200 000.241
NS With Multiple Lentigines HETEROTAXY AND CILIOPATHIES
NSML (formerly known as LEOPARD syndrome) has the
unique finding of multiple lentigines of the face, back, Cilia Structure and Function
and upper trunk that number in the thousands by Cilia are ancient organelles with a broad range of bio-
adulthood. There is a higher prevalence of sensorineu- logical functions that center on sending and receiving
ral hearing loss and a lower prevalence of short stat- signals to and from the extracellular environment. Ab-
ure than is reported in NS.243 The overall prevalence of normal cilia structure and function result in diverse dis-
NSML is unknown. Mild learning issues are reported in eases, including syndromic ciliopathies, primary ciliary
≈30% of individuals, but intellectual disability is rare.244 dyskinesia (PCD), and heterotaxy syndrome.249 Finally,
Cardiac Features there is growing evidence that abnormal function of
Three-fourths of individuals with a RASopathy have a car- cilia can result in isolated congenital HD.250,251
diac abnormality, which is the second most common rea- All cilia extend from a basal body and contain dou-
son a child comes to medical attention (after admission blet microtubules (Figure [C]). These doublets extend as
to a neonatal intensive care unit).245 Although there are the axoneme, a highly ordered arrangement that is rec-
a wide variety of cardiovascular diagnoses reported, PVS, ognizable by transmission electron microscopy. Motile
HCM, and ASD are the most common complications re- cilia are primarily found on epithelial cells that line the
ported in each of the RASopathies. The majority of individ- respiratory tract, brain ventricles, and oviducts. These
uals with NSML have HCM compared with only one-fifth cilia function to propel cells or extracellular fluid and are
of those with NS.246 CS can be complicated by arrhythmia, characterized by 9 microtubule doublets surrounding a
usually supraventricular tachycardia, and most distinctive central pair, a “9+2” arrangement that is visible by elec-
is chaotic atrial rhythm/multifocal atrial tachycardia.242 tron microscopy of cross-sectional views (Figure [A]).
Absence or dysfunction of motile cilia causes PCD. A
Molecular Genetics special subtype of motile cilia are the cilia found on the
The majority of cases of CFC are caused by a heterozy- left-right organizer (LRO) that have a “9+0” arrange-
gous pathogenic variant in BRAF, MAP2K1, MAP2K2, ment but are motile. In contrast, sensory cilia have a
or KRAS. HRAS is the only gene in which pathogenic “9+0” arrangement of microtubules (Figure [B]) but
variants are known to cause CS, and >95% of variants are nonmotile cilia. These cilia extend from the surface
affect amino acid p.Gly12 or p.Gly13.247 Ninety percent of of almost all cell types in the human body, including
NSML cases are caused by loss-of-function variants in epithelial cells lining the kidney tubules and bile ducts,
PTPN11 that impair SHP2 catalytic activity.248 Less than as well as nonepithelial cells such as chondrocytes and
5% of NSML cases have been ascribed to a heterozy- neurons.252 These cilia are responsible for sensing the
gous pathogenic variant in RAF1, BRAF, or MAP2K1. extracellular environment, are important for transduc-
Clinical Genetic Testing ing signals, and play a role in intercellular signaling dur-
Potential approaches include single-gene testing, multi- ing developmental patterning.
gene panel testing, and more comprehensive genomic
approaches such as whole-exome or whole-genome Cilia in Heart Development
sequencing. Because there is significant genetic hetero-
The best understood role for cilia in heart develop-
geneity for a given diagnosis and extensive phenotypic
ment is establishing left-right (LR) asymmetry. The
overlap between diagnoses, multigene panel testing
heart has striking asymmetries along the LR axis, all of
that includes all of the RASopathy genes is likely the
which depend on global LR positional cues that origi-
most cost-effective and clinically indicated approach. A
nate from a ciliated LRO early in development, before
molecular genetic diagnosis allows for specific progno-
cardiac morphogenesis. The LRO is highly conserved
sis, anticipatory guidance, and recurrence risk estimates
among vertebrates253 and functions through motile
for families.
LRO cilia to generate directional fluid flow.254 Sens-
Suggested Cardiac Follow-up ing this flow requires functional polycystin channels
If not completed already, an evaluation with a cardiolo- localized to the LRO sensory cilia.255,256 Activation of
gist, including an echocardiogram and ECG, is indicat- the sensory LRO cilia leads to LR asymmetrical gene
ed at the time of diagnosis. Follow-up is tailored to the expression of genes including cerl2, nodal, lefty, and
individual findings, ideally informed by the spectrum of pitx2. The precise mechanisms that connect asymmet-
disease and natural history of cardiac abnormalities in rical signals to heart development remain unknown.

CLINICAL STATEMENTS
AND GUIDELINES
Figure. Ciliary structure.

A, Transmission electron microgram (TEM) cross section of a 9+2 motile cilium. The central pair is indicated by the yellow arrowhead. Outer dynein arms (black
arrow) and inner dynein arms (red arrow) are shown linking the 9 sets of microtubule doublets. Location in the ciliary axoneme in (C) is indicated. B, TEM of a 9+0
sensory cilium; note the absence of central pair. C, Diagrammatic representation of a cilium indicating structures that have been linked to congenital heart disease.
Hh indicates hedgehog.
Finally, asymmetrical left-sided signals are constrained integrate mechanical signals such as those generated
by a midline barrier.249,257 This framework predicts rela- by cardiac contraction or blood flow with cardiovascu-
tionships between gene variants that result in abnor- lar development.
mal cilia function and the specific associated cardiac
laterality defects (Table 6).
Beyond their role at the LRO in establishing LR asym- Heterotaxy Syndrome
metry, cilia are found in cardiac tissue, including the Common Features
second heart field, where cilia are required for signaling Heterotaxy, from the Greek heteros (different) and
via the sonic hedgehog pathway. Mouse and human taxis (arrangement), refers to any placement of organs
mutations affecting ciliary hedgehog signaling, includ- along the LR axis that deviates from complete situs soli-
ing genes important for syndromic ciliopathies such as tus and complete situs inversus and includes left atrial
MKS1 (Meckel-Gruber syndrome type 1, Bardet-Biedl isomerism (LAI) and right atrial isomerism (RAI). In LAI,
syndrome type 13),250 MKKS (Bardet-Biedl syndrome there are 2 “left” sides with 2 left atrial appendages,
type 6, McKusick-Kaufman syndrome),258 and EVC and absent sinus node, and multiple spleens; conversely, in
EVC2 (Ellis-van Creveld syndrome)123,259,260 lead to atrio- RAI, there are 2 right atrial appendages, bilateral sinus
ventricular canal defects without accompanying later- nodes, and absent spleen. In both LAI and RAI, the liver
ality defects. Cilia are also found on embryonic myo- is located at the midline, and abnormal positioning of
cardial cells, in mesenchymal cells in the developing the gall bladder and stomach is common. Abnormalities
AV valves, and in the developing vasculature.261,262 It is of spleen number (asplenia or polysplenia) can result
possible that in these settings, they could function to in functional asplenia that requires management. Gut

Table 6. Summary of Ciliopathies
CLINICAL STATEMENTS
Ciliopathy Features Gene(s) Cardiac Defects
AND GUIDELINES
Primary ciliary Bronchiectasis, sinusitis, AK7, ARMC4, C21orf59, CCDC103, CCDC114, CCDC151, CCDC39, CCDC40, Dextrocardia; heterotaxy
dyskinesia otitis media, infertility, situs CCDC65, CCNO, DNAAF1, DNAAF2, DNAAF3, DNAAF5, DNAH11, DNAH5, spectrum heart defects
defects DNAH6, DNAI2, DNAL1, DNAJB13, DRC1, DYX1C1, GAS8, HEATR2, HYDIN, in ≈12%; heterotaxy not
LRRC6, MCIDAS, NME8, PIH1D3, RPGR, TXNDC3, RSPH1, RSPH3, RSPH4A, thought to occur with
RSPH9, SPAG1, TTC25, ZMYND10 genes associated with
central pair or radial spoke
Polycystic kidney Renal cysts; hepatic GANAB, PKHD1, PKD1, PKD2 Reported association
disease fibrosis; autosomal with aortic dilation
dominant and recessive
forms
Nephronophthisis Renal cysts with or without NPHP1-4, IQCB1, CEP290, ANKS6, GLIS2, CEP83, CEP164, RPGRIP1L, NEK8, Reported in conjunction
extrarenal symptoms SDCCAG8, TMEM67, TTC21B, DCDC2, IFT172, WDR19, ZNF423 with allelic syndromes
Meckel-Gruber Renal cysts, CNS MKS1, TMEM216, TMEM67, CEP290, RPGRIP1L, CC2D2A, NPHP3, TCTN2, Situs inversus;
syndrome anomalies (encephalocele), B9D1, B9D2, TMEM231, KIF14, TMEM107 heterotaxy; HLHS
polydactyly, hepatic
fibrosis, congenital heart
defects
Joubert and Hypoplasia of the AH1, C5ORF42, CC2D2A, CSPP1, TMEM216, NPHP1, CEP290, TMEM67, Laterality defects; heart
related syndromes cerebellar vermis (molar RPGRIP1L, INPP5E, TCTN2, MKS1, CEP104, CEP120, CEP41, KIAA0556, defects including septal
tooth sign), dysregulated PDE6D, PIBF1, TCTN1, TCTN3, ARL13B, CEP41, KIAA0586, TMEM237, defects, aortic valve
breathing pattern, retinal TMEM231, TMEM138, KIAA0753, TMEM107, KIF7, OFD1, C2CD3, anomalies, coarctation;
dystrophy, renal anomalies IFT172, ARL13B, ZNF423, TTC21B, PDE60, POC18, B9D2, B9D1 in some cases, associated
with features of OFD
Bardet-Biedl Obesity, polydactyly, BBS1, 2, ARL6 (BBS3), 4, 5, MKKS (BBS6), 7, TTC8 (BBS8), 9, 10, TRIM32 Heart defects with
syndrome retinitis pigmentosa, (BBS11), 12. MKS1, CEP290, WDPCP, SDCCAG8, IFT27, IFT172, LZTFL1, incomplete penetrance
anosmia, congenital heart BBIP1, IFT27; modifiers MKS3, CCDC28B (7%–50%); AS,
defects PDA, PS, ASD, VSD,
cardiomyopathy
Oral-facial-digital Oral cavity, face, and OFD1, TMEM216, C5orf42, TMEM107, TCTN3, TMEM231, TMEM138, Mitral and tricuspid valve
syndromes digit anomalies; CNS KIAA0753, SCLT1, C2CD3, DDX59, WDPCP, INTU, TMEM231, IFT57 dysplasia, TOF, VSD, CoA,
(types I-XVI and abnormalities; cystic hypoplastic LV
unclassified) kidney disease

Alström syndrome Dilated cardiomyopathy, ALMS1 Dilated cardiomyopathy
obesity, sensorineural
hearing loss, retinitis
pigmentosa, endocrine
abnormalities, renal and
hepatic disease
McKusick- Urogenital MKKS AVC defects, ASD, VSD,
Kaufman anomalies including TOF, PDA, hypoplastic LV,
syndrome hydrometrocolpos, LSVC; defects in ≈14%
postaxial polydactyly,
congenital heart defects
Ellis van Creveld Skeletal dysplasia; EVC, EVC2 AVC defects, APVR,
syndrome congenital heart defects; septal defects
polydactyly; ectodermal
dysplasia
Short rib thoracic Skeletal dysplasia; thoracic IFT80, DYNC2H1, TTC21B, WDR19, NEK1, WDR35, WDR60, IFT140, IFT172, Rare; septal defects,
dysplasias deformities; polydactyly; WDR34, CEP120, KIAA0586, DYNC2LI1, IFT52, TCTEX1D2 laterality defects
including Jeune renal cysts; retinitis
chondrodysplasia, pigmentosa
Saldino-Mainzer
Cranioectodermal Cranioectodermal IFT122, WDR35, IFT 43, WDR19 PDA, ASD, VSD, PS, LVH
dysplasia dysplasia; narrow thorax, in 25%–50%
(Sensenbrenner dental anomalies, hepatic
syndrome) and renal involvement
Carpenter Acrocephaly; RAB23, MEGF8, RAB23 PDA, PS, VSD, situs
syndrome polysyndactyly, inversus, heterotaxy
hypogenitalism, obesity,
congenital heart defects
APVR indicates anomalous pulmonary vein return; AS, aortic stenosis; ASD, atrial septal defect; AVC, atrioventricular canal; CNS, central nervous system; CoA,
coarctation of the aorta; HLHS, hypoplastic left heart syndrome; LSVC, left superior vena cava; LV, left ventricle; LVH, left ventricular hypertrophy; OFD, oral-facial-digital;
PDA, patent ductus arteriosus; PS, pulmonary stenosis; TOF, tetralogy of Fallot; and VSD, ventricular septal defect.

malrotation poses a risk for volvulus. Extrahepatic biliary tor ZIC3, a zinc-finger transcription factor that is re-
CLINICAL STATEMENTS
atresia is a severe extracardiac complication that affects quired to form a functional LRO276 and is required to
AND GUIDELINES
prognosis and mortality rate. Central nervous system direct heart looping, causes heterotaxy in up to 5% of
abnormalities can also be seen.263–265 Heterotaxy is also males and a smaller percentage of females with het-
associated with PCD, with one study finding that 37% erotaxy.277–281 ZIC3 pathogenic variants are identified
of heterotaxy patients had features suggesting the pos- in ≈75% of pedigrees with possible X-linked inheri-
sibility of PCD.266 In a minority of cases, heterotaxy can tance. Although penetrance is high, at least 1 case of
be identified in patients with other genetic syndromes nonpenetrance has been identified.282
such as trisomy 13, 22q11.2DS, CHARGE syndrome, or Although many genes linked to heterotaxy are as-
a syndromic ciliopathy. However, the majority of cases sociated with cilia and LRO structure and function,
of heterotaxy do not occur as part of a larger genetic there are many additional genes, including SHROOM3,
syndromic condition, and intellectual development is GRK5, and ANKS3, that have been reported to con-
usually normal. tribute to heterotaxy with functions distinct from cilia.
Sequence variants in genes required for propagation of
Cardiac Features the asymmetrical signal at the left lateral plate meso-
Heterotaxy is associated with congenital HD in 50% derm, including NODAL, CFC1, LEFTY2, GDF1, SMAD2,
to 95% of cases; the majority of cases with heterotaxy and ACVR2B, have been associated with human later-
spectrum including RAI, levocardia with abdominal si- ality disturbances.283–285 Environmental modifiers such
tus inversus (isolated levocardia), or dextrocardia with as maternal diabetes mellitus and monozygotic twin-
abdominal situs solitus (isolated dextrocardia) have sig- ning have also been associated with heterotaxy spec-
nificant congenital HD, which leads to major morbidity trum defects.
and mortality.265 Notably, LAI is not always associated
with significant intracardiac defects. Heterotaxy can be Cardiovascular Genotype/Phenotype
associated with almost all known congenital HD. The Correlations
most prominent cardiac findings are atrioventricular ca- One of the hallmarks of inherited laterality disorders is
nal defects that are frequently unbalanced and associ- the broad range of both laterality and cardiac pheno-
ated with other congenital HD such as malposed great types that result from any given mutation. For example,
vessels. Right ventricular obstruction and anomalous loss-of-function variants in ZIC3 have been correlated
pulmonary venous return are more commonly observed with a range of phenotypes ranging from classic het-
in RAI, whereas left ventricular obstruction, interrupted erotaxy with variable extracardiac manifestations to iso-
inferior vena cava, and rhythm disturbances resulting lated congenital HD.
from an absent sinus node are more commonly associ-
ated with LAI. The hallmark of congenital HD in het- Primary Ciliary Dyskinesia
erotaxy, however, is that there is no absolutely defined
pattern to the possible combination of cardiac and vas- The link between ciliary defects and congenital HD was
cular defects. first identified when Bjorn Afzelius identified defective
ciliary structure in electron microscopic analysis of tra-
Prevalence cheal cilia with Kartagener’s triad, a syndrome consist-
Heterotaxy is estimated to occur in 1 per 10 000 live- ing of respiratory disease, male infertility, and situs in-
births265 and constitutes ≈3% of congenital HD cases. versus in 50% of affected patients.286
Its incidence could be underestimated because of subtle
or clinically insignificant findings of laterality disorders, Common Features
such as bilateral superior vena cava. Kartagener syndrome is a subset of PCD, a disorder de-
fined by abnormal ciliary motility in the airway epithelia.
Molecular Genetics PCD is a highly heterogeneous disorder with pathogenic
Aneuploidies, complex chromosomal rearrangements, variants in >39 genes identified (Table 6), of which 23
and microdeletions have all been identified in pa- have been linked to cardiac abnormalities.287 Not surpris-
tients with heterotaxy.263,267 Clinically relevant CNVs ingly, a retrospective study of patients diagnosed with
have been identified in 15% to 26% of patients with PCD identified heterotaxy in a subset of the cohort.288
heterotaxy syndrome.268–272 Heterotaxy has the high- Neonatal respiratory distress (not related to cardiovascu-
est relative risk among all classes of congenital HDs, lar malformations) is a frequent manifestation of PCD.
which supports a strong genetic component.273 Auto- Chronic wet, productive cough, daily rhinitis, recurrent
somal dominant, autosomal recessive, and X-linked in- or chronic bacterial infections of the lower airways, re-
heritance patterns have all been described, but unlike current sinusitis, and otitis media are common features.
other types of congenital HD, de novo sequence vari- Bronchiectasis is seen in adults. The diagnosis of PCD is
ants are not major contributors to heterotaxy.14,274,275 made through sequencing PCD genes, by either WES or
Pathogenic variants in the X-linked transcription fac- dedicated PCD panels, combined with nasal ciliary bi-

opsy and analysis of ciliary structure and motility. Low most commonly affected are those in which nonmotile
CLINICAL STATEMENTS
nasal nitric oxide is a useful marker of PCD, but testing sensory cilia play important roles, such as the eyes, ears,
AND GUIDELINES
is not reliable in infants and young children. skeleton, brain, kidney, and liver.291–296 Abnormal signal
transduction via hedgehog, Hippo, and Wnt pathways
Cardiac Features
underlies a variety of patterning defects and congeni-
Situs inversus totalis (mirror image reversal of all organs),
tal anomalies identified in these syndromes, although
the most common laterality phenotype associated with
other developmental pathways are also involved.
PCD, is part of the spectrum of laterality disorders result-
ing from ciliary dysfunction (Table 6) and occurs in 40% Common Features
to 50% of cases. At least 12.1% of patients with classic Eye and Ear
PCD exhibit heterotaxy.289 Because a diagnosis of PCD Retinitis pigmentosa and cone-rod dystrophy are com-
in patients with congenital HD is inherently challenging mon eye findings. Sensorineural hearing loss occurs in
given the difficulty in differentiating whether respiratory a variety of ciliopathies.
symptoms are primary or secondary to the underlying
cardiac pathology and the medical and surgical interven- Central Nervous System
tions required to manage the congenital HD, it is possible Structural defects have been described, including the
that some patients thought to have isolated congenital classic brain stem malformations (molar tooth sign) in
HD actually have congenital HD as part of PCD. Joubert syndrome, Dandy-Walker malformation, and
neural tube defects, including encephalocele, holopros-
Prevalence encephaly, and agenesis of the corpus callosum.
The prevalence of PCD is not known with certainty, but
PCD is estimated to affect ≈1 per 20 000 individuals. Growth and Endocrine
Obesity is seen as a result of abnormal energy ho-
Molecular Genetics meostasis/hypothalamic dysfunction and is common
PCD is most commonly inherited as an autosomal reces- in Bardet-Biedl, Alstrom, and Carpenter syndromes.
sive condition, although a rare association of X-linked
Diabetes mellitus is the most common endocrine
PCD with retinitis pigmentosa has been described and
abnormality.
a new X-linked form of PCD has recently been iden-
tified.290 There are at least 39 genes known to cause Skeletal
PCD, with additional candidate genes identified in ani- Dwarfism, thoracic dysplasia, short limbs, and polydac-
mal models. The number of PCD-causing genes that tyly characterize a variety of ciliopathies, some of which
can also cause isolated congenital HD is unknown, but are perinatal lethal. Four groups with major skeletal in-
recent work shows that predicted damaging variants volvement include the cranioectodermal dysplasias, the
are found in genes required for ciliary motility and func- short-rib thoracic dysplasias, EVC, and the oral-facial-
tion in patients with congenital HD.14 digital syndromes.
Cardiovascular Genotype/Phenotype Hepatic
Correlations Prototypical features are hepatic fibrosis and hepatic
Absence of cilia motility in the setting of otherwise nor- cysts. Liver disease in ciliopathies is not a primary dis-
mal sensation and signal propagation results in random ease of the hepatocytes but rather is a developmental
LR asymmetry: random movement of extraembryonic defect of the portobiliary system.
fluid is still able to trigger a “left identity” signal that is
randomly distributed between the anatomic right and left Renal
side of the embryo. This leads to the characteristic pheno- Polycystic kidneys are common features of many ciliop-
type observed in the setting of PCD caused by ciliary mo- athies. Nephronophthisis is characterized by renal cysts,
tility components such as the axonemal dynein DNAH5, tubular basement membrane disruption, and tubuloin-
DNAH11, and the dynein assembly factor DNAI1. Patients terstitial fibrosis.
with PCD pathogenic variants most commonly present Skin
with randomization of situs (resulting in situs inversus Ectodermal dysplasia affects hair, skin, teeth, and
or situs solitus) and only rarely with heterotaxy.288 nails.
Cardiac Features
Syndromic Sensory Ciliopathies Congenital HDs and laterality defects occur in a subset of
The sensory ciliopathies are a group of genetically and sensory ciliopathies (Tables 6 and 7). In addition to situs
phenotypically heterogeneous disorders caused by ab- abnormalities of the heart, atrioventricular canal defects,
normalities in the sensory or signaling functions of cilia. septal defects, and valve defects can occur with reduced
They are inherited in an autosomal dominant, autosomal penetrance. The mechanistic basis of the congenital HDs
recessive (most common), or X-linked pattern. Organs has not yet been established for each syndrome. Find-

ings of laterality defects should reflect disruption of LRO tal HD will likely yield additional cilia genes with a role
CLINICAL STATEMENTS
function, whereas isolated congenital HDs might result in congenital HD and begin to establish more focused
AND GUIDELINES
from abnormalities of cilia within the heart. Cardiomy- genotype-phenotype correlations.

opathy is identified in Alstrom syndrome.
Prevalence Clinical Genetic Testing in Ciliopathies
The prevalence varies by syndrome subtype, but all Clinical genetic testing is directed on the basis of the
syndromes are quite rare, with estimates ranging from differential established through medical history, in-
1:50 000 to 1:1 000 000. There are examples of founder cluding family history, and physical examination. All
effects, with the incidence of Meckel-Gruber as high as patients with heterotaxy should have CMA because
1:9000 in some populations (Finnish).292 of associations with chromosome abnormalities and
Molecular Genetics pathogenic CNVs. In addition, strong consideration
As seen in Table 7, several of the disorders have allelic should be given to ZIC3 testing, particularly in males
overlap. For example, Joubert syndrome and Meckel- with heterotaxy. Recurrence risk estimates are sub-
Gruber syndrome share many of the same genetic stantially impacted by test results. Although additional
causes. More than 140 genes have been established studies are necessary to further establish the preva-
as causative for syndromic sensory ciliopathies, along lence of PCD in patients with heterotaxy, consider-
with >200 additional candidate genes.293 Most cases ation should be given to evaluation for PCD, because
are caused by loss of gene function. respiratory and pulmonary management could be op-
timized to improve the higher than expected surgical
Genotype-Phenotype Correlations morbidity and mortality in this patient group.335 Ge-
How the same allele causes disparate phenotypes for netic testing for PCD is available through multigene
many of the ciliopathies is not fully apparent. For the panels. Concern for syndromic ciliopathies should
multisystem disorders, specific organ involvement or prompt molecular testing for these disorders via cili-
severity can correlate with the particular gene involved. opathy panels or exome sequencing.
For example, in a patient with Joubert syndrome,
pathogenic variants in NPHP1, a gene that can also
cause nephronophthisis, are more likely to be found in The Impact of Ciliopathy Pathologic
association with renal involvement. Modifier alleles and Variants on Clinical Outcomes in Patients
digenic inheritance have been described, and these pre- With Congenital HD
sumably affect phenotypic presentation. In some cases,
One of the challenging aspects of caring for patients
the variant type (eg, loss of function versus missense)
requiring surgical repair of congenital HD is the varia-
will dictate presentation. Genotype-phenotype correla-
tion in postoperative outcomes even for patients with
tions have not been described for cardiac presentations.
anatomically and physiologically identical congenital
HD. Respiratory complications are one of the most
Isolated Congenital HD Related to Ciliary important modulators of postoperative outcome
Defects that can be influenced by genetic pathogenesis of
the congenital HD. If patients at increased risk for re-
General
spiratory and other complications can be identified
Studies of the mouse model predict that ciliary de-
preoperatively, it might be possible to modify their
fects will be identified that cause recessively inherited
care and improve clinical outcomes. Pathological vari-
isolated congenital HD in the absence of a syndromic
ants in ciliary genes are known to cause heterotaxy,
ciliopathy or PCD,251 and recent studies show an over-
some types of nonheterotaxy congenital HD,251,288 and
representation of rare, predicted damaging variants in
PCD.286,336 Poor mucociliary clearance leads to infec-
recessive genes in patients with isolated congenital HD
tion and inflammation that damage the airway, and
versus control subjects.14
it is especially important to note that patients with
Cardiac Features ciliary dysfunction depend entirely on cough for mu-
Recent work on large cohorts of patients with severe cociliary clearance, a function that is compromised
mitral valve prolapse identified that mutations affecting in patients on mechanical ventilatory support, such
DCHS1 are linked to congenital mitral valve defects,333 as postoperative congenital HD patients. With this in
and DCHS1 localizes to the base of the ciliary appa- mind, it is not surprising that patients with congenital
ratus.334 In addition, patients with situs inversus with HD, heterotaxy, and associated airway ciliary dysfunc-
or without TGA have been identified with a deletion tion have a higher rate of respiratory complication
that affects NPHP2 (inversin), and mutations that affect postoperatively than similar patients without airway
GDF1 have been associated with RAI (Table 6). In the ciliary dysfunction.335 These findings suggest that
future, genomic analyses of large cohorts of congeni- prospective knowledge of which patients might have

Table 7. The Relationship of Ciliary Components Shown in Figure 1 and the Associated Congenital HD
CLINICAL STATEMENTS
Gene Molecular Function Cardiac Phenotype Reference
AND GUIDELINES
LRO formation GDF1 LRO formation RAI, congenital HD 297
GALNT11 LRO formation HTX 271
Centriole MKKS Centriole Congenital HD 258
NEK2 Centriole HTX 271
Transition zone/inversion NPHP2 SI, TGA 298–300
compartment NPHP3 VSD, HTX 301, 302
ANKS6 SI, congenital HD 303
NEK8 Congenital HD, HTX 304
Ciliary motility DNAAF3 Dynein assembly SI 305
CCDC39 Dynein assembly SI, HTX 306
CCDC40 Dynein assembly SI 307
CCDC103 Dynein assembly S1, HTX 308
HEATR2 Dynein assembly SI, HTX, congenital HD 309
ARMC4 Dynein assembly SI 310
DYX1C1 Dynein assembly SI, HTX, congenital HD 311
C210RF59 Dynein assembly SI, HTX 312
SPAGI Dynein assembly SI 313
CCDC151 Dynein assembly SI, HTX, congenital HD 314
PIHID3 Dynein assembly SI 290
DNAAF1 Dynein assembly SI 315, 316
DNAAF2 Dynein assembly SI 317
DNAH5 Dynein outer arm SI, HTX, congenital HD 288, 318
TXNDC3 Dynein outer arm SI, HTX 319
DNAH11 Dynein outer arm SI 320
DNA11 Dynein intermediate chain SI, HTX, congenital HD 321, 322
DNALI Dynein light chain SI 288, 323, 324
CCDC114 Dynein docking SI, HTX, congenital HD 325
TTC25 Dynein docking SI 326

LRRC6 Dynein transcription SI 320
ZMYND10 Dynein transcription SI 327
CCDC11 Centriole SI, HTX 328, 329
330
Polycystin complex PKD2 SI 331
PKD1L1 HTX 332
Other EVC Hedgehog signaling AVC 123
EVC2 Hedgehog signaling AVC 123
MKS1 Hedgehog signaling AVC 250
DCHS1 Mitral prolapse 333
AVC indicates atrioventricular canal; HD, heart disease; HTX, heterotaxy; LRO, left-right organizer; RAI, right atrial isomerism; SI, situs inversus; TGA,
transposition of the great arteries; and VSD, ventricular septal defect.
airway ciliary dysfunction could improve postoperative it occurs in the setting of a genetic syndrome, but the
outcome by tailored modifications to their respiratory identification of the genetic contributors of nonsyn-
care. In addition, immotile cilia are found in the kidney dromic congenital HD has proved to be more challeng-
and brain, and it is possible that cilial defects impact the ing. Although initial insights were based on studies of
kidney’s response to injury,337 neurodevelopment,338,339 large, multigenerational kindreds in which multiple
and metabolic function.339 family members were affected with a cardiac malfor-
mation, these families are relatively uncommon, and
the congenital HD is often less severe. With the elu-
NONSYNDROMIC CONGENITAL HD cidation of an increasing number of genes involved
ATTRIBUTABLE TO SINGLE-GENE in the molecular regulation of cardiac morphogenesis
by either a better understanding of cardiac develop-
VARIATION mental regulation through model organism studies
As discussed earlier, numerous genes have been im- or through identification of candidate cardiac genes
plicated in the pathogenesis of congenital HD when within microdeletions/microduplications in individuals

with congenital HD, there has been a relative explosion HD, with lesions including persistent truncus arterio-
CLINICAL STATEMENTS
of rare sequence variants in these heart development sus, PVS, ASD, and PDA.351 The link between GATA6
AND GUIDELINES
genes identified in children with congenital HD. Estab- mutations and human disease was expanded by the
lishing disease causality, especially of a specific vari- identification of de novo inactivating mutations in
ant, remains a challenge. These genes mostly encode GATA6 in ≈50% (15 of 27) of individuals with pan-
transcription factors, signaling molecules, or structural creatic agenesis, among whom 90% had congenital
proteins important in cardiac development, structure, HD.354
and function. The genes most strongly associated with Another important transcription factor family linked
congenital HD are briefly discussed in Transcription to congenital HD is the Tbox family. Besides the asso-
Factors, Cell Signaling and Adhesion Molecules, and ciation with syndromic congenital HD (TBX5 with HOS,
Structural Proteins. Detailed information about the TBX1 with cardiac lesions in 22q11.2DS), mutations in
associated cardiac phenotypes and references to sup- TBX5 and TBX1 might be responsible for nonsyndromic
porting studies are reviewed in Anderson et al340 and congenital HD.408,409 In addition, mutations in another
Fahed et al341 and are provided in Table 8. In addition to family member, TBX20, were identified in 2 families
these “gold standard” congenital HD genes, there are with cardiac septation defects, mitral valve stenosis,
several hundred genes with purported roles in cardiac and dilated cardiomyopathy.366 Mutations in TBX20
development and congenital HD, and advances in ge- have subsequently been described in other cardiac mal-
nomic technology over the past 3 years have enabled formations, including tetralogy of Fallot, truncus arte-
us to unravel the genomic architecture of isolated or riosus, and double-outlet right ventricle. Other cardiac
nonsyndromic congenital HD at a rapid pace. Many of transcription factors implicated in congenital HD patho-
the congenital HD genes identified to date can be as- genesis are listed in Table 8.369
signed to one of the following functional categories.
Cell Signaling and Adhesion Molecules
Transcription Factors Although mutations in the Notch signaling pathway
Initial insights into the genetic pathogenesis of non- are a cause of ALGS as well as AOS (both discussed
syndromic congenital HD were based on the discovery previously),141 this pathway is also implicated in nonsyn-
of disease-causing sequence variants in critical cardiac dromic congenital HD. Garg et al reported a multigen-
transcription factors identified as important for normal eration family with autosomal dominant cardiovascular
heart development in multiple animal model systems.401 disease in which 9 members had aortic valve disease,
Mutations in the transcription factor gene NKX2-5 were primarily BAV, but also 1 member with tetralogy of
reported in multiple familial and sporadic cases of con- Fallot.185 Since then, mutations in NOTCH1 have been
genital HD, with the first report in 1998 in 4 kindreds implicated in familial nonsyndromic congenital HD,
with autosomal dominant congenital HD.358 Familial predominantly affecting the cardiac outflow tract and
ASD with atrioventricular conduction abnormalities is semilunar valves.384 A recent report using clinical exome
the primary cardiac phenotype associated with NKX2- sequencing in a patient with HLHS identified a NOTCH1
5 mutations, but additional phenotypes include VSD, mutation although affected paternal family members
tetralogy of Fallot, subvalvar aortic stenosis, pulmonary had mostly right-sided heart lesions,385 which suggests
atresia, and mitral valve abnormalities (reviewed in that the phenotype might not be limited to the left-sid-
Stallmeyer et al362 and Ellesøe et al363) These discoveries ed semilunar valve.383 Pathological sequence variants in
have been supported by the reports of similar cardiac other cardiac developmental signaling pathway genes
phenotypes in mouse models harboring mutations in have also been identified in patients with congenital HD
Nkx2.5.402–404 (Table 8).
A similar approach identified heterozygous muta-
tions in GATA4, a gene encoding another important
cardiac transcription factor, in familial congenital Structural Proteins
HD.113 The predominant and most penetrant phe- Mutations in sarcomeric genes, known to cause car-
notype is secundum ASD but can include VSD, PVS, diomyopathy, have also been reported in congenital
AVSD, and tetralogy of Fallot (reviewed in Prendiville et HD, for example, α-cardiac actin (ACTC1) and myosin
al405). Evidence supporting these genetic associations heavy chain 6 (MYH6) mutations in familial ASD,389,394
has come from analysis of mice haploinsufficient for β-myosin heavy chain (MYH7) mutations in Ebstein’s
Gata4 or harboring disease-causing Gata4 mutations. anomaly of the tricuspid valve and left ventricular
These mouse models have replicated human disease noncompaction cardiomyopathy,397,398 and myosin
phenotypes.347,406,407 Additionally, another member of heavy chain 11 (MYH11) mutations in PDA, usually
the GATA family of transcription factors, GATA6, has in association with thoracic aortic aneurysms.399,400
been implicated in sporadic and familial congenital As discussed, elastin (ELN) haploinsufficiency causes

Table 8. Disease Genes for Nonsyndromic Congenital Cardiovascular Disease
CLINICAL STATEMENTS
Nonsyndromic (NS) or
AND GUIDELINES
Gene Cardiovascular Malformation Syndromic (S) Gene MIM References
Transcription factors
CITED2 ASD, VSD NS 602937 342
GATA4 ASD, VSD, AVSD, PVS, TOF NS 600576 113, 343–350
GATA6 PTA, TOF NS 601656 351–355
MED13L TGA NS 608771 356
NR2F2 AVSD, AS, CoA, VSD, HLHS, TOF NS 107773 357
NKX2-5 ASD, atrioventricular conduction NS 600584 358–363
delay, TOF, HLHS
NKX2.6 PTA NS 611770 364, 365
TBX20 ASD, VSD, MS, DCM NS 606061 366–369
ZFPM2/FOG2 TOF, DORV NS 603693 370–372
Cell signaling and adhesion proteins
ACVR1/ALK2 AVSD NS 102576 373
CRELD1 ASD, AVSD NS 607170 374–376
GJA1 HLHS, VSD, PA S (oculodentodigital dysplasia) 121014 377–379
and NS
JAG1 TOF, PVS, PAS S (Alagille syndrome) and NS 601920 380–382
NOTCH1 BAV, AS, HLHS, TOF, PVS S (Adams-Oliver syndrome) 190198 141, 185, 383–385
and NS
PDGFRA TAPVR NS 173490 386
SMAD6 BAV, CoA, AS NS 602931 387
TAB2 BAV, AS, TOF NS 605101 388
Structural proteins
ACTC1 ASD, HCM, DCM, LVNC NS 102540 389, 390

DCHS1 MVP NS 603057 333
ELN SVAS S (Williams-Beuren syndrome) 130160 80, 391–393
and NS
MYH6 ASD, HCM, DCM NS 160710 394–396
MYH7 Ebstein’s anomaly, LVNC, HCM, DCM NS 160760 397, 398
MYH11 PDA, TAA NS 160745 399, 400
AS indicates aortic valve stenosis; ASD, atrial septal defect; AVSD, atrioventricular septal defect; BAV, bicuspid aortic valve; CoA, coarctation of aorta; DCM,
dilated cardiomyopathy; DORV, double-outlet right ventricle; HCM, hypertrophic cardiomyopathy; HLHS, hypoplastic left heart syndrome; LVNC, left ventricular
noncompaction cardiomyopathy; MIM, Mendelian Inheritance in Man; MS, mitral valve stenosis; MVP, mitral valve prolapse; NS, nonsyndromic; PA, pulmonary
atresia; PAS, pulmonary artery stenosis; PDA, patent ductus arteriosus; PS, pulmonic valve stenosis; PTA, persistent truncus arteriosus; PVS, pulmonary vein stenosis;
S, syndromic; SVAS, supravalvar aortic stenosis; TAA, thoracic aortic aneurysm; TAPVR, total anomalous pulmonary venous return; TGA, transposition of great
arteries; TOF, tetralogy of Fallot; and VSD, ventricular septal defect.
syndromic congenital HD in WS, whereas point mu- congenital HD cases (parent-offspring trios), congeni-
tations in ELN cause supravalvular aortic stenosis and tal HD cases showed a significant excess of protein-
other large artery stenoses without a syndromic phe- altering de novo sequence variants in genes expressed
notype.392,393 in the developing heart, with particular enrichment
of histone-modifying genes that regulate expression
Recent Insights Into the Complex of key developmental genes.275 Of note, the involve-
ment of histone modifier mutations in several forms of
Genetic Architecture of Nonsyndromic congenital HD suggests that epigenetic modifications
Congenital HD more broadly (eg, ones that alter DNA methylation or
Given the large number of genes that contribute to noncoding RNAs) might prove relevant for congenital
congenital HD, NGS is being increasingly used in both HD pathogenesis.275,410 De novo point variants in several
research and clinical settings in congenital HD patients. hundred genes together contributed to ≈10% of severe
In one of the earliest studies led by the Pediatric Cardi- congenital HD. Of note, the vast majority of variants
ac Genomics Consortium that used WES in 362 severe were “private” in that they were not identified in more

than 1 individual. The same group performed exome caused by synergy between variants in multiple devel-
CLINICAL STATEMENTS
sequencing of 1213 congenital HD parent-offspring opmental genes rather than a single gene.
AND GUIDELINES
trios and identified an excess of protein-damaging de In summary, in recent years, NGS approaches in iso-
novo variants in genes highly expressed in the develop- lated congenital HD have revealed the following:
ing heart and brain. These potentially disease-causing 1. There are several hundred genes that either cause
variants accounted for 20% of patients with syndromic or contribute to congenital HD.275
congenital HD, that is, congenital HD with neurode- 2. Sequence variants in congenital HD genes can
velopmental disabilities and extracardiac congenital cause both sporadic and inherited congenital
anomalies, but only 2% of patients with isolated con- HD.
genital HD. These findings revealed shared genetic con- 3. Sequence variants in congenital HD genes can
tributions to congenital HD, neurodevelopment, and cause both syndromic and nonsyndromic con-
extracardiac anomalies.274 genital HD, with strong association of de novo
A large international study using WES of 1891 variants with syndromic CHD274 and of inherited
probands found a significant enrichment of de novo variants with nonsyndromic congenital HD.411
protein-truncating variants but not inherited protein- 4. There is phenotypic heterogeneity, with sequence
truncating variants in known congenital HD genes in variants in the same genes often associated with
syndromic congenital HD. Conversely, in nonsyndromic different cardiac phenotypes, not only between
congenital HD, there was a significant enrichment of families but also within families. This discordance
protein-truncating variants inherited from unaffected in phenotype among family members was further
parents in congenital HD genes. The study further iden- highlighted in a Danish national study in which
tified 3 genome-wide significant syndromic congeni- only 50% of siblings had the same type of con-
tal HD disorders caused by de novo variants in CHD4, genital HD as the proband.415
CDK13, and PRKD1. This study underscored the distinct 5. Family studies often show incomplete segrega-
genetic architectures of syndromic versus nonsyndrom- tion even in familial congenital HD, with could
ic congenital HD.411 be attributable in part to incomplete penetrance
Although these studies involved heterogeneous but could also be related to oligogenic origins
cohorts of congenital HD, WES of a targeted cohort of congenital HD.413 The occurrence of multiple
of nonsyndromic AVSD cases provided important in- variants in some patients might explain why
sights into congenital HD genetic architecture, includ- some affected individuals have a more severe
ing the identification of NR2F2, a novel potentially phenotype.414

causal gene in patients with nonsyndromic AVSD.357
Because NR2F2 mutations explained <5% of AVSDs,
the investigators also performed a candidate gene Clinical Implications
search of 112 potential AVSD-associated genes and The above findings have clinical implications. Al-
found a significant enrichment of rare, damaging vari- though several laboratories offer congenital HD gene
ants in 6 genes, 3 of which were known syndrome- panels of various sizes for clinical testing, the rela-
associated genes (NIPBL, CHD7, and CEP152).412 This tively large numbers of genes involved and the role
highlighted that syndrome-associated genes can con- of novel and ultra-rare variants in causing rare dis-
tribute to nonsyndromic congenital HD. A follow-up orders coupled with the oligogenic origins of some
study identified an even larger gene set enriched for of the more complex congenital HDs suggest that a
potential disease-contributing variants compared with genome-wide search for congenital HD–associated
control subjects, with 32% of trios carrying at least 1 variants might be cost-effective in the future as the
putatively disease-associated variant, either inherited accuracy of variant interpretation improves. Experi-
or de novo, across a heterogeneous group of loci.413 ence, challenges, and cost-effectiveness of clinical
Together, these studies revealed the complex and oli- exome sequencing have been reported recently.385,400
gogenic origins of AVSDs, as well as the ability of NGS Also, given the overlap in genes associated with syn-
to unravel some of this complexity. dromic and nonsyndromic congenital HD, it is impor-
Finally, a recent study using mouse forward genet- tant to continue medical follow-up of patients with
ics identified sequence variants in novel genes not nonsyndromic congenital HD caused by a syndrome-
previously associated with congenital HD, Sap130 and associated gene, because noncardiac findings can
Pcdha9, as being digenic causes of HLHS. Sap130 me- sometimes manifest later than cardiac findings. Ad-
diated left ventricular hypoplasia, whereas Pcdha9 in- ditional clinical implications of knowledge of genetic
creased penetrance of aortic valve abnormalities. The pathogenesis in screening, surveillance, and manage-
investigators also identified a subject with HLHS with ment of congenital HD have been discussed in de-
both SAP130 and PCDHA13 sequence variants.414 This tail in a recent American Heart Association scientific
study highlighted that complex congenital HD can be statement.416

FUNCTIONALITY OF CONGENITAL at a single specific site (eg, CRISPR/Cas9) have expe-
CLINICAL STATEMENTS
dited targeted mutagenesis by dramatically increasing
HD GENES
AND GUIDELINES
the efficiency of site-directed mutagenesis.419
Widespread exome and genome sequencing of con- These techniques for modifying the mouse genome
genital HD patients is uncovering an ever-increasing have been used to study cardiovascular development
number of candidate disease genes and disease-caus- and disease in a number of ways.420 Transgenesis is of-
ing variants.274,417 These sequence variants and candi- ten used for gain-of-function experiments, in which a
date disease genes need to be studied in model systems promoter with specific spatiotemporal expression prop-
to rapidly and accurately determine which variants are erties is used to drive a gene of interest. The opposite
responsible for congenital HD causation, to character- loss-of-function strategy is achieved by constitutive
ize pathogenic mechanisms, and to identify new candi- gene knockout or by excising an essential portion of
date genes for evaluation in clinical studies. Several in a floxed gene of interest using Cre recombinase, ex-
vitro and in vivo model systems are available, each with pressed from a transgene or knocked into a second lo-
its own strengths and weaknesses. In vivo animal mod- cus so that it is expressed in a known spatiotemporal
els, including mammalian (eg, mouse), “other” verte- domain. Gene knockout approaches have traditionally
brate (eg, zebrafish, frog, and chick), and invertebrate focused on coding regions. However, this strategy will
(eg, fruit fly) organisms, allow evaluation of the impact also be useful to test the functional importance of con-
of genetic perturbations on cardiac development and served transcriptional regulatory elements that have
function within the context of an intact organism. Re- been linked to congenital HD causation using high-
cently, in vitro strategies have been developed in cell throughput mapping technologies.421–424
and tissue engineered models that complement the Cre recombinase is also often used to dissect a cell’s
animal models and facilitate mechanistic studies.418 In developmental history, a technique known as genetic
combination, these in vivo and in vitro model systems lineage tracing.425 Here, Cre recombination is used to
enable the elucidation of pathogenic mechanisms, the activate expression of a reporter gene such as LacZ
discovery of additional candidate congenital HD genes, or GFP in a particular tissue beginning at a selected
and the development of novel, molecularly targeted developmental stage. Because reporter activation in-
therapeutic strategies. volves modification of the genome, it is transmitted to
all of the progeny of the Cre-expressing cells. Lineage
tracing has been critical to deduce the developmental
Mouse Models events that generate the heart, including the contribu-
Because of the high degree of conservation between tions of the second heart field, which adds cells onto
mouse and human cardiac development and the avail- the arterial and venous ends of the linear heart tube to
ability of well-established techniques for genetic ma- form parts of the atria and most of the right ventricle
nipulation, the mouse model has been used to study and outflow tract,426 as well as the contribution of the
heart development for >25 years, resulting in an ex- dorsal mesenchymal protrusion to form portions of the
tensive knowledge base with bountiful reagents and atrioventricular septae at the crux of the heart.427,428
resources. These key features have made the murine In spite of the similarities between mouse and human
system the most widely studied animal model of cardio- cardiac development, there also can be important dif-
vascular development. ferences. Because of practical considerations, congeni-
The mouse genome can be modified by many tech- tal HD gene defects are often modeled in mice as ho-
niques. These can be grouped into methods that ran- mozygous gene knockouts, whereas most congenital
domly insert DNA sequences into the genome (trans- HD mutations are heterozygous point or truncating
genesis) and those that modify an endogenous locus mutations.274,417 These point mutations can result in
(targeted mutagenesis). Transgenesis, performed by partial gain or loss of function or could have dominant-
introduction of foreign DNA (using a targeting vector) negative activity that is imperfectly modeled by gene
into a fertilized oocyte, is most commonly used to direct knockout. Biologically, gene dosage and redundancy
expression of a gene in an altered form or at an ecto- are important factors that influence the expression of
pic time, location, or level. The targeting vector used to mutations, and these parameters often vary between
modify the endogenous locus can be engineered to in- species. For instance, haploinsufficiency of TBX1 in
activate the gene (knockout), to introduce recombinase 22q11 deletion syndromes is an important contribu-
sites into the gene so that it can be conditionally inac- tor to congenital HD429; however, Tbx1 haploinsuffi-
tivated by a second recombinase allele (eg, flank gene ciency is well tolerated in mouse models, and a more
with loxP sites [floxed] that can be excised at a spe- severe reduction of Tbx1 dosage is required to produce
cific time in a specific tissue by Cre recombinase), or to cardiac defects.430 Genetic modifiers modulate the ex-
modify the endogenous gene (knockin). More recently, pression of gene mutations in human congenital HD.48
nucleases that can be programmed to cut the genome Exploration of genetic modifiers in mouse models can

be productive405,431 but is rarely undertaken because scribed above for mice.437 These approaches are more
CLINICAL STATEMENTS
these experiments are time and resource intensive. time consuming but have a lower level of nonspecific or
AND GUIDELINES
As a result of these technical and biological factors, off-target effects. One important consideration when
mouse models often yield important principles and performing targeted genetic modifications is that the
genetic pathways responsible for congenital HDs, but zebrafish underwent a genome duplication event dur-
genotype-phenotype relationships can differ between ing evolution after divergence from its common ances-
the mouse and the human. tor with mammals.438 As a result, for many mammalian
As noted above, cost and time are important consid- genes, zebrafish often have 2 different genetic loci en-
erations when developing mouse models of congenital coding for slightly different versions of the same gene,
HD. Creating a new mouse allele and characterizing it both of which might need to be targeted to have the
can take 6 to 12 months, and in models that require same developmental effect as targeting the single gene
combining several different alleles, breeding mice to in other vertebrates.
obtain the required genotype can be a critical practical One popular approach to verifying that newly iden-
bottleneck. Acquiring the correct mouse alleles for an tified variants are indeed pathogenic is to determine
experiment can also be time consuming and expensive. whether a full-length expression construct of the wild-
In some cases, these practical limitations can be circum- type and mutated versions of the gene is capable of res-
vented through in vivo gene transfer and somatic mu- cuing the phenotype of zebrafish that lack a functional
tagenesis.432 Adeno-associated virus has proven to be copy of the gene. This can be readily accomplished by
an extremely efficient method for postnatal gene trans- directly injecting capped mRNA into 2- to 4-cell-stage
fer to cardiomyocytes, and adeno-associated virus can embryos, leading to widespread expression of wild-type
be combined with CRISPR/Cas9 to efficiently introduce or mutant transcripts of genes known or suspected to be
somatic mutations into cardiomyocytes. Although it is involved in cardiac development. Furthermore, expres-
possible to deliver adeno-associated virus to late-stage sion of a mutant form of the gene in a wild-type embryo
mouse embryos,433 unfortunately at the present time, can help rapidly validate gain-of-function variants that
adeno-associated virus transduction of mid-gestation have a dominant-negative effect on heart development.
mouse embryos and noncardiomyocytes (such as en- The ex utero development of zebrafish embryos
dothelial cells and valve cells) is inefficient and thus not also permits interventions that are not possible in
applicable to many heart development studies. mouse. Addition of agents to the aquatic environ-
ment of the embryo can be used to examine the
teratogenic effects of environmental toxins439 or in-

Zebrafish and Other Vertebrate Models terrogate the developmental contributions of specific
The limitations of the mouse model have led to the use signaling pathways.440 The embryo can also be di-
of alternative vertebrate models to study cardiovascular rectly accessed, and laser energy can be used to acti-
development. The zebrafish has become an attractive vate a specific gene in a specific cell,441 photoconvert
experimental model; the genes and signaling pathways a green fluorescing cell to a red fluorescence (which
involved in human cardiac development and respon- allows examination of a particular cell with respect
sible for human congenital cardiac defects are highly to the surrounding cells),442 or lesion a specific tis-
conserved in the zebrafish, and the zebrafish offers sue (to alter cardiovascular hemodynamics or ablate
some important advantages for developmental studies. a specific group of cells).443 Transfer of cells from one
A key advantage of the zebrafish system over mice is very early-stage embryo to another can enable the
that embryos are transparent and develop outside the examination of genetically modified cells when sur-
body of the mother (ex utero), which permits the devel- rounded by normal cells and tissues. Each of these
oping cardiovascular system to be imaged throughout interventions has helped to examine specific aspects
the developmental process.434,435 One can also rapidly of cardiac development in a manner that would not
and economically generate genetically modified zebraf- be possible in a higher vertebrate model in which the
ish models. Rapid screening of candidate congenital embryo develops in utero.
HD disease genes for essential functions in heart de- A major limitation of the zebrafish model is that the
velopment can be performed with antisense strategies zebrafish has a 2-chambered heart (1 atrium and 1
to diminish expression of specific genes beginning very ventricle), which makes it unsuitable for examination
early in development. Unfortunately, this approach, of the developmental process of septation. However,
which uses stable antisense RNA constructs called mor- genetic mutations that lead to septal defects in hu-
pholinos,436 can yield nonspecific morphological defects mans cause detectable cardiac phenotypes in zebraf-
that can obscure gene function, requiring careful con- ish embryos, which means the zebrafish is still a useful
firmation of observed phenotypes. Recent advances screening tool to examine the pathogenicity of muta-
have enabled rapid and efficient stable gene targeting tions that are suspected of causing septation defects
using CRISP-R/Cas9 approaches similar to those de- in humans.

Other Models main viable and continue to develop for hours to days
CLINICAL STATEMENTS
in culture environments, which permits key questions
Another vertebrate model system that has the benefit
AND GUIDELINES
on lineage, mechanics, and molecular signaling to be
of developing ex utero, which enables the observation
studied. For example, whole embryo culture was used
and manipulation of developmental processes, is the
to dissect the interaction of vascular endothelial growth
chick embryo. It has the additional benefit of having
factor and calcineurin/NFAT (nuclear factor of activated
a 4-chambered heart that is much more similar to the
T cells) signaling to regulate endocardial epithelial-mes-
human heart and can be used to study septation and
enchymal transition.448 Culture of microdissected pha-
other, more complex processes in cardiac morphogen-
ryngeal arch arteries revealed a cardiac progenitor niche
esis. As with the zebrafish model, delivery of gene ex-
in the second pharyngeal arch artery that promotes re-
pression or antisense RNA constructs can be used to
newal and expansion of cardiac progenitor cells, per-
manipulate gene expression, allowing examination of
turbation of which can contribute to congenital HD.449
gene functions and the developmental pathways. A
Atrial and ventricular explant culture has been used to
strength of the chick model system is the ability to ex-
demonstrate the origin of coronary endothelial cells
amine the effects of embryo manipulation on cardiac
from precursors on the atrial explant.450
development. For instance, surgical interventions such
Primary cell culture models have also been essential
as left atrial or vitelline vein ligation alter intracardiac
for studies of cardiovascular development. Primary fetal
flow patterns and result in abnormalities of cardiac
and neonatal cardiomyocytes can be maintained in cul-
morphogenesis,444,445 and ablation of specific develop-
ture for >1 week, and these systems have been essential
mental fields, such as the cardiac neural crest, allows
determination of the contribution of those domains to for dissecting mechanisms that regulate cardiomyocyte
the cardiac development. The combination of mechani- survival, proliferation, and hypertrophy.451,452 Culture of
cal or pharmacological intervention with modification epicardial cells and explants has also been critical to dis-
of gene expression can facilitate characterization of sect the function of these cells in regulating growth of
the effects of gene-environment interactions on heart myocardium and coronary vasculature.453,454
development and is a particular strength of the chick Stem cell differentiation into cardiomyocytes has be-
embryo model system. come a powerful method to study cardiogenesis and
Other animal models that have been used to help early heart development. Cardiac progenitor cells are
characterize specific aspects of heart development in- scarce in developing embryos, which makes studies
that require thousands to millions of cells difficult. In
clude the frog (genus Xenopus), which has been very

helpful in examining determination of “sidedness,”253 contrast, millions of these cells can be efficiently gener-
and the fruit fly (genus Drosophila), which has been ated in stem cell differentiation cultures. This has al-
effectively used to examine cardiomyocyte specifica- lowed key regulatory steps of cardiogenesis and early
tion.446 Relatively high-throughput methods for cardiac heart development to be carefully dissected.455 More-
gene knockdown and overexpression have been devel- over, the availability of human pluripotent stem cells
oped in Drosophila, which has enabled in vivo study of and protocols to efficiently direct their differentiation
the functional significance of identified congenital HD into cardiomyocytes has enabled the study of human
mutations.447 cardiogenesis.456
The maturation of a number of transformative tech-
nologies has recently permitted the effect of gene mu-
In Vitro Model Systems tations found in congenital HD patients to be studied
Although each animal model has its strengths in study- using human “disease-in-a-dish” models. These tech-
ing cardiac development and the pathological process- nologies include (1) development of efficient methods
es that cause human congenital cardiac defects, many for human stem cell differentiation; (2) reprogram-
lack the resolution to study the cellular interactions that ming of somatic cells to induced pluripotent stem cells,
are the foundation of organ development, and none which allows for the creation of patient-specific disease
can fully recapitulate the complex and unique genetic models; (3) facile genome editing, which permits rapid
environment of a patient with congenital HD. There- genetic manipulation of stem cells; and (4) develop-
fore, in vitro model systems, including those with the ment of bioengineered systems to build engineered
ability to directly examine the development of human heart tissues and assay them for relevant physiologi-
patient–derived cells, have been developed to better cal parameters. This confluence of technical advances
understand cell-level interactions that guide heart de- has allowed the impact of congenital HD mutations on
velopment. cardiomyocyte gene expression, cardiac differentiation,
Although mammalian heart development cannot be and myocardial function to be evaluated in patient-spe-
fully recapitulated ex utero in culture systems, culture cific genetic backgrounds, yielding new insights in dis-
systems have been essential for mechanistic studies of ease pathogenesis.457–460 Although these advances have
cardiovascular development. Mammalian embryos re- opened exciting new approaches to studying congeni-

tal HD pathogenesis, a number of challenges need to constitute a significant portion of birth defects,1,341
CLINICAL STATEMENTS
be overcome before they can realize their full potential. knowledge of genetic predispositions to congenital HD
AND GUIDELINES
Among these are developing in vitro, stem cell–based could also be used by patients and their family mem-
models of cardiac morphogenesis; enhancing directed bers to support reproductive decisions and expecta-
differentiation of stem cells to the full gamut of cardiac tions, as well as to help guide prenatal and perinatal
cell types; and improving the maturation of in vitro dif- management. In addition, there is increasing evidence
ferentiated cardiomyocytes. that certain types of genetic variations that cause con-
Although beyond the scope of this scientific state- genital HD also affect clinical outcomes such as cog-
ment, it is important to mention the growing role of nition, behavior, and motor skills (collectively termed
in silico modeling of genetic variants to determine the neurodevelopmental performance).341 Although this is
potential effects of the variant on protein structure and still an emerging field, it is possible that in the near
function. Early algorithms relied almost entirely on the future, genetic testing could help identify patients at
effect of the amino acid alteration on protein structure risk for abnormalities of neurodevelopment and help
to determine whether the mutation was likely to be target intervention strategies.
pathogenic. More recently, algorithms have incorpo- Despite these potential benefits, uncertainty about
rated degree of evolutionary conservation, population the clinical significance of many genetic variants and
frequency, and, in some cases, more advanced func- the complexity of conveying this information present
tional modeling to determine potential pathogenicity challenges. Sequencing has uncovered many more
of a novel genetic variant. Increasingly, advances in the genetic associations with congenital HD,94 but variant
understanding of the functions of and pathophysiologi- interpretation is imprecise, and the interplay between
cal mechanisms associated with specific disease-caus- genetic and environmental factors that contribute to
ing variants (gained from the above in vivo and in vitro congenital HD continues to be elusive.341,463,464
models) will allow more refined disease gene–specific With NGS, there is also the possibility that genetic vari-
mathematical modeling to assess potential pathogenic- ants associated with congenital HD might be discovered
ity of specific genetic variants, better characterization incidentally when testing for an unrelated phenotype, or
of disease mechanisms, and identification of structural that clinically significant incidental findings unrelated to
domains suitable for pharmacological targeting. congenital HD could be detected when testing for con-
In summary, technical advances and our expanding genital HD. In 2013, the American College of Medical
knowledge base have fueled dramatic advances in the Genetics and Genomics (ACMG) recommended that cer-
in vitro and in vivo modeling of cardiac development. tain clinically actionable secondary findings, including a
Continued expansion of these modeling capabilities will number of cardiac-related variants, such as Ehlers-Danlos
allow the rapid screening and adjudication of potential syndrome, familial thoracic aortic aneurysms, Marfan
congenital HD disease genes and pathogenic variants and syndrome, and HCM, ought to be offered to all patients
the examination of potential therapeutic approaches. Ad- undergoing clinical WES or whole genome sequenc-
vanced bioinformatics analyses of data generated in the ing.465,466 As a result, noncardiac specialists could be chal-
in vitro and in vivo developmental models and genomic/ lenged with communicating complex genetic findings to
genetic/epigenetic data from patients with congenital HD potentially unsuspecting patients. In these situations, re-
have the potential to better define developmental path- ferral to a cardiovascular geneticist is advisable.
ways involved in cardiac development, to greatly improve On the flipside, when performing a genomic test for
our understanding of congenital HD pathogenesis, and to congenital HD, patients ought to be informed about
identify novel approaches for prevention and treatment. the potential to discover incidental findings unrelated
to congenital HD and should be given an opportunity
to opt out of those results.466 This respects the patient’s
ETHICAL CONSIDERATIONS autonomy and preserves the “right not to know.”467
As noted above, genetic testing for congenital HD Pretest and posttest counseling is also important to
has increased over the past 10 years94,461 and is par- facilitate informed decision making, and it is essential
ticularly helpful in diagnosing syndromes responsible that it be offered to patients and their families.
for congenital HD and related noncardiac phenotypes Additional challenges are raised when performing ge-
that might require clinical management.1,341,461 Benefits netic testing in children with congenital HD. For many
of genetic testing for congenital HD include establish- years, there has been a general consensus that children
ing a genetic diagnosis, facilitating presymptomatic should only receive genetic testing that offers the poten-
screening of at-risk family members, enabling anticipa- tial for direct clinical benefit during childhood.1,468,469 The
tory management of congenital HD, directing clinical primary justifications for deferring testing for adult-onset
screening and management of associated noncardiac conditions are respect for the child’s future autonomy
conditions, and accelerating the development of novel and right to an open future470 and the potential psycho-
therapeutic targets.462 Because cardiac malformations social harm of knowing one’s genetic risk of disease. Tar-

geted genetic testing is only plausible when there is a discrimination is needed if we are to reap the benefits
CLINICAL STATEMENTS
known family history of a mendelian condition that puts of advances in genetic testing for congenital HD that
AND GUIDELINES
the child at risk for disease. In this situation, the affected have been realized over the past 10 years.
family member already knows that he or she has, or is at
risk for, the targeted genetic variant. In the context of ge-
nomic sequencing, however, a variant associated with an GENETIC COUNSELING/RECURRENCE
adult-onset condition that is discovered in a child could RISK/PRENATAL SCREENING
benefit parents or other family members, who would not
otherwise know they are at risk.465,471 Thus, increased Genetic Counseling
attention is now being paid to the potential benefit of The National Society of Genetic Counselors describes ge-
testing to families, and some professional organizations netic counseling as the process of helping people under-
and scholars have recommended that the presence of stand and adapt to medical, psychological, and familial im-
clinically significant genetic variants discovered inciden- plications of genetic contributions to disease. This process
tally during the course of clinical WES or whole genome integrates (1) interpretation of family and medical histories
sequencing be offered to patients, regardless of age and to assess the probability of disease occurrence or reoccur-
irrespective of age of onset.465,471,472 Comporting with rence; (2) education about inheritance, testing, manage-
standard ethical practice, children should be involved in ment, prevention, resources, and research; and (3) coun-
the decision about whether to receive these incidental seling to promote informed choices and adaptation to the
findings commensurate with their level of maturity and risk or condition.478 A genetic counselor is a graduate-level
should provide assent whenever possible.473 trained healthcare professional who receives training in
Pretest genetic counseling for congenital HD should ad- medical genetics, genomics, and counseling. In the United
dress the potential risks and benefits of testing, including States and Canada, this terminal degree leads to certifica-
the psychological and social impact of receiving a positive tion through the American Board of Genetic Counseling
test result. Recent studies suggest that neither adults474 after the individual passes a national certification exami-
nor children475,476 experience significantly increased anxiety nation. As of May 2017, 20 states issue and require licen-
or distress after learning of their genetic status. However, sure for genetic counselors to practice, and 3 states have
the potential psychosocial impact of genetic testing can licensure laws in progress. As the need for cardiovascu-
be greater when test results offer little therapeutic value lar genetic counseling is increasingly recognized, genetic
and could include alterations of self-image and disruption counseling training programs are developing curricula and
in family relationships, including increased perceptions of clinical rotations to meet this growing need.415,479 Never-
child vulnerability that negatively impact development.468 theless, there are 3-fold more genetic counseling positions
These risks must be weighed against the potential psy- available than new graduates each year.
chological benefits of testing. For example, patients and Genetic counselors skilled in cardiovascular genetics
families might experience relief from the reduction of un- have become an invaluable clinical asset, helping not
certainty when a genetic cause is discovered.468 Additional only to provide accurate recurrence risks but also to ob-
research is needed to fully understand the impact of ge- tain family and medical histories, facilitate appropriate
netic testing for congenital HD on individuals, especially genetic testing, interpret test results, make necessary
children, and their families, as well as to better appreci- subspecialty referrals, and provide attendant psychoso-
ate how patients evaluate these trade-offs when deciding cial support for patients and their families. Physicians
whether or not to undergo testing. with subspecialty training in medical genetics are trained
Even when the clinical and psychological benefits in dysmorphology, metabolism, monogenic conditions,
outweigh the risks, however, uptake of genetic testing genomics, and diagnostic testing and are able to gener-
for congenital HD can be limited if patients are con- ate a differential, determine a diagnostic evaluation ap-
cerned about the misuse of genetic information for proach, and provide specific management and treatment
discriminatory purposes. The 2008 Genetic Informa- recommendations for patient care. In addition, geneti-
tion Non-Discrimination Act (GINA) protects individuals cists can evaluate family members for other syndromic
in the United States from being discriminated against features and facilitate appropriate genetic testing or re-
by health insurers and employers because of a genetic ferrals. Studies have shown that genetics consultation
diagnosis.477 However, GINA does not prevent life, dis- increases the diagnostic rate of genetic syndromes in in-
ability, or long-term care insurers from using genetic fants in the cardiac intensive care unit, as well as in older
information to make coverage decisions. Although children with congenital HD seen for follow-up in a car-
there have been very few documented cases of genetic diac neurodevelopmental clinic.480,481 Single-site studies
discrimination, even before the passage of GINA,477 have shown underutilization of cytogenetic testing in in-
current regulatory uncertainty has the potential to fants with congenital HD, but multisite studies to address
negatively impact patients and families. A trustworthy genetic testing practices have not been performed.482
system that provides robust protection against genetic Carey et al47 found that pathogenic CNVs are identified

in >10% of single-ventricle forms of congenital HD and advancements in genetic testing have increased the di-
CLINICAL STATEMENTS
that patients with these cytogenetic abnormalities have agnostic yield. Studies of patients with congenital HD
AND GUIDELINES
more adverse outcomes. Dysmorphology evaluation is do not always apply the same criteria to distinguish
challenging in infants, and expanded testing identifies syndromic from nonsyndromic cases, and the age of
abnormalities missed even by trained dysmorphologists.47 patient evaluation influences assessment.
These findings support a more comprehensive, standard- In general, recurrence estimates are more precise
ized approach to genetic testing in infants with congeni- for syndromic than for isolated congenital HDs, be-
tal HD. Algorithms have been proposed based on expert cause genes and associated inheritance patterns for
recommendation; further evidence-based investigation is many congenital HD–associated monogenic conditions
necessary.13,483 Table 9 highlights indications for genetics are already known. Importantly, not all patients with a
involvement in patients with congenital HD. particular syndrome will present with structural heart
Genetic counseling services are valued by fami- defects, and the proportion who do can vary consider-
lies.25,484 In the prenatal setting, cardiovascular genetic ably depending on the specific diagnosis.13 The pres-
counseling is important for conveying information ence or severity of a congenital HD in a parent is often
about the use and limitations of genetic testing and for not predictive of the risk for offspring. The likelihood of
providing psychosocial support to the patient and fam- affected individuals reaching reproductive age or hav-
ily.485,486 Recent surveys of adult congenital HD popula- ing children (reproductive fitness) is related to the new
tions have demonstrated that a majority of patients lack mutation rate that is a common cause of syndromic
accurate understanding of their individual recurrence congenital HDs. As a result, some genetic syndromes
risk but that provision and recall of genetic information that are highly penetrant for congenital HD contribute
can be significantly improved by incorporating genet- less to the congenital HD burden in the next generation
ics providers into routine cardiovascular care.484,487 In than is the case for patients with isolated congenital
children, access to genetic services plays an important HD or less severe lesions. Epidemiological studies can
role in improving diagnostic yield, addressing ongoing underestimate the number of familial cases because of
health supervision needs of patients with genetic syn- the high rate of miscarriages of fetuses with congenital
dromes, and ensuring appropriate subspecialist refer- HDs and reproductive decisions to limit future pregnan-
ral.481 Unfortunately, the shortage of both geneticists cies in families with a child with a congenital HD.462
and genetic counselors limits more widespread integra- As genetic testing technologies have evolved to offer
higher resolution and higher diagnostic yields than those
tion of services within cardiology. Telemedicine services

are emerging in response to this need. Many centers provided by conventional chromosomal analyses, CNVs
are developing triage algorithms and testing new coun- have emerged as important causes of both syndromic
seling models. Genetic assistants are being piloted to and nonsyndromic congenital HDs. Moreover, an increas-
augment genetic counselor functions and expand ca- ing recognition of contributing environmental490 and epi-
pacity. Continued integration of genetic evaluation and genetic factors has revealed a previously unanticipated
genetic counseling are important components for im- breadth to congenital HD pathogenesis.13 Although all
proving utilization of increasingly comprehensive and mendelian inheritance patterns have been identified in
affordable genetic services. Furthermore, it is becoming families with congenital HDs, the empiric sibling or off-
increasingly important that practitioners in the care of spring recurrence risk across all types of congenital HDs
patients with congenital HD develop a level of comfort of 1% to 4% suggests that the majority of congenital
and expertise in genetic concepts and terminology. HDs have a multifactorial pathogenesis.491,492
With that in mind, the American Heart Association re- The study of groups of embryologically related car-
cently published a scientific statement on enhancing diac malformations has identified subclasses of congen-
provider literacy in cardiovascular genetics.415 ital HDs with strong familial clustering in first-degree
relatives, ranging from 3-fold to 80-fold compared
with the prevalence in the population.273,491 Heritabil-
Recurrence Risk ity rates of 70% to 90% support the strong genetic
On the basis of epidemiological studies such as the contribution for some types of congenital HDs.493–495
Baltimore-Washington Infant Study and the Danish Three classes of defects with the highest relative risk
national epidemiologic study, syndromic congenital of recurrence of the same heart defect phenotype are
HDs are thought to constitute at least 25% of all con- heterotaxy, with a relative risk of 79.1 (95% confidence
genital HDs.273,488,489 Identifying the underlying cause interval, 32.9–190); right ventricular outflow tract de-
of congenital HD in these cases is important for medi- fects, with a relative risk of 48.6 (95% confidence in-
cal management, surveillance, and communication of terval, 27.5–85.6); and left ventricular outflow tract
reproductive risks necessary for family planning. The obstructive defects, with a relative risk of 12.9 (95%
distinction between syndromic and nonsyndromic, or confidence interval, 7.48–22.2).273 These findings are
isolated, congenital HD can be subtle. Technological important because they alter information on recurrence

Table 9. Indications for Consultation With Genetics Professionals
CLINICAL STATEMENTS
Reason for Referral Examples/Features Care Provider
AND GUIDELINES
Genetic testing for known familial variant Facilitation of genetic testing for infant born Genetic counselor
to a parent with long-QT syndrome Geneticist
Pretest or posttest genetic counseling Provision of educational resources and Genetic counselor
anticipatory guidance after a positive genetic Geneticist
test result
Preconception or prenatal genetic counseling Parent with congenital HD interested in Genetic counselor
regarding recurrence risk discussing recurrence risk for offspring before
pursuing pregnancy
Prenatal genetic counseling regarding fetal Discussion of prenatal genetic testing options Genetic counselor
anomaly for fetus with congenital HD
Family history of congenital HD, other Three generations with AVSD Genetic counselor
malformations, learning disability, or multiple Geneticist
miscarriages
Isolated congenital HD highly associated with Interrupted aortic arch, truncus arteriosus, Genetic counselor
specific syndromes etc Geneticist
Suspicion of an underlying genetic syndrome Intellectual disability; learning disability; Genetic counselor
autism; other cognitive impairment Geneticist
Dysmorphic features
Short stature
Congenital anomalies
Endocrine abnormalities
Sensory deficits such as hearing loss or visual
impairment
Neurological deficits
AVSD indicates atrioventricular septal defect; and HD, heart disease.
risk based on congenital HD subtype. In the case of mains one of the most consistently identified risk fac-
left ventricular outflow tract obstructive defect, it also tors for identifying congenital HD prenatally.
has implications for cardiac screening in family mem-
bers. Not all families show evidence of similar types of

congenital HDs, and familial clustering of discordant Preimplantation Genetic Diagnosis
congenital HDs has also been documented, which sug- Preimplantation genetic diagnosis is an assisted reproduc-
gests that common genetic pathways might underlie a tive technology that allows screening for a genetic con-
spectrum of CHDs496 (reviewed in Landis and Ware462). dition after in vitro fertilization and before implantation.
Because congenital HDs are so common, the majority Preimplantation genetic diagnosis can be used in couples
of cases occur in individuals without a family history at risk for passing on a genetic condition, including carri-
despite high heritability. Although the incidence of con- ers of X-linked disorders, single-gene disorders, and chro-
genital HDs appears to be similar in most populations, mosomal disorders.503,504 Prenatal genetic counselors pro-
there are some specific types of congenital HD that vide information on risks and benefits of the procedure
show important differences.494,497,498 In addition, there and work together with reproductive endocrinologists.
is an increased rate of congenital HDs in populations Preimplantation genetic diagnosis has been used success-
with increased consanguinity, often attributed to auto- fully in >100 genetic conditions, including inherited car-
somal recessive variants.462 Studies have examined rates diac conditions such as Marfan syndrome, HCM, dilated
of recurrence among first-degree relatives of patients cardiomyopathy, and muscular dystrophies.505 Preimplan-
with isolated congenital HDs and collectively suggest an tation genetic diagnosis requires a clear understanding of
overall risk of 5% to 10% for any congenital HD when the cause of a genetic condition within a family.
either 1 parent or >2 siblings are affected499–501 or ≈3%
with 1 affected child (Table 10; reviewed in Cowan and
Ware13). Risk estimates for individual defects vary but Prenatal Screening
are generally estimated in the range of 2% to 6%, with Until 2011, noninvasive prenatal screening consisted
higher risk afforded to children of affected mothers mainly of measurements of maternal serum analytes
(Table 10).13 These figures are low relative to congenital and ultrasonography. These tests have a false-positive
HDs with demonstrable monogenic inheritance but can rate of 5% and detection rates of 50% to 95%.506
still have potentially important implications, particularly These techniques were used to provide families with
with respect to future reproductive decision making information to optimize their pregnancy outcomes. In
and prospective screening of presumably unaffected 2011, fcfDNA screening (also referred to as noninvasive
family members.13 Family history of congenital HD re- prenatal testing, NIPT, or noninvasive prenatal diagnos-

Table 10. Recurrence Risks for Isolated (Nonsyndromic) Congenital HDs Expanded fcfDNA screening for sex chromosome
CLINICAL STATEMENTS
Father Mother 1 Sibling 2 Siblings anomalies and CNVs is also currently offered by some
AND GUIDELINES
Defect Affected, % Affected, % Affected, % Affected, % laboratories. fcfDNA screening for sex chromosome ab-
ASD 1.5–3.5 4–6 2.5–3 8 normalities is less accurate than autosomal aneuploidies
AVSD 1–4.5 11.5–14 3–4 10 because of the potential for maternal X-chromosome bio-
VSD 2–3.5 6–10 3 10
logical variation. Clinically significant CNVs are rare in the
population, and the positive predictive value is much lower
AS 3–4 8–18 2 6
than for whole chromosome aneuploidy. Therefore, at this
PVS 2–3.5 4–6.5 2 6
time, the ACMG guidelines only recommend providing in-
TOF 1.5 2–2.5 2.5–3 8 formation on the availability of expanded use of fcfDNA
CoA 2–3 4–6.5 2 6 screening for sex chromosome abnormalities and CNVs.
PDA 2–2.5 3.5–4 3 10 If fcfDNA screening should identify a CNV or sex chromo-
HLHS 21495 2–9* 6 some abnormality, then invasive diagnostic testing by cho-
TGA 2502
1.5 5
rionic villus sampling or amniocentesis is recommended by
the ACMG guidelines to confirm the diagnosis.
L-TGA 3–5 5–6 NR
If fetal ultrasounds or echocardiograms are abnormal,
EA NR 6502 1 3
the American College of Obstetricians and Gynecologists
TrA NR NR 1 3 and the Society of Maternal Fetal Medicine recommend
TA NR NR 1 3 prenatal CMA if invasive prenatal diagnosis is performed.
PA NR NR 1 3 Informed consent and comprehensive pretest and post-
test genetic counseling are necessary.509 Establishing a di-
Data from references 499–501 except where otherwise noted. Merged
cells indicate recurrence when 1 parent is affected, irrespective of sex, and are agnosis before delivery can facilitate medical care plans.
used in the absence of sex-stratified risks. AS indicates aortic stenosis; ASD,
atrial septal defect; AVSD, atrioventricular septal defect; CoA, coarctation of
the aorta; EA, Ebstein’s anomaly; HD, heart disease; HLHS, hypoplastic left Indications for Fetal Echocardiography
heart syndrome; L-TGA, congenitally corrected transposition of the great
arteries; NR, not reported/insufficient data; PA, pulmonary atresia; PDA, Fetal echocardiography is now widely used to detect,
patent ductus arteriosus; PVS, pulmonary valve stenosis; TA, tricuspid atresia; characterize, and help manage congenital cardiac mal-
TGA, d-transposition of the great arteries; TOF, tetralogy of Fallot; TrA, truncus
arteriosus; and VSD, ventricular septal defect. formations. Indications for performing a fetal echocar-
diogram have been formulated and were described in
*Eight percent recurrence risk for HLHS; up to 22% recurrence risk for any
congenital HD.495 a recent American Heart Association scientific state-
Reprinted from Cowan and Ware13 with permission from Elsevier. Copyright
© 2015, Elsevier Inc. ment.510 In addition to the further evaluation of con-
cerns raised by screening ultrasounds performed as
part of standard obstetrical care, specific risk factors
tic screening) became clinically available.507 This new for congenital HDs, including those related to maternal
testing uses bioinformatics algorithms and NGS of fetal health (eg, diabetes mellitus and autoimmune condi-
DNA fragments present in maternal serum to estimate tions), maternal drug or toxin exposure, abnormalities
the probability of chromosome aneuploidy in the fetus. of umbilical-placental development (eg, single umbili-
The ACMG has provided guidelines for the conditions cal artery and monochorionic twinning), and known,
for use of fcfDNA screening for aneuploidy.506 These in- suspected, or potentially heritable genetic conditions,
clude providing up-to-date genetic counseling concern- have achieved sufficient Classification of Recommenda-
ing the new technique so that families can select diag- tions (Class) and Level of Evidence (Level) to warrant
nostic or screening options according to their personal performance of a fetal echocardiogram. As it pertains
goals. The ACMG recommends informing all pregnant to known, suspected, or potentially heritable genetic
women that fcfDNA screening is the most sensitive conditions, performance of fetal echocardiograms
noninvasive screening for aneuploidies such as trisomy in pregnancies in which the mother, father, or sibling
21, trisomy 18, and trisomy 13. One review analysis, has a congenital cardiac defect have been assigned a
published in 2016, found the pooled sensitivities for Class I/Level B indication, which means that it should
fcfDNA screening to be 99.3% for trisomy 21, 97.4% be performed and that evidence from limited studies
for trisomy 18, and 97.4% for trisomy 13.508 If a positive is supportive. As might be expected, the strength of
screen test result is obtained, then the couple should be Classification of Recommendation is reduced in more
offered diagnostic testing. Screening for other autoso- distantly related family members: with congenital HD
mal aneuploidies besides trisomy 21, 18, and 13 is not in a second-degree family member, a fetal echocardio-
yet recommended. The ACMG guidelines recommend gram may be considered (Class IIb); with the nearest
offering fcfDNA screening to high-risk families (those relative(s) with congenital HD being a third-degree or
with advanced maternal age or fetal anomalies on ul- more distant family member(s), a fetal echocardiogram
trasound), as well as lower-risk families. is not recommended (Class III). Similarly, fetal echocar-

diograms should be performed in pregnancies in which be determined by (1) studies with larger numbers of
CLINICAL STATEMENTS
there is a heritable condition in a first-degree family individuals with congenital HD using existing technolo-
AND GUIDELINES
member that is associated with a risk of heart defects gies (eg, WES), as well as application of other “omic”
(such as NS) even if the affected relative does not have a approaches (eg, whole genome sequencing, DNA
heart defect. However, for heritable cardiac conditions methylation analysis, RNA sequencing with discarded
with a later onset of manifestation (such as HCM, Mar- cardiac tissues, and increasingly advanced bioinformat-
fan syndrome, or Loeys-Dietz syndrome), fetal echocar- ics analyses), and (2) new research with animal and cell
diography may not be necessary if screening obstetrical models to utilize innovative molecular technologies
ultrasound does not demonstrate any abnormalities. to study RNA expression, splicing alterations, signal-
Demonstration of noncardiac abnormalities suggestive ing technology, transcription factor fate, and epigen-
of a potential genetic syndrome, teratogen, or malforma- etic processes.13 Current induced pluripotent stem cell
tion sequence is also an important indication to perform and gene-editing approaches have enabled the study
a fetal echocardiogram. The risk of a concomitant con- of human cardiomyocytes relevant for congenital HD,
genital HD in the fetus with another anomaly varies, but whereas advances in generating tissues and organoids
abnormalities of the central nervous system (microcephaly, could allow the study of genetic variation relevant to
hydrocephaly, agenesis of the corpus callosum, or other congenital HD in contexts more relevant physiologically
structural abnormalities), gastrointestinal system/abdomen and developmentally in the near future.
(esophageal or duodenal atresia, diaphragmatic hernia, or
omphalocele/gastroschisis), kidney (structural abnormali-
ties), craniofacial structures, or limbs should prompt refer- ARTICLE INFORMATION
ral for evaluation with a fetal echocardiogram.511 In addi- The American Heart Association makes every effort to avoid any actual or po-
tential conflicts of interest that may arise as a result of an outside relationship or
tion, unexplained fetal growth delay512 or features such a personal, professional, or business interest of a member of the writing panel.
as increased nuchal translucency513 are associated with a Specifically, all members of the writing group are required to complete and
significant risk of congenital cardiac abnormalities and are submit a Disclosure Questionnaire showing all such relationships that might be
perceived as real or potential conflicts of interest.
indications for performing a fetal echocardiogram even if This statement was approved by the American Heart Association Science
fcfDNA screening does not detect a chromosomal abnor- Advisory and Coordinating Committee on April 13, 2018, and the Ameri-
mality. Recent data indicate that of fetuses with increased can Heart Association Executive Committee on June 25, 2018. A copy of
the document is available at http://professional.heart.org/statements by using
nuchal translucency and normal karyotype, ≈10% had either “Search for Guidelines & Statements” or the “Browse by Topic” area.
positive testing for NS.514 Furthermore, persistence of nu-
To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@

chal translucency into the second trimester as nuchal ede- wolterskluwer.com.
The American Heart Association requests that this document be cited as
ma identified a high prevalence of NS (11 of 15 cases).515 follows: Pierpont ME, Brueckner M, Chung WK, Garg V, Lacro RV, McGuire
AL, Mital S, Priest JR, Pu WT, Roberts A, Ware SM, Gelb BD, Russell MW; on
behalf of the American Heart Association Council on Cardiovascular Disease
SUMMARY in the Young; Council on Cardiovascular and Stroke Nursing; and Council on
Genomic and Precision Medicine. Genetic basis for congenital heart disease: re-
Our understanding of the role of genetics in the patho- visited: a scientific statement from the American Heart Association. Circulation.
genesis of congenital HD has advanced at a rapid pace 2018;138:e653–e711. DOI: 10.1161/CIR.0000000000000606.
The expert peer review of AHA-commissioned documents (eg, scientific
over the past 10 to 15 years. The availability of new statements, clinical practice guidelines, systematic reviews) is conducted by the
molecular techniques has facilitated gene discoveries AHA Office of Science Operations. For more on AHA statements and guidelines
that have changed the medical and cardiological care development, visit http://professional.heart.org/statements. Select the “Guide-
lines & Statements” drop-down menu, then click “Publication Development.”
of many individuals with congenital HD. CNV detection Permissions: Multiple copies, modification, alteration, enhancement, and/
and NGS gene panels are now in widespread use by or distribution of this document are not permitted without the express permis-
geneticists, genetic counselors, and cardiologists for ac- sion of the American Heart Association. Instructions for obtaining permission
are located at https://www.heart.org/permissions. A link to the “Copyright
curate diagnosis of congenital HD patients. Cardiovas- Permissions Request Form” appears in the second paragraph (https://www.
cular genetics clinics are now available in many major heart.org/en/about-us/statements-and-policies/copyright-request-form).
medical centers in the United States. Accurate diagnosis
of congenital HD pathogenesis is allowing for determi- Acknowledgments
nation of familial recurrence risks, providing reproduc- The authors thank Patricia Buenzle, University of Minnesota, for her assistance
tive options, identifying extracardiac manifestations of in the preparation of the manuscript.
the genetic diagnosis that could affect clinical care, and

improving long-term medical decisions in the care of Sources of Funding
congenital HD. Additionally, WES is now used in many The authors acknowledge support by the following grants: U01 HL098163 (Wen-
dy Chung), R01 HL109758 (Vidu Garg), R35 HL135742 and UM1 HL098123
centers for those congenital HD patients suspected of (Bruce Gelb), U01 HG006500, U19 HD077671, and U01 HG006485 (Amy Mc-
having a genetic disorder when no pathogenetic diag- Guire), Heart and Stroke Foundation of Canada Chair in Cardiovascular Science
nosis was obtained by other molecular testing. (Seema Mital), R00 HL130523 (James Priest), 2UM1 HL098166, R01 HL 128694,
R01 HL116461, and 16CSA28750006 AHA (William T. Pu), U10 HL109737 (Mark
The future of understanding of other genetic fac- Russell), 1 P01 HL134599-01, and March of Dimes Research Foundation 6-FY16-
tors important in the causation of congenital HD will 176, R01 HL1114590-05, and AHA 13EIA 13460001 (Stephanie Ware).

Disclosures
CLINICAL STATEMENTS
AND GUIDELINES
Writing Group Disclosures
Speakers’ Consultant/
Writing Group Other Research Bureau/ Expert Ownership Advisory
Member Employment Research Grant Support Honoraria Witness Interest Board Other
Mary Ella Pierpont University of None None None None None None None
Minnesota
Bruce D. Gelb Icahn School of None GeneDx, LabCorp, None None None None None
Medicine at Mount Prevention Genetics
Sinai (royalties for
Noonan syndrome
genetic testing)*
Mark W. Russell University of None None None None None None None
Michigan
Martina Brueckner Yale School of NIH (principal None None None None None None
Medicine investigator, SC
member of NIH
grants)†
Wendy K. Chung Columbia University None None None None None None None
Vidu Garg Nationwide Children’s NIH/NHLBI (grant None None None None None None
Hospital/Ohio State support that ended
University Center 7/31/2017)†
for Cardiovascular
Research/Pediatrics
Ronald V. Lacro Boston Children’s None None None None None None None
Hospital
Amy L. McGuire Baylor College of None None None None None None None
Medicine
Seema Mital The Hospital for Sick None None None None None None None
Children
James R. Priest Stanford University None None None None None None None
School of Medicine
William T. Pu Boston Children’s None None None None None None None
Hospital
Amy Roberts Children’s Hospital None None None None None None None
Boston
Stephanie M. Ware Indiana University None None None None None None None
School of Medicine
This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on
the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if
(a) the person receives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the
voting stock or share of the entity or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than
“significant” under the preceding definition.
*Modest.
†Significant.
Reviewer Disclosures
Other Speakers’ Consultant/

Research Bureau/ Expert Ownership Advisory
Reviewer Employment Research Grant Support Honoraria Witness Interest Board Other
Maria Grazia CNR, Institute of Clinical None None None None None None None
Andreassi Physiology (Italy)
Paul Grossfeld UCSD AHA GIA (AHA None None None None None None
Grant-in-Aid ended
December, 2017)*
Julien I. E. University of California None None None None None None None
Hoffman
This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure
Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $10 000 or more
during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns
$10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Significant.

APPENDIX
CLINICAL STATEMENTS
Appendix. Chromosomal Aneuploidies and Copy Number Variants Associated With Congenital HD1,177
AND GUIDELINES
Percent With
Chromosome Change Main Features Congenital HD Heart Anomaly References
I. Aneuploidies (identifiable by routine karyotype)
Trisomy 8 mosaicism Widely spaced eyes, broad nasal bridge, small jaw, 25 VSD, PDA, CoA, PVS, TAPVR, TrA 516
high arched palate, cryptorchidism, renal anomalies,
skeletal/vertebral anomalies
Trisomy 9/mosaicism Prenatal and postnatal growth retardation, 65 PDA, LSVC, VSD, TOF/PA, DORV 517
microcephaly, deep-set eyes, low-set ears, severe
Trisomy 13 (Patau Cleft lip and palate, scalp defects, hypotelorism, 57–80 ASD, VSD, PDA, HLHS, laterality 518, 519
syndrome) microphthalmia or anophthalmia, colobomata of irides, defects, atrial isomerism
holoprosencephaly, microcephaly, deafness, severe
intellectual disability, rib abnormalities, polydactyly,
omphalocele, renal abnormalities, hypospadias,
cryptorchidism, uterine abnormalities
Trisomy 18 (Edwards IUGR, polyhydramnios, micrognathia, short sternum, 80–90 ASD, VSD, PDA, TOF, DORV, 518
syndrome) hypertonia, rocker-bottom feet, overlapping fingers TGA, CoA, BAV, BPV, polyvalvular
and toes, TEF, CDH, omphalocele, renal anomalies, nodular dysplasia
biliary atresia, severe intellectual disability
Trisomy 21 (Down Hypotonia, hyperextensibility, epicanthal folds, up- 40–50 AVSD, VSD, ASD, (TOF, TGA less 33, 37
syndrome) slanting palpebral fissures, single palmar transverse common)
crease, clinodactyly of fifth finger, brachydactyly,
variable intellectual disability, premature aging
Monosomy X (Turner Lymphedema of hands and feet, widely spaced 23–35 CoA, BAV, AS, HLHS, aortic 41, 520
syndrome, 45,X) hypoplastic nipples, webbed neck, primary dissection
amenorrhea, short stature, normal intelligence or mild
learning disability
II. Chromosome abnormalities (identifiable on karyotype and more recently using chromosomal microarray)
3p25 deletion Prenatal and postnatal growth deficiency, polydactyly, 33 VSD, AVSD, 521
microcephaly, intellectual disability, renal anomalies tricuspid atresia
Deletion 4p16.3 (Wolf- Microcephaly, widely spaced eyes, broad nasal bridge 50–65 ASD, VSD, PDA, LSVC, aortic 522
Hirschhorn syndrome) (Greek helmet appearance), downturned mouth, atresia, dextrocardia, TOF,
micrognathia, preauricular skin tags, severe intellectual tricuspid atresia
disability, seizures, growth retardation
Deletion 4q Growth retardation, intellectual disability, cleft palate, 50 VSD, PDA, AS, ASD, TOF, CoA 523
broad nasal bridge, micrognathia, abnormal ears,
genitourinary defects
Deletion 5p (cri-du-chat) Catlike cry, prenatal and postnatal growth retardation, 30–60 VSD, ASD, PDA 524, 525
round face, widely spaced eyes, epicanthal folds, single
palmar transverse crease, severe intellectual disability
Deletion 9p syndrome Craniosynostosis, trigonocephaly, up-slanting palpebral 35–50 VSD, PDA, PVS 526
fissures, abnormal ear pinnae, scoliosis, micropenis,
cryptorchidism, intellectual disability
Deletion 10p Frontal bossing, short down-slanting palpebral fissures, 42 BAV, ASD, VSD, PDA, PVS, CoA 527
small low-set ears, micrognathia, cleft palate, short
neck, urinary/genital and upper-limb anomalies
Duplication 10q24-qter Prenatal growth retardation, intellectual disability, 50 AVSD, VSD 528
camptodactyly, renal anomalies, cryptorchidism
III. Copy number variants (identifiable by chromosomal microarray)
1p36 deletion Growth deficiency, intellectual disability, microcephaly, 70 PDA, VSD, ASD, BAV, Ebstein 99
deep-set eyes, low-set ears, hearing loss, hypotonia, anomaly, noncompaction
seizures, CNS defects, genital anomalies cardiomyopathy
1q21.1 deletion Short stature, microcephaly, colobomas, N/A PDA, VSD, ASD, TrA, TOF 102, 105
microphthalmia, hearing loss, seizures, mild
intellectual disability, autism spectrum disorder, skeletal
malformations
1q21.1 duplication Large head size, hemivertebrae, variable intellectual N/A TOF, TGA, PVS 105
disability, variable autistic features, hypospadias,
clubfoot
(Continued )

Appendix. Continued
CLINICAL STATEMENTS
Percent With
AND GUIDELINES
Chromosome Change Main Features Congenital HD Heart Anomaly References

III. Copy number variants (identifiable by chromosomal microarray) (Continued)
1q41q42 microdeletion Growth retardation, intellectual disability, 40 BAV, ASD, VSD, TGA 529
microcephaly, diaphragmatic hernia, seizures, short
limbs
1q43q44 microdeletion Prenatal and postnatal growth retardation, intellectual N/A VSD, CoA, HLHS 530
disability, limited speech, microcephaly, deep-set eyes,
microcephaly, large low-set ears, cleft palate, agenesis
of corpus callosum
2q31.1 microdeletion Prenatal and postnatal growth retardation, large 25 VSD, ASD, PDA 531
ventricles, microcephaly, narrow forehead down-
slanting palpebral fissures, cleft palate/cleft lip, limb
defects, hypoplastic genitalia
2q37 microdeletion Short stature, obesity, intellectual disability, sparse hair, 30 VSD, ASD, CoA, hypoplastic 532, 533
arched eyebrows, epicanthal folds, thin upper lip, small aortic arch
hands and feet, clinodactyly
Deletion Infantile hypercalcemia, skeletal and renal anomalies, 53–85 Supravalvar AS and PS, PPS 41, 74
7q11.23(Williams- cognitive deficits, “social” personality, elfin facies
Beuren syndrome)
8p23.1 deletion Microcephaly, growth retardation, deep-set eyes, 50–75 AVSD, PVS, VSD, TOF 112
malformed ears, small chin, genital anomalies in males,
9q34.3 Subtelomeric Short stature, obesity, intellectual disability, 31–44 ASD, VSD, TOF, pulmonary 534
deletion (Kleefstra microcephaly, behavior abnormalities, brain anomalies, arterial stenosis
syndrome) hypertelorism, arched eyebrows, midface hypoplasia
Deletion 11q (Jacobsen Growth retardation, developmental delay, 56 HLHS, AS, VSD, CoA, Shone’s 91, 92
syndrome) thrombocytopenia, platelet dysfunction, widely spaced complex
eyes, strabismus, broad nasal bridge, thin upper lip,
prominent forehead, intellectual disability
15q24 microdeletion Prenatal and postnatal growth retardation, intellectual 40 PDA, pulmonary arterial stenosis, 535
disability, abnormal corpus callosum, microcephaly, PVS

high forehead, down-slanting palpebral fissures,
tapered eyebrows, abnormal ear pinnae, hearing loss,
hypospadias, scoliosis, coloboma, strabismus
16p11.2p12.2 Hypotonia, intellectual disability, long narrow face, 33 TOF, BAV, pulmonary atresia 536
microdeletion deep-set eyes, low-set malformed ears
17q21 microdeletion Abnormal hair pigmentation, up-slanting palpebral 27 PVS, ASD, VSD, BAV 537
fissures, epicanthal folds, bulbous nasal tip, strabismus,
ptosis, long slender fingers, hip dislocation, renal
anomalies, spine deformities, cryptorchidism, global
developmental delay
Deletion 20p12 (Alagille Bile duct paucity, cholestasis, skeletal or ocular 85–94 Peripheral PA hypoplasia, TOF, 538
syndrome) anomalies, broad forehead, widely spaced eyes, PVS (left-sided heart lesions and
underdeveloped mandible septal defects less common)
22q11.2DS (DiGeorge, Hypertelorism, micrognathia, low-set posteriorly 75 IAA-B, TrA, isolated aortic arch 60, 70
velocardiofacial, and rotated ears, thymic and parathyroid hypoplasia, anomalies, TOF, conoventricular
conotruncal anomaly hypocalcemia, feeding/speech/learning/behavioral VSD
face syndrome) disorders, immunodeficiency, palate/skeletal/renal
anomalies, learning disability
22q11.2 duplication Very variable phenotype, some with velopharyngeal 15 TOF, HLHS, VSD, PVS, TrA 66
insufficiency, cleft palate, hearing loss, minor facial
anomalies, mild learning disability to normal learning
ability, hypotonia, scoliosis, frequent infections
22q13 microdeletion Normal growth, intellectual disability, dolichocephaly, >25 PDA, VSD, ASD, TAPVR 539
(Phelan-McDermid dysplastic ears, pointed chin, large fleshy hands,
syndrome) hypotonia
22q11.2DS indicates 22q11.2 deletion syndrome; AS, aortic stenosis; ASD, atrial septal defect; AVSD, atrioventricular septal defect; BAV, bicuspid aortic valve;
BPV, bicuspid pulmonary valve; CDH, congenital diaphragmatic hernia; CoA, coarctation of the aorta; DORV, double-outlet right ventricle; HD, heart disease; HLHS,
hypoplastic left heart syndrome; IAA-B, interrupted aortic arch type B; IUGR, intrauterine growth retardation; LSVC, persistent left superior vena cava; N/A, not
available; PA, pulmonary artery; PDA, patent ductus arteriosus; PPS, peripheral pulmonary stenosis; PS, pulmonary stenosis; PVS, pulmonic valve stenosis; TAPVR,
total anomalous pulmonary venous return; TEF, tracheoesophageal fistula; TGA, d-transposition of the great arteries; TOF, tetralogy of Fallot; TOF/PA, tetralogy of
Fallot with pulmonary atresia; TrA, truncus arteriosus; and VSD, ventricular septal defect.

REFERENCES sequencing: single-gene, gene panel, or exome/genome sequencing.
CLINICAL STATEMENTS
Genet Med. 2015;17:444–451. doi: 10.1038/gim.2014.122
1. Pierpont ME, Basson CT, Benson DW Jr, Gelb BD, Giglia TM, Goldmuntz E,
AND GUIDELINES
19. Martin CL, Warburton D. Detection of chromosomal aberrations in clinical
McGee G, Sable CA, Srivastava D, Webb CL. Genetic basis for congenital practice: from karyotype to genome sequence. Annu Rev Genomics Hum
heart defects: current knowledge: a scientific statement from the Ameri- Genet. 2015;16:309–326. doi: 10.1146/annurev-genom-090413-025346
can Heart Association Congenital Cardiac Defects Committee, Council on 20. Bi W, Borgan C, Pursley AN, Hixson P, Shaw CA, Bacino CA, Lalani SR,
Cardiovascular Disease in the Young. Circulation. 2007;115:3015–3038. Patel A, Stankiewicz P, Lupski JR, Beaudet AL, Cheung SW. Comparison of
doi: 10.1161/CIRCULATIONAHA.106.183056
chromosome analysis and chromosomal microarray analysis: what is the
2. Paterick TE, Humphries JA, Ammar KA, Jan MF, Loberg R, Bush M, Khand-
value of chromosome analysis in today’s genomic array era? Genet Med.
heria BK, Tajik AJ. Aortopathies: etiologies, genetics, differential diag-
2013;15:450–457. doi: 10.1038/gim.2012.152
nosis, prognosis and management. Am J Med. 2013;126:670–678. doi:
21. Priest JR. A primer to clinical genome sequencing. Curr Opin Pediatr.
10.1016/j.amjmed.2013.01.029
2017;29:513–519. doi: 10.1097/MOP.0000000000000532
3. Priori SG, Wilde AA, Horie M, Cho Y, Behr ER, Berul C, Blom N, Brugada
22. McKenna A, Hanna M, Banks E, Sivachenko A, Cibulskis K, Kernytsky
J, Chiang CE, Huikuri H, Kannankeril P, Krahn A, Leenhardt A, Moss A,
A, Garimella K, Altshuler D, Gabriel S, Daly M, DePristo MA. The Ge-
Schwartz PJ, Shimizu W, Tomaselli G, Tracy C. HRS/EHRA/APHRS expert
nome Analysis Toolkit: a MapReduce framework for analyzing next-gen-
consensus statement on the diagnosis and management of patients with
eration DNA sequencing data. Genome Res. 2010;20:1297–1303. doi:
inherited primary arrhythmia syndromes. Heart Rhythm. 2013;10:1932–
10.1101/gr.107524.110
1963. doi: 10.1016/j.hrthm.2013.05.014
23. Dewey FE, Grove ME, Priest JR, Waggott D, Batra P, Miller CL, Wheeler
4. Lee TM, Hsu DT, Kantor P, Towbin JA, Ware SM, Colan SD, Chung WK,
M, Zia A, Pan C, Karzcewski KJ, Miyake C, Whirl-Carrillo M, Klein TE,
Jefferies JL, Rossano JW, Castleberry CD, Addonizio LJ, Lal AK, Lamour
Datta S, Altman RB, Snyder M, Quertermous T, Ashley EA. Sequence to
JM, Miller EM, Thrush PT, Czachor JD, Razoky H, Hill A, Lipshultz
medical phenotypes: a framework for interpretation of human whole
SE. Pediatric cardiomyopathies. Circ Res. 2017;121:855–873. doi:
genome DNA sequence data. PLoS Genet. 2015;11:e1005496. doi:
10.1161/CIRCRESAHA.116.309386
10.1371/journal.pgen.1005496
5. Vacanti G, Maragna R, Priori SG, Mazzanti A. Genetic causes of sudden
24. Tester DJ, Benton AJ, Train L, Deal B, Baudhuin LM, Ackerman MJ.
cardiac death in children: inherited arrhythmogenic diseases. Curr Opin
Prevalence and spectrum of large deletions or duplications in the ma-
Pediatr. 2017;29:552–559. doi: 10.1097/MOP.0000000000000537
jor long QT syndrome-susceptibility genes and implications for long QT
6. van der Linde D, Konings EE, Slager MA, Witsenburg M, Helbing WA,
syndrome genetic testing. Am J Cardiol. 2010;106:1124–1128. doi:
Takkenberg JJ, Roos-Hesselink JW. Birth prevalence of congenital heart
10.1016/j.amjcard.2010.06.022
disease worldwide: a systematic review and meta-analysis. J Am Coll Car-
25. Arscott P, Caleshu C, Kotzer K, Kreykes S, Kruisselbrink T, Orland K,
diol. 2011;58:2241–2247. doi: 10.1016/j.jacc.2011.08.025
Rigelsky C, Smith E, Spoonamore K, Larsen Haidle J, Marvin M, Acker-
7. Hoffman JI, Kaplan S. The incidence of congenital heart disease. J Am Coll
man MJ, Hadi A, Mani A, Ommen S, Cherny S. A case for inclusion of
Cardiol. 2002;39:1890–1900.
8. Wren C. The epidemiology of cardiovascular malformations. In: Moller JH, genetic counselors in cardiac care. Cardiol Rev. 2016;24:49–55. doi:
ed. Pediatric Cardiovascular Medicine. 2nd ed. West Sussex, UK: Blackwell 10.1097/CRD.0000000000000081
Publishing; 2012: 268–275. 26. Bowdin S, Gilbert A, Bedoukian E, Carew C, Adam MP, Belmont J, Bern-
9. Marelli AJ, Ionescu-Ittu R, Mackie AS, Guo L, Dendukuri N, Kaouache hardt B, Biesecker L, Bjornsson HT, Blitzer M, D’Alessandro LC, Deardorff
M. Lifetime prevalence of congenital heart disease in the general MA, Demmer L, Elliott A, Feldman GL, Glass IA, Herman G, Hindorff L,
population from 2000 to 2010. Circulation. 2014;130:749–756. doi: Hisama F, Hudgins L, Innes AM, Jackson L, Jarvik G, Kim R, Korf B, Led-
better DH, Li M, Liston E, Marshall C, Medne L, Meyn MS, Monfared N,
10.1161/CIRCULATIONAHA.113.008396
10. Larson EW, Edwards WD. Risk factors for aortic dissection: a necropsy Morton C, Mulvihill JJ, Plon SE, Rehm H, Roberts A, Shuman C, Spin-
study of 161 cases. Am J Cardiol. 1984;53:849–855. ner NB, Stavropoulos DJ, Valverde K, Waggoner DJ, Wilkens A, Cohn RD,
11. Steinberger J, Moller JH, Berry JM, Sinaiko AR. Echocardiographic di- Krantz ID. Recommendations for the integration of genomics into clinical
agnosis of heart disease in apparently healthy adolescents. Pediatrics. practice. Genet Med. 2016;18:1075–1084. doi: 10.1038/gim.2016.17
2000;105(pt 1):815–818. 27. Goldfeder RL, Priest JR, Zook JM, Grove ME, Waggott D, Wheeler MT,
12. Tutar E, Ekici F, Atalay S, Nacar N. The prevalence of bicuspid aortic valve Salit M, Ashley EA. Medical implications of technical accuracy in genome
in newborns by echocardiographic screening. Am Heart J. 2005;150:513– sequencing. Genome Med. 2016;8:24. doi: 10.1186/s13073-016-0269-0
515. doi: 10.1016/j.ahj.2004.10.036 28. Dewey FE, Grove ME, Pan C, Goldstein BA, Bernstein JA, Chaib H, Merker
13. Cowan JR, Ware SM. Genetics and genetic testing in congenital heart dis- JD, Goldfeder RL, Enns GM, David SP, Pakdaman N, Ormond KE, Caleshu
ease. Clin Perinatol. 2015;42:373–393, ix. doi: 10.1016/j.clp.2015.02.009 C, Kingham K, Klein TE, Whirl-Carrillo M, Sakamoto K, Wheeler MT, Butte
14. Jin SC, Homsy J, Zaidi S, Lu Q, Morton S, DePalma SR, Zeng X, Qi H, AJ, Ford JM, Boxer L, Ioannidis JP, Yeung AC, Altman RB, Assimes TL,
Chang W, Sierant MC, Hung WC, Haider S, Zhang J, Knight J, Bjornson Snyder M, Ashley EA, Quertermous T. Clinical interpretation and implica-
RD, Castaldi C, Tikhonoa IR, Bilguvar K, Mane SM, Sanders SJ, Mital S, tions of whole-genome sequencing. JAMA. 2014;311:1035–1045. doi:
Russell MW, Gaynor JW, Deanfield J, Giardini A, Porter GA Jr, Srivastava D, 10.1001/jama.2014.1717
Lo CW, Shen Y, Watkins WS, Yandell M, Yost HJ, Tristani-Firouzi M, New- 29. Gil MM, Accurti V, Santacruz B, Plana MN, Nicolaides KH. Analysis of
burger JW, Roberts AE, Kim R, Zhao H, Kaltman JR, Goldmuntz E, Chung cell-free DNA in maternal blood in screening for aneuploidies: updated
WK, Seidman JG, Gelb BD, Seidman CE, Lifton RP, Brueckner M. Contribu- meta-analysis. Ultrasound Obstet Gynecol. 2017;50:302–314. doi:
tion of rare inherited and de novo variants in 2,871 congenital heart dis- 10.1002/uog.17484
ease probands. Nat Genet. 2017;49:1593–1601. doi: 10.1038/ng.3970 30. Grace MR, Hardisty E, Dotters-Katz SK, Vora NL, Kuller JA. Cell-free DNA
15. International Human Genome Sequencing Consortium. Finishing the eu- screening: complexities and challenges of clinical implementation. Obstet
chromatic sequence of the human genome. Nature. 2004;431:931–945. Gynecol Surv. 2016;71:477–487. doi: 10.1097/OGX.0000000000000342
16. Schneider VA, Graves-Lindsay T, Howe K, Bouk N, Chen HC, Kitts PA, Mur- 31. Merker JD, Wenger AM, Sneddon T, Grove M, Zappala Z, Fresard L,
phy TD, Pruitt KD, Thibaud-Nissen F, Albracht D, Fulton RS, Kremitzki M, Waggott D, Utiramerur S, Hou Y, Smith KS, Montgomery SB, Wheeler
Magrini V, Markovic C, McGrath S, Steinberg KM, Auger K, Chow W, Col- M, Buchan JG, Lambert CC, Eng KS, Hickey L, Korlach J, Ford J, Ash-
lins J, Harden G, Hubbard T, Pelan S, Simpson JT, Threadgold G, Torrance J, ley EA. Long-read genome sequencing identifies causal structural
Wood JM, Clarke L, Koren S, Boitano M, Peluso P, Li H, Chin CS, Phillippy variation in a Mendelian disease. Genet Med. 2018;20:159–163. doi:
AM, Durbin R, Wilson RK, Flicek P, Eichler EE, Church DM. Evaluation of 10.1038/gim.2017.86
GRCh38 and de novo haploid genome assemblies demonstrates the en- 32. Hartman RJ, Rasmussen SA, Botto LD, Riehle-Colarusso T, Martin CL, Cra-
during quality of the reference assembly. Genome Res. 2017;27:849–864. gan JD, Shin M, Correa A. The contribution of chromosomal abnormali-
doi: 10.1101/gr.213611.116 ties to congenital heart defects: a population-based study. Pediatr Cardiol.
17. Osoegawa K, Mammoser AG, Wu C, Frengen E, Zeng C, Catanese JJ, 2011;32:1147–1157. doi: 10.1007/s00246-011-0034-5
de Jong PJ. A bacterial artificial chromosome library for sequencing 33. Bull MJ; Committee on Genetics. Health supervision for children with Down
the complete human genome. Genome Res. 2001;11:483–496. doi: syndrome [published correction appears in Pediatrics. 2011;128:1212].
10.1101/gr.169601 Pediatrics. 2011;128:393–406. doi: 10.1542/peds.2011-1605
18. Xue Y, Ankala A, Wilcox WR, Hegde MR. Solving the molecular diagnostic 34. Allen HD, Driscoll D J, Shaddy RE, Feltes TF. Moss and Adams’ Heart Dis-
testing conundrum for Mendelian disorders in the era of next-generation ease in Infants, Children, and Adolescents: Including the Fetus and Young

Adult. 8th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams defects associated with deletion 22q11. Genet Med. 2001;3:45–48. doi:
CLINICAL STATEMENTS
& Wilkins; 2013. 10.109700125817-200101000-00010

AND GUIDELINES
35. Bittles AH, Bower C, Hussain R, Glasson EJ. The four ages of Down syn- 54. Cassidy SB, Allanson JE. Management of Genetic Syndromes. 3rd ed.
drome. Eur J Public Health. 2007;17:221–225. doi: 10.1093/eurpub/ckl103 Hoboken, NJ: Wiley-Blackwell; 2010.
36. Landis BJ, Cooper DS, Hinton RB. CHD associated with syndromic di- 55. Goldmuntz E, Clark BJ, Mitchell LE, Jawad AF, Cuneo BF, Reed L, Mc-
agnoses: peri-operative risk factors and early outcomes. Cardiol Young. Donald-McGinn D, Chien P, Feuer J, Zackai EH, Emanuel BS, Driscoll DA.
2016;26:30–52. doi: 10.1017/S1047951115001389 Frequency of 22q11 deletions in patients with conotruncal defects. J Am
37. Fudge JC Jr, Li S, Jaggers J, O’Brien SM, Peterson ED, Jacobs JP, Welke Coll Cardiol. 1998;32:492–498.
KF, Jacobs ML, Li JS, Pasquali SK. Congenital heart surgery outcomes 56. Momma K, Kondo C, Ando M, Matsuoka R, Takao A. Tetralogy of Fallot
in Down syndrome: analysis of a national clinical database. Pediatrics. associated with chromosome 22q11 deletion. Am J Cardiol. 1995;76:618–
2010;126:315–322. doi: 10.1542/peds.2009-3245 621.
38. Sybert VP. Cardiovascular malformations and complications in Turner syn- 57. Beauchesne LM, Warnes CA, Connolly HM, Ammash NM, Grogan M, Jalal
drome. Pediatrics. 1998;101:E11. SM, Michels VV. Prevalence and clinical manifestations of 22q11.2 micro-
39. Lin AE, Lippe B, Rosenfeld RG. Further delineation of aortic dilation, deletion in adults with selected conotruncal anomalies. J Am Coll Cardiol.
dissection, and rupture in patients with Turner syndrome. Pediatrics. 2005;45:595–598. doi: 10.1016/j.jacc.2004.10.056
1998;102:e12. 58. Anaclerio S, Di Ciommo V, Michielon G, Digilio MC, Formigari R, Picchio
40. Bordeleau L, Cwinn A, Turek M, Barron-Klauninger K, Victor G. Aortic FM, Gargiulo G, Di Donato R, De Ioris MA, Marino B. Conotruncal heart
dissection and Turner’s syndrome: case report and review of the literature. defects: impact of genetic syndromes on immediate operative mortality.
J Emerg Med. 1998;16:593–596. Ital Heart J. 2004;5:624–628.
41. Gravholt CH, Andersen NH, Conway GS, Dekkers OM, Geffner ME, Klein 59. Mahle WT, Crisalli J, Coleman K, Campbell RM, Tam VK, Vincent RN,
KO, Lin AE, Mauras N, Quigley CA, Rubin K, Sandberg DE, Sas TCJ, Sil- Kanter KR. Deletion of chromosome 22q11.2 and outcome in patients
berbach M, Soderstrom-Anttila V, Stochholm K, van Alfen-van derVelden with pulmonary atresia and ventricular septal defect. Ann Thorac Surg.
JA, Woelfle J, Backeljauw PF; International Turner Syndrome Consensus 2003;76:567–571.
Group. Clinical practice guidelines for the care of girls and women with 60. Peyvandi S, Lupo PJ, Garbarini J, Woyciechowski S, Edman S, Eman-
Turner syndrome: proceedings from the 2016 Cincinnati International uel BS, Mitchell LE, Goldmuntz E. 22q11.2 deletions in patients with
Turner Syndrome Meeting. Eur J Endocrinol. 2017;177:G1–G70. doi: conotruncal defects: data from 1,610 consecutive cases. Pediatr Cardiol.
10.1530/EJE-17-0430 2013;34:1687–1694. doi: 10.1007/s00246-013-0694-4
42. Nielsen J, Wohlert M. Chromosome abnormalities found among 34,910 61. McElhinney DB, Clark BJ 3rd, Weinberg PM, Kenton ML, McDonald-
newborn children: results from a 13-year incidence study in Arhus, Den- McGinn D, Driscoll DA, Zackai EH, Goldmuntz E. Association of chromo-
mark. Hum Genet. 1991;87:81–83. some 22q11 deletion with isolated anomalies of aortic arch laterality and
43. Gøtzsche CO, Krag-Olsen B, Nielsen J, Sørensen KE, Kristensen BO. Preva- branching. J Am Coll Cardiol. 2001;37:2114–2119.
lence of cardiovascular malformations and association with karyotypes in 62. John AS, McDonald-McGinn DM, Zackai EH, Goldmuntz E. Aortic root
Turner’s syndrome. Arch Dis Child. 1994;71:433–436. dilation in patients with 22q11.2 deletion syndrome. Am J Med Genet A.
44. Mazzanti L, Cacciari E; Italian Study Group for Turner Syndrome (ISGTS). 2009;149A:939–942. doi: 10.1002/ajmg.a.32770
Congenital heart disease in patients with Turner’s syndrome. J Pediatr. 63. John AS, Rychik J, Khan M, Yang W, Goldmuntz E. 22q11.2 deletion syn-
1998;133:688–692. drome as a risk factor for aortic root dilation in tetralogy of Fallot. Cardiol
45. Goldmuntz E, Paluru P, Glessner J, Hakonarson H, Biegel JA, White PS, Gai Young. 2014;24:303–310. doi: 10.1017/S1047951113000309
X, Shaikh TH. Microdeletions and microduplications in patients with con- 64. Kunishima S, Imai T, Kobayashi R, Kato M, Ogawa S, Saito H. Bernard-
genital heart disease and multiple congenital anomalies. Congenit Heart Soulier syndrome caused by a hemizygous GPIbβ mutation and 22q11.2
Dis. 2011;6:592–602. doi: 10.1111/j.1747-0803.2011.00582.x deletion. Pediatr Int. 2013;55:434–437. doi: 10.1111/ped.12105
46. Kim DS, Kim JH, Burt AA, Crosslin DR, Burnham N, Kim CE, McDonald- 65. Wentzel C, Fernström M, Ohrner Y, Annerén G, Thuresson AC. Clini-
McGinn DM, Zackai EH, Nicolson SC, Spray TL, Stanaway IB, Nickerson cal variability of the 22q11.2 duplication syndrome. Eur J Med Genet.
DA, Heagerty PJ, Hakonarson H, Gaynor JW, Jarvik GP. Burden of po- 2008;51:501–510. doi: 10.1016/j.ejmg.2008.07.005
tentially pathologic copy number variants is higher in children with iso- 66. Portnoï MF. Microduplication 22q11.2: a new chromosomal syndrome.
lated congenital heart disease and significantly impairs covariate-adjusted Eur J Med Genet. 2009;52:88–93. doi: 10.1016/j.ejmg.2009.02.008
transplant-free survival. J Thorac Cardiovasc Surg. 2016;151:1147–1151. 67. Ou Z, Berg JS, Yonath H, Enciso VB, Miller DT, Picker J, Lenzi T, Keegan
e4. doi: 10.1016/j.jtcvs.2015.09.136 CE, Sutton VR, Belmont J, Chinault AC, Lupski JR, Cheung SW, Roeder
47. Carey AS, Liang L, Edwards J, Brandt T, Mei H, Sharp AJ, Hsu DT, New- E, Patel A. Microduplications of 22q11.2 are frequently inherited and are
burger JW, Ohye RG, Chung WK, Russell MW, Rosenfeld JA, Shaffer LG, associated with variable phenotypes. Genet Med. 2008;10:267–277. doi:
Parides MK, Edelmann L, Gelb BD. Effect of copy number variants on 10.1097/GIM.0b013e31816b64c2
outcomes for infants with single ventricle heart defects. Circ Cardiovasc 68. Ben-Shachar S, Ou Z, Shaw CA, Belmont JW, Patel MS, Hummel M, Am-
Genet. 2013;6:444–451. doi: 10.1161/CIRCGENETICS.113.000189 ato S, Tartaglia N, Berg J, Sutton VR, Lalani SR, Chinault AC, Cheung SW,
48. Gelb BD, Chung WK. Complex genetics and the etiology of human con- Lupski JR, Patel A. 22q11.2 distal deletion: a recurrent genomic disorder
genital heart disease. Cold Spring Harb Perspect Med. 2014;4:a013953. distinct from DiGeorge syndrome and velocardiofacial syndrome. Am J
doi: 10.1101/cshperspect.a013953 Hum Genet. 2008;82:214–221. doi: 10.1016/j.ajhg.2007.09.014
49. Botto LD, May K, Fernhoff PM, Correa A, Coleman K, Rasmussen SA, 69. Breckpot J, Thienpont B, Bauters M, Tranchevent LC, Gewillig M, Allegaert
Merritt RK, O’Leary LA, Wong LY, Elixson EM, Mahle WT, Campbell RM. K, Vermeesch JR, Moreau Y, Devriendt K. Congenital heart defects in a
A population-based study of the 22q11.2 deletion: phenotype, incidence, novel recurrent 22q11.2 deletion harboring the genes CRKL and MAPK1.
and contribution to major birth defects in the population. Pediatrics. Am J Med Genet A. 2012;158A:574–580. doi: 10.1002/ajmg.a.35217
2003;112(pt 1):101–107. 70. Mlynarski EE, Xie M, Taylor D, Sheridan MB, Guo T, Racedo SE, Mc-
50. Digilio MC, Angioni A, De Santis M, Lombardo A, Giannotti A, Dallapicco- Donald-McGinn DM, Chow EW, Vorstman J, Swillen A, Devriendt K,
la B, Marino B. Spectrum of clinical variability in familial deletion 22q11.2: Breckpot J, Digilio MC, Marino B, Dallapiccola B, Philip N, Simon TJ,
from full manifestation to extremely mild clinical anomalies. Clin Genet. Roberts AE, Piotrowicz M, Bearden CE, Eliez S, Gothelf D, Coleman
2003;63:308–313. K, Kates WR, Devoto M, Zackai E, Heine-Suñer D, Goldmuntz E, Bas-
51. McDonald-McGinn DM, Emanuel BS, Zackai EH. 22q11.2 deletion syn- sett AS, Morrow BE, Emanuel BS; International Chromosome 22q11.2
drome. In: Pagon RA, Adam MP, Ardinger HH, Wallace SE, Amemiya A, Consortium. Rare copy number variants and congenital heart defects in
Bean LJH, Bird TD, Ledbetter N, Mefford HC, Smith RJH, Stephens K, eds. the 22q11.2 deletion syndrome. Hum Genet. 2016;135:273–285. doi:
GeneReviews®. Seattle, WA: University of Washington, Seattle; 1993. 10.1007/s00439-015-1623-9
52. Agergaard P, Olesen C, Østergaard JR, Christiansen M, Sørensen KM. The 71. McDonald-McGinn DM, Fahiminiya S, Revil T, Nowakowska BA, Suhl J,
prevalence of chromosome 22q11.2 deletions in 2,478 children with car- Bailey A, Mlynarski E, Lynch DR, Yan AC, Bilaniuk LT, Sullivan KE, Warren
diovascular malformations: a population-based study. Am J Med Genet A. ST, Emanuel BS, Vermeesch JR, Zackai EH, Jerome-Majewska LA. Hemizy-
2012;158A:498–508. doi: 10.1002/ajmg.a.34250 gous mutations in SNAP29 unmask autosomal recessive conditions and
53. Marino B, Digilio MC, Toscano A, Anaclerio S, Giannotti A, Feltri C, de contribute to atypical findings in patients with 22q11.2DS. J Med Genet.
Ioris MA, Angioni A, Dallapiccola B. Anatomic patterns of conotruncal 2013;50:80–90. doi: 10.1136/jmedgenet-2012-101320

72. Morris CA. Williams syndrome. In: Pagon RA, Adam MP, Ardinger HH, 94. Glessner JT, Bick AG, Ito K, Homsy J, Rodriguez-Murillo L, Fromer M,
CLINICAL STATEMENTS
Wallace SE, Amemiya A, Bean LJH, Bird TD, Ledbetter N, Mefford HC, Mazaika E, Vardarajan B, Italia M, Leipzig J, DePalma SR, Golhar R,
AND GUIDELINES
Smith RJH, Stephens K, eds. GeneReviews®. Seattle, WA: University of Sanders SJ, Yamrom B, Ronemus M, Iossifov I, Willsey AJ, State MW,
Washington, Seattle; 1993. Kaltman JR, White PS, Shen Y, Warburton D, Brueckner M, Seidman
73. Wessel A, Pankau R, Kececioglu D, Ruschewski W, Bürsch JH. Three C, Goldmuntz E, Gelb BD, Lifton R, Seidman J, Hakonarson H, Chung
decades of follow-up of aortic and pulmonary vascular lesions in the WK. Increased frequency of de novo copy number variants in congenital
Williams-Beuren syndrome. Am J Med Genet. 1994;52:297–301. doi: heart disease by integrative analysis of single nucleotide polymorphism
10.1002/ajmg.1320520309 array and exome sequence data. Circ Res. 2014;115:884–896. doi:
74. Eronen M, Peippo M, Hiippala A, Raatikka M, Arvio M, Johansson R, Käh- 10.1161/CIRCRESAHA.115.304458
könen M. Cardiovascular manifestations in 75 patients with Williams syn- 95. Grossfeld P. Brain hemorrhages in Jacobsen syndrome: a retrospective
drome. J Med Genet. 2002;39:554–558. review of six cases and clinical recommendations. Am J Med Genet A.
75. Conway EE Jr, Noonan J, Marion RW, Steeg CN. Myocardial infarction 2017;173:667–670. doi: 10.1002/ajmg.a.38032
leading to sudden death in the Williams syndrome: report of three cases. 96. Coldren CD, Lai Z, Shragg P, Rossi E, Glidewell SC, Zuffardi O,
J Pediatr. 1990;117:593–595. Mattina T, Ivy DD, Curfs LM, Mattson SN, Riley EP, Treier M, Grossfeld
76. Latham GJ, Ross FJ, Eisses MJ, Richards MJ, Geiduschek JM, Joffe DC. Peri- PD. Chromosomal microarray mapping suggests a role for BSX and
operative morbidity in children with elastin arteriopathy. Paediatr Anaesth. Neurogranin in neurocognitive and behavioral defects in the 11q termi-
2016;26:926–935. doi: 10.1111/pan.12967 nal deletion disorder (Jacobsen syndrome). Neurogenetics. 2009;10:89–
77. Bird LM, Billman GF, Lacro RV, Spicer RL, Jariwala LK, Hoyme HE, Zamora- 95. doi: 10.1007/s10048-008-0157-x
Salinas R, Morris C, Viskochil D, Frikke MJ, Jones MC. Sudden death in 97. Akshoomoff N, Mattson SN, Grossfeld PD. Evidence for autism spec-
Williams syndrome: report of ten cases. J Pediatr. 1996;129:926–931. trum disorder in Jacobsen syndrome: identification of a candidate
78. Wessel A, Gravenhorst V, Buchhorn R, Gosch A, Partsch CJ, Pankau R. Risk gene in distal 11q. Genet Med. 2015;17:143–148. doi: 10.1038/
of sudden death in the Williams-Beuren syndrome. Am J Med Genet A. gim.2014.86
2004;127A:234–237. doi: 10.1002/ajmg.a.30012 98. Battaglia A. 1p36 deletion syndrome. In: Pagon RA, Adam MP, Ardinger
79. Olsen M, Fahy CJ, Costi DA, Kelly AJ, Burgoyne LL. Anaesthesia-related HH, Wallace SE, Amemiya A, Bean LJH, Bird TD, Ledbetter N, Mefford
haemodynamic complications in Williams syndrome patients: a review of HC, Smith RJH, Stephens K, eds. GeneReviews®. Seattle, WA: University
one institution’s experience. Anaesth Intensive Care. 2014;42:619–624. of Washington, Seattle; 1993.
80. Ewart AK, Morris CA, Atkinson D, Jin W, Sternes K, Spallone P, Stock 99. Battaglia A, Hoyme HE, Dallapiccola B, Zackai E, Hudgins L, McDonald-
AD, Leppert M, Keating MT. Hemizygosity at the elastin locus in a de- McGinn D, Bahi-Buisson N, Romano C, Williams CA, Brailey LL, Braley LL,
velopmental disorder, Williams syndrome. Nat Genet. 1993;5:11–16. doi: Zuberi SM, Carey JC. Further delineation of deletion 1p36 syndrome in
10.1038/ng0993-11 60 patients: a recognizable phenotype and common cause of develop-
81. Huang L, Sadler L, O’Riordan MA, Robin NH. Delay in diagnosis of Wil- mental delay and mental retardation. Pediatrics. 2008;121:404–410. doi:
liams syndrome. Clin Pediatr (Phila). 2002;41:257–261. doi: 10.1177/ 10.1542/peds.2007-0929
000992280204100410 100. Heilstedt HA, Ballif BC, Howard LA, Kashork CD, Shaffer LG. Population
82. Sadler LS, Pober BR, Grandinetti A, Scheiber D, Fekete G, Sharma AN, Ur- data suggest that deletions of 1p36 are a relatively common chromo-
bán Z. Differences by sex in cardiovascular disease in Williams syndrome. some abnormality. Clin Genet. 2003;64:310–316.
J Pediatr. 2001;139:849–853. doi: 10.1067/mpd.2001.118889 101. Slavotinek A, Shaffer LG, Shapira SK. Monosomy 1p36. J Med Genet.
83. Merla G, Brunetti-Pierri N, Micale L, Fusco C. Copy number variants at 1999;36:657–663.
Williams-Beuren syndrome 7q11.23 region. Hum Genet. 2010;128:3–26. 102. Christiansen J, Dyck JD, Elyas BG, Lilley M, Bamforth JS, Hicks M,
doi: 10.1007/s00439-010-0827-2 Sprysak KA, Tomaszewski R, Haase SM, Vicen-Wyhony LM, Somerville MJ.
84. Morris CA, Mervis CB, Paciorkowski AP, Abdul-Rahman O, Dugan SL, Chromosome 1q21.1 contiguous gene deletion is associated with congen-
Rope AF, Bader P, Hendon LG, Velleman SL, Klein-Tasman BP, Osborne LR. ital heart disease. Circ Res. 2004;94:1429–1435. doi: 10.1161/01.RES.
7q11.23 duplication syndrome: physical characteristics and natural history. 0000130528.72330.5c
Am J Med Genet A. 2015;167A:2916–2935. doi: 10.1002/ajmg.a.37340 103. Haldeman-Englert CR, Jewett T. 1q21.1 recurrent microdeletion. In:
85. Mervis CB, Morris CA, Klein-Tasman BP, Velleman SL, Osborne LR. 7q11.23 du- Pagon RA, Adam MP, Ardinger HH, Wallace SE, Amemiya A, Bean
plication syndrome. In: Pagon RA, Adam MP, Ardinger HH, Wallace SE, Ame- LJH, Bird TD, Ledbetter N, Mefford HC, Smith RJH, Stephens K, eds.
miya A, Bean LJH, Bird TD, Ledbetter N, Mefford HC, Smith RJH, Stephens K, GeneReviews®. Seattle, WA: University of Washington, Seattle; 1993.
eds. GeneReviews®. Seattle, WA: University of Washington, Seattle; 1993. 104. Bernier R, Steinman KJ, Reilly B, Wallace AS, Sherr EH, Pojman N, Mefford
86. Committee on Genetics, American Academy of Pediatrics. Health care HC, Gerdts J, Earl R, Hanson E, Goin-Kochel RP, Berry L, Kanne S, Snyder
supervision for children with Williams syndrome [published correction ap- LG, Spence S, Ramocki MB, Evans DW, Spiro JE, Martin CL, Ledbetter
pears in Pediatrics. 2002;109:329]. Pediatrics. 2001;107:1192–1204. DH, Chung WK; Simons VIP Consortium. Clinical phenotype of the recur-
87. Pober BR, Lacro RV, Rice C, Mandell V, Teele RL. Renal findings in 40 indi- rent 1q21.1 copy-number variant. Genet Med. 2016;18:341–349. doi:
viduals with Williams syndrome. Am J Med Genet. 1993;46:271–274. doi: 10.1038/gim.2015.78
10.1002/ajmg.1320460306 105. Digilio MC, Bernardini L, Consoli F, Lepri FR, Giuffrida MG, Baban
88. Broder K, Reinhardt E, Ahern J, Lifton R, Tamborlane W, Pober B. Elevated A, Surace C, Ferese R, Angioni A, Novelli A, Marino B, De Luca A,
ambulatory blood pressure in 20 subjects with Williams syndrome. Am J Dallapiccola B. Congenital heart defects in recurrent reciprocal 1q21.1
Med Genet. 1999;83:356–360. deletion and duplication syndromes: rare association with pulmonary
89. Mervis CB, Robinson BF, Bertrand J, Morris CA, Klein-Tasman BP, Arm- valve stenosis. Eur J Med Genet. 2013;56:144–149. doi: 10.1016/j.
strong SC. The Williams syndrome cognitive profile. Brain Cogn. ejmg.2012.12.004
2000;44:604–628. doi: 10.1006/brcg.2000.1232 106. Mefford HC, Sharp AJ, Baker C, Itsara A, Jiang Z, Buysse K, Huang S,
90. Jacobsen P, Hauge M, Henningsen K, Hobolth N, Mikkelsen M, Philip J. An Maloney VK, Crolla JA, Baralle D, Collins A, Mercer C, Norga K, de Ravel
(11;21) translocation in four generations with chromosome 11 abnormali- T, Devriendt K, Bongers EM, de Leeuw N, Reardon W, Gimelli S, Bena F,
ties in the offspring: a clinical, cytogenetical, and gene marker study. Hum Hennekam RC, Male A, Gaunt L, Clayton-Smith J, Simonic I, Park SM,
Hered. 1973;23:568–585. doi: 10.1159/000152624 Mehta SG, Nik-Zainal S, Woods CG, Firth HV, Parkin G, Fichera M, Reitano
91. Grossfeld PD, Mattina T, Lai Z, Favier R, Jones KL, Cotter F, Jones C. The S, Lo Giudice M, Li KE, Casuga I, Broomer A, Conrad B, Schwerzmann
11q terminal deletion disorder: a prospective study of 110 cases. Am J M, Räber L, Gallati S, Striano P, Coppola A, Tolmie JL, Tobias ES, Lilley C,
Med Genet A. 2004;129A:51–61. doi: 10.1002/ajmg.a.30090 Armengol L, Spysschaert Y, Verloo P, De Coene A, Goossens L, Mortier
92. Favier R, Akshoomoff N, Mattson S, Grossfeld P. Jacobsen syndrome: ad- G, Speleman F, van Binsbergen E, Nelen MR, Hochstenbach R, Poot M,
vances in our knowledge of phenotype and genotype. Am J Med Genet C Gallagher L, Gill M, McClellan J, King MC, Regan R, Skinner C, Stevenson
Semin Med Genet. 2015;169:239–250. doi: 10.1002/ajmg.c.31448 RE, Antonarakis SE, Chen C, Estivill X, Menten B, Gimelli G, Gribble S,
93. Ye M, Coldren C, Liang X, Mattina T, Goldmuntz E, Benson DW, Ivy D, Schwartz S, Sutcliffe JS, Walsh T, Knight SJ, Sebat J, Romano C, Schwartz
Perryman MB, Garrett-Sinha LA, Grossfeld P. Deletion of ETS-1, a gene CE, Veltman JA, de Vries BB, Vermeesch JR, Barber JC, Willatt L, Tassabehji
in the Jacobsen syndrome critical region, causes ventricular septal de- M, Eichler EE. Recurrent rearrangements of chromosome 1q21.1 and
fects and abnormal ventricular morphology in mice. Hum Mol Genet. variable pediatric phenotypes. N Engl J Med. 2008;359:1685–1699. doi:
2010;19:648–656. doi: 10.1093/hmg/ddp532 10.1056/NEJMoa0805384

107. Guida V, Ferese R, Rocchetti M, Bonetti M, Sarkozy A, Cecchetti S, 122. Lin AE, Alexander ME, Colan SD, Kerr B, Rauen KA, Noonan J, Baffa J,
CLINICAL STATEMENTS
Gelmetti V, Lepri F, Copetti M, Lamorte G, Cristina Digilio M, Marino Hopkins E, Sol-Church K, Limongelli G, Digilio MC, Marino B, Innes AM,
AND GUIDELINES
B, Zaza A, den Hertog J, Dallapiccola B, De Luca A. A variant in the Aoki Y, Silberbach M, Delrue MA, White SM, Hamilton RM, O’Connor W,
carboxyl-terminus of connexin 40 alters GAP junctions and increases Grossfeld PD, Smoot LB, Padera RF, Gripp KW. Clinical, pathological, and
risk for tetralogy of Fallot. Eur J Hum Genet. 2013;21:69–75. doi: molecular analyses of cardiovascular abnormalities in Costello syndrome:
10.1038/ejhg.2012.109 a Ras/MAPK pathway syndrome. Am J Med Genet A. 2011;155A:486–
108. Rosenfeld JA, Traylor RN, Schaefer GB, McPherson EW, Ballif BC, 507. doi: 10.1002/ajmg.a.33857
Klopocki E, Mundlos S, Shaffer LG, Aylsworth AS; 1q21.1 Study Group. 123. Ruiz-Perez VL, Ide SE, Strom TM, Lorenz B, Wilson D, Woods K, King L,
Proximal microdeletions and microduplications of 1q21.1 contribute to Francomano C, Freisinger P, Spranger S, Marino B, Dallapiccola B, Wright
variable abnormal phenotypes. Eur J Hum Genet. 2012;20:754–761. doi: M, Meitinger T, Polymeropoulos MH, Goodship J. Mutations in a new
10.1038/ejhg.2012.6 gene in Ellis-van Creveld syndrome and Weyers acrodental dysostosis
109. Soemedi R, Topf A, Wilson IJ, Darlay R, Rahman T, Glen E, Hall D, Huang [published correction appears in Nat Genet. 2000;25:125]. Nat Genet.
N, Bentham J, Bhattacharya S, Cosgrove C, Brook JD, Granados-Riveron 2000;24:283–286. doi: 10.1038/73508
J, Setchfield K, Bu’lock F, Thornborough C, Devriendt K, Breckpot 124. Ruiz-Perez VL, Tompson SW, Blair HJ, Espinoza-Valdez C, Lapunzina P, Silva
J, Hofbeck M, Lathrop M, Rauch A, Blue GM, Winlaw DS, Hurles M, EO, Hamel B, Gibbs JL, Young ID, Wright MJ, Goodship JA. Mutations in
Santibanez-Koref M, Cordell HJ, Goodship JA, Keavney BD. Phenotype- two nonhomologous genes in a head-to-head configuration cause Ellis-
specific effect of chromosome 1q21.1 rearrangements and GJA5 du- van Creveld syndrome. Am J Hum Genet. 2003;72:728–732.
plications in 2436 congenital heart disease patients and 6760 controls. 125. McDermott DA, Bressan MC, He J, Lee JS, Aftimos S, Brueckner M,
Hum Mol Genet. 2012;21:1513–1520. doi: 10.1093/hmg/ddr589 Gilbert F, Graham GE, Hannibal MC, Innis JW, Pierpont ME, Raas-
110. Brunetti-Pierri N, Berg JS, Scaglia F, Belmont J, Bacino CA, Sahoo T, Lalani SR, Rothschild A, Shanske AL, Smith WE, Spencer RH, St John-Sutton MG,
Graham B, Lee B, Shinawi M, Shen J, Kang SH, Pursley A, Lotze T, Kennedy van Maldergem L, Waggoner DJ, Weber M, Basson CT. TBX5 genetic
G, Lansky-Shafer S, Weaver C, Roeder ER, Grebe TA, Arnold GL, Hutchison testing validates strict clinical criteria for Holt-Oram syndrome. Pediatr
T, Reimschisel T, Amato S, Geragthy MT, Innis JW, Obersztyn E, Nowakowska Res. 2005;58:981–986. doi: 10.1203/01.PDR.0000182593.95441.64
B, Rosengren SS, Bader PI, Grange DK, Naqvi S, Garnica AD, Bernes SM, 126. Wessels MW, Brooks AS, Hoogeboom J, Niermeijer MF, Willems PJ.
Fong CT, Summers A, Walters WD, Lupski JR, Stankiewicz P, Cheung SW, Kabuki syndrome: a review study of three hundred patients. Clin
Patel A. Recurrent reciprocal 1q21.1 deletions and duplications associated Dysmorphol. 2002;11:95–102.
with microcephaly or macrocephaly and developmental and behavioral 127. Hannibal MC, Buckingham KJ, Ng SB, Ming JE, Beck AE, McMillin MJ,
abnormalities. Nat Genet. 2008;40:1466–1471. doi: 10.1038/ng.279 Gildersleeve HI, Bigham AW, Tabor HK, Mefford HC, Cook J, Yoshiura K,
111. Claeys I, Holvoet M, Eyskens B, Adriaensens P, Gewillig M, Fryns JP, Matsumoto T, Matsumoto N, Miyake N, Tonoki H, Naritomi K, Kaname
Devriendt K. A recognisable behavioural phenotype associated with ter- T, Nagai T, Ohashi H, Kurosawa K, Hou JW, Ohta T, Liang D, Sudo A,
minal deletions of the short arm of chromosome 8. Am J Med Genet. Morris CA, Banka S, Black GC, Clayton-Smith J, Nickerson DA, Zackai
1997;74:515–520. EH, Shaikh TH, Donnai D, Niikawa N, Shendure J, Bamshad MJ. Spectrum
112. Wat MJ, Shchelochkov OA, Holder AM, Breman AM, Dagli A, Bacino of MLL2 (ALR) mutations in 110 cases of Kabuki syndrome. Am J Med
C, Scaglia F, Zori RT, Cheung SW, Scott DA, Kang SH. Chromosome Genet A. 2011;155A:1511–1516. doi: 10.1002/ajmg.a.34074
8p23.1 deletions as a cause of complex congenital heart defects and 128. Romano AA, Allanson JE, Dahlgren J, Gelb BD, Hall B, Pierpont ME,
diaphragmatic hernia. Am J Med Genet A. 2009;149A:1661–1677. doi: Roberts AE, Robinson W, Takemoto CM, Noonan JA. Noonan syndrome:
10.1002/ajmg.a.32896 clinical features, diagnosis, and management guidelines. Pediatrics.
113. Garg V, Kathiriya IS, Barnes R, Schluterman MK, King IN, Butler CA, 2010;126:746–759. doi: 10.1542/peds.2009-3207
Rothrock CR, Eapen RS, Hirayama-Yamada K, Joo K, Matsuoka R, Cohen 129. Al-Farqani A, Panduranga P, Al-Maskari S, Thomas E. VACTERL associa-
JC, Srivastava D. GATA4 mutations cause human congenital heart de- tion with double-chambered left ventricle: a rare occurrence. Ann Pediatr
fects and reveal an interaction with TBX5. Nature. 2003;424:443–447. Cardiol. 2013;6:200–201. doi: 10.4103/0974-2069.115283
doi: 10.1038/nature01827 130. Pober BR. Williams-Beuren syndrome [published correction appears in
114. Turnpenny PD, Ellard S. Alagille syndrome: pathogenesis, diagno- N Engl J Med. 2010;362:2142]. N Engl J Med. 2010;362:239–252. doi:
sis and management. Eur J Hum Genet. 2012;20:251–257. doi: 10.1056/NEJMra0903074
10.1038/ejhg.2011.181 131. Jenkins D, Seelow D, Jehee FS, Perlyn CA, Alonso LG, Bueno DF, Donnai
115. McDaniell R, Warthen DM, Sanchez-Lara PA, Pai A, Krantz ID, Piccoli D, Josifova D, Josifiova D, Mathijssen IM, Morton JE, Orstavik KH,
DA, Spinner NB. NOTCH2 mutations cause Alagille syndrome, a het- Sweeney E, Wall SA, Marsh JL, Nurnberg P, Passos-Bueno MR, Wilkie
erogeneous disorder of the notch signaling pathway. Am J Hum Genet. AO. RAB23 mutations in Carpenter syndrome imply an unexpected role
2006;79:169–173. doi: 10.1086/505332 for hedgehog signaling in cranial-suture development and obesity. Am J
116. Pierpont ME, Magoulas PL, Adi S, Kavamura MI, Neri G, Noonan J, Hum Genet. 2007;80:1162–1170. doi: 10.1086/518047
Pierpont EI, Reinker K, Roberts AE, Shankar S, Sullivan J, Wolford M, 132. Santen GW, Clayton-Smith J; ARID1B-CSS Consortium. The ARID1B phe-
Conger B, Santa Cruz M, Rauen KA. Cardio-facio-cutaneous syndrome: notype: what we have learned so far. Am J Med Genet C Semin Med
clinical features, diagnosis, and management guidelines. Pediatrics. Genet. 2014;166C:276–289. doi: 10.1002/ajmg.c.31414
2014;134:e1149–e1162. doi: 10.1542/peds.2013-3189 133. Kosho T, Okamoto N; Coffin-Siris Syndrome International Collaborators.
117. Scurr I, Wilson L, Lees M, Robertson S, Kirk E, Turner A, Morton J, Kidd Genotype-phenotype correlation of Coffin-Siris syndrome caused
A, Shashi V, Stanley C, Berry M, Irvine AD, Goudie D, Turner C, Brewer by mutations in SMARCB1, SMARCA4, SMARCE1, and ARID1A.
C, Smithson S. Cantú syndrome: report of nine new cases and expansion Am J Med Genet C Semin Med Genet. 2014;166C:262–275. doi:
of the clinical phenotype. Am J Med Genet A. 2011;155A:508–518. doi: 10.1002/ajmg.c.31407
10.1002/ajmg.a.33885 134. Selicorni A, Colli AM, Passarini A, Milani D, Cereda A, Cerutti M, Maitz
118. Grange DK, Lorch SM, Cole PL, Singh GK. Cantu syndrome in a woman S, Alloni V, Salvini L, Galli MA, Ghiglia S, Salice P, Danzi GB. Analysis
and her two daughters: Further confirmation of autosomal dominant of congenital heart defects in 87 consecutive patients with Brachmann-
inheritance and review of the cardiac manifestations. Am J Med Genet de Lange syndrome. Am J Med Genet A. 2009;149A:1268–1272. doi:
A. 2006;140:1673–1680. doi: 10.1002/ajmg.a.31348 10.1002/ajmg.a.32838
119. Satoda M, Zhao F, Diaz GA, Burn J, Goodship J, Davidson HR, Pierpont 135. Digilio MC, Calzolari F, Capolino R, Toscano A, Sarkozy A, de Zorzi A,
ME, Gelb BD. Mutations in TFAP2B cause Char syndrome, a famil- Dallapiccola B, Marino B. Congenital heart defects in patients with oculo-
ial form of patent ductus arteriosus. Nat Genet. 2000;25:42–46. doi: auriculo-vertebral spectrum (Goldenhar syndrome). Am J Med Genet A.
10.1038/75578 2008;146A:1815–1819. doi: 10.1002/ajmg.a.32407
120. Sweeney E, Fryer A, Walters M. Char syndrome: a new family and review 136. Garavelli L, Zollino M, Mainardi PC, Gurrieri F, Rivieri F, Soli F, Verri R,
of the literature emphasising the presence of symphalangism and the Albertini E, Favaron E, Zignani M, Orteschi D, Bianchi P, Faravelli F,
variable phenotype. Clin Dysmorphol. 2000;9:177–182. Forzano F, Seri M, Wischmeijer A, Turchetti D, Pompilii E, Gnoli M, Cocchi
121. Trider CL, Arra-Robar A, van Ravenswaaij-Arts C, Blake K. Developing G, Mazzanti L, Bergamaschi R, De Brasi D, Sperandeo MP, Mari F, Uliana
a CHARGE syndrome checklist: health supervision across the lifes- V, Mostardini R, Cecconi M, Grasso M, Sassi S, Sebastio G, Renieri A,
pan (from head to toe). Am J Med Genet A. 2017;173:684–691. doi: Silengo M, Bernasconi S, Wakamatsu N, Neri G. Mowat-Wilson syn-
10.1002/ajmg.a.38085 drome: facial phenotype changing with age: study of 19 Italian patients

and review of the literature. Am J Med Genet A. 2009;149A:417–426. 154. Badiner N, Taylor SP, Forlenza K, Lachman RS, University of Washington
CLINICAL STATEMENTS
doi: 10.1002/ajmg.a.32693 Center for Mendelian Genomics, Bamshad M, Nickerson D, Cohn DH,
AND GUIDELINES
137. Zweier C, Thiel CT, Dufke A, Crow YJ, Meinecke P, Suri M, Ala-Mello Krakow D. Mutations in DYNC2H1, the cytoplasmic dynein 2, heavy
S, Beemer F, Bernasconi S, Bianchi P, Bier A, Devriendt K, Dimitrov B, chain 1 motor protein gene, cause short-rib polydactyly type I, Saldino-
Firth H, Gallagher RC, Garavelli L, Gillessen-Kaesbach G, Hudgins L, Noonan type. Clin Genet. 2017;92:158-165. doi: 10.1111/cge.12947
Kääriäinen H, Karstens S, Krantz I, Mannhardt A, Medne L, Mücke J, 155. Lin AE, Neri G, Hughes-Benzie R, Weksberg R. Cardiac anomalies in the
Kibaek M, Krogh LN, Peippo M, Rittinger O, Schulz S, Schelley SL, Temple Simpson-Golabi-Behmel syndrome. Am J Med Genet. 1999;83:378–381.
IK, Dennis NR, Van der Knaap MS, Wheeler P, Yerushalmi B, Zenker M, 156. Gertsch E, Kirmani S, Ackerman MJ, Babovic-Vuksanovic D. Transient QT
Seidel H, Lachmeijer A, Prescott T, Kraus C, Lowry RB, Rauch A. Clinical interval prolongation in an infant with Simpson-Golabi-Behmel syndrome.
and mutational spectrum of Mowat-Wilson syndrome. Eur J Med Genet. Am J Med Genet A. 2010;152A:2379–2382. doi: 10.1002/ajmg.a.33561
2005;48:97–111. doi: 10.1016/j.ejmg.2005.01.003 157. Leventopoulos G, Kitsiou-Tzeli S, Kritikos K, Psoni S, Mavrou A,
138. Hennekam RC. Rubinstein-Taybi syndrome. Eur J Hum Genet. Kanavakis E, Fryssira H. A clinical study of Sotos syndrome patients
2006;14:981–985. doi: 10.1038/sj.ejhg.5201594 with review of the literature. Pediatr Neurol. 2009;40:357–364. doi:
139. Waterham HR, Hennekam RC. Mutational spectrum of Smith-Lemli-Opitz 10.1016/j.pediatrneurol.2008.11.013
syndrome. Am J Med Genet C Semin Med Genet. 2012;160C:263–284. 158. Miller EM, Hopkin R, Bao L, Ware SM. Implications for genotype-
doi: 10.1002/ajmg.c.31346 phenotype predictions in Townes-Brocks syndrome: case report of a
140. Hassed S, Li S, Mulvihill J, Aston C, Palmer S. Adams-Oliver syndrome novel SALL1 deletion and review of the literature. Am J Med Genet A.
review of the literature: refining the diagnostic phenotype. Am J Med 2012;158A:533–540. doi: 10.1002/ajmg.a.34426
Genet A. 2017;173:790–800. doi: 10.1002/ajmg.a.37889 159. Spinner NB, Leonard LD, Krantz ID. Alagille syndrome. In: Pagon RA,
141. Stittrich AB, Lehman A, Bodian DL, Ashworth J, Zong Z, Li H, Lam P, Adam MP, Ardinger HH, Wallace SE, Amemiya A, Bean LJH, Bird TD,
Khromykh A, Iyer RK, Vockley JG, Baveja R, Silva ES, Dixon J, Leon Ledbetter N, Mefford HC, Smith RJH, Stephens K, eds. GeneReviews®.
EL, Solomon BD, Glusman G, Niederhuber JE, Roach JC, Patel MS. Seattle, WA: University of Washington, Seattle; 1993.
Mutations in NOTCH1 cause Adams-Oliver syndrome. Am J Hum Genet. 160. Emerick KM, Rand EB, Goldmuntz E, Krantz ID, Spinner NB, Piccoli DA.
2014;95:275–284. doi: 10.1016/j.ajhg.2014.07.011 Features of Alagille syndrome in 92 patients: frequency and relation to
142. Van Maldergem L, Siitonen HA, Jalkh N, Chouery E, De Roy M, Delague prognosis. Hepatology. 1999;29:822–829. doi: 10.1002/hep.510290331
V, Muenke M, Jabs EW, Cai J, Wang LL, Plon SE, Fourneau C, Kestilä 161. Kamath BM, Bason L, Piccoli DA, Krantz ID, Spinner NB. Consequences
M, Gillerot Y, Mégarbané A, Verloes A. Revisiting the craniosynostosis- of JAG1 mutations. J Med Genet. 2003;40:891–895.
radial ray hypoplasia association: Baller-Gerold syndrome caused by 162. Hingorani M, Nischal KK, Davies A, Bentley C, Vivian A, Baker
mutations in the RECQL4 gene. J Med Genet. 2006;43:148–152. doi: AJ, Mieli-Vergani G, Bird AC, Aclimandos WA. Ocular abnormali-
10.1136/jmg.2005.031781 ties in Alagille syndrome. Ophthalmology. 1999;106:330–337. doi:
143. Elliott M, Bayly R, Cole T, Temple IK, Maher ER. Clinical features and 10.1016/S0161-6420(99)90072-6
natural history of Beckwith-Wiedemann syndrome: presentation of 74 163. Makino S, Ohkubo Y, Tampo H. Optical coherence tomography and fun-
new cases. Clin Genet. 1994;46:168–174. dus autofluorescence imaging study of chorioretinal atrophy involving
144. Rogers RC, Abidi FE. Coffin-Lowry syndrome. In: Pagon RA, Adam MP, the macula in Alagille syndrome. Clin Ophthalmol. 2012;6:1445–1448.
Ardinger HH, Wallace SE, Amemiya A, Bean LJH, Bird TD, Ledbetter N, doi: 10.2147/OPTH.S36146
Mefford HC, Smith RJH, Stephens K, eds. GeneReviews®. Seattle, WA: 164. Kamath BM, Podkameni G, Hutchinson AL, Leonard LD, Gerfen J, Krantz
University of Washington, Seattle; 1993. ID, Piccoli DA, Spinner NB, Loomes KM, Meyers K. Renal anomalies
145. Kohlhase J, Heinrich M, Schubert L, Liebers M, Kispert A, Laccone F, in Alagille syndrome: a disease-defining feature. Am J Med Genet A.
Turnpenny P, Winter RM, Reardon W. Okihiro syndrome is caused by 2012;158A:85–89. doi: 10.1002/ajmg.a.34369
SALL4 mutations. Hum Mol Genet. 2002;11:2979–2987. 165. Warthen DM, Moore EC, Kamath BM, Morrissette JJ, Sanchez-Lara PA,
146. Saul RA, Tarleton JC. FMR1-related disorders. In: Pagon RA, Adam MP, Sanchez P, Piccoli DA, Krantz ID, Spinner NB. Jagged1 (JAG1) muta-
Ardinger HH, Wallace SE, Amemiya A, Bean LJH, Bird TD, Ledbetter N, tions in Alagille syndrome: increasing the mutation detection rate. Hum
Mefford HC, Smith RJH, Stephens K, eds. GeneReviews®. Seattle, WA: Mutat. 2006;27:436–443. doi: 10.1002/humu.20310
University of Washington, Seattle; 1993. 166. Lu F, Morrissette JJ, Spinner NB. Conditional JAG1 mutation shows the
147. Coccia M, Brooks SP, Webb TR, Christodoulou K, Wozniak IO, Murday V, developing heart is more sensitive than developing liver to JAG1 dosage.
Balicki M, Yee HA, Wangensteen T, Riise R, Saggar AK, Park SM, Kanuga Am J Hum Genet. 2003;72:1065–1070.
N, Francis PJ, Maher ER, Moore AT, Russell-Eggitt IM, Hardcastle AJ. 167. McDermott DA, Fong JC, Basson CT. Holt-Oram syndrome. In: Pagon
X-linked cataract and Nance-Horan syndrome are allelic disorders. Hum RA, Adam MP, Ardinger HH, Wallace SE, Amemiya A, Bean LJH, Bird TD,
Mol Genet. 2009;18:2643–2655. doi: 10.1093/hmg/ddp206 Ledbetter N, Mefford HC, Smith RJH, Stephens K, eds. GeneReviews®.
148. Maillette de Buy Wenniger-Prick LJ, Hennekam RC. The Peters’ plus syn- Seattle, WA: University of Washington, Seattle; 1993.
drome: a review. Ann Genet. 2002;45:97–103. 168. Basson CT, Cowley GS, Solomon SD, Weissman B, Poznanski AK, Traill
149. Lesnik Oberstein SA, Kriek M, White SJ, Kalf ME, Szuhai K, den Dunnen TA, Seidman JG, Seidman CE. The clinical and genetic spectrum of the
JT, Breuning MH, Hennekam RC. Peters Plus syndrome is caused by Holt-Oram syndrome (heart-hand syndrome) [published correction ap-
mutations in B3GALTL, a putative glycosyltransferase [published cor- pears in N Engl J Med. 1994;330:1627]. N Engl J Med. 1994;330:885–
rection appears in Am J Hum Genet. 2006;79:985]. Am J Hum Genet. 891. doi: 10.1056/NEJM199403313301302
2006;79:562–566. doi: 10.1086/507567 169. Barisic I, Boban L, Greenlees R, Garne E, Wellesley D, Calzolari E, Addor
150. Goh ES, Li C, Horsburgh S, Kasai Y, Kolomietz E, Morel CF. The Roberts MC, Arriola L, Bergman JE, Braz P, Budd JL, Gatt M, Haeusler M, Khoshnood
syndrome/SC phocomelia spectrum: a case report of an adult with re- B, Klungsoyr K, McDonnell B, Nelen V, Pierini A, Queisser-Wahrendorf A,
view of the literature. Am J Med Genet A. 2010;152A:472–478. doi: Rankin J, Rissmann A, Rounding C, Tucker D, Verellen-Dumoulin C, Dolk
10.1002/ajmg.a.33261 H. Holt Oram syndrome: a registry-based study in Europe. Orphanet J
151. Mazzeu JF, Pardono E, Vianna-Morgante AM, Richieri-Costa A, Ae Kim Rare Dis. 2014;9:156. doi: 10.1186/s13023-014-0156-y
C, Brunoni D, Martelli L, de Andrade CE, Colin G, Otto PA. Clinical 170. Basson CT, Huang T, Lin RC, Bachinsky DR, Weremowicz S, Vaglio A,
characterization of autosomal dominant and recessive variants of Bruzzone R, Quadrelli R, Lerone M, Romeo G, Silengo M, Pereira A,
Robinow syndrome. Am J Med Genet A. 2007;143:320–325. doi: Krieger J, Mesquita SF, Kamisago M, Morton CC, Pierpont ME, Müller
10.1002/ajmg.a.31592 CW, Seidman JG, Seidman CE. Different TBX5 interactions in heart and
152. Person AD, Beiraghi S, Sieben CM, Hermanson S, Neumann AN, Robu limb defined by Holt-Oram syndrome mutations. Proc Natl Acad Sci U S
ME, Schleiffarth JR, Billington CJ Jr, van Bokhoven H, Hoogeboom JM, A. 1999;96:2919–2924.
Mazzeu JF, Petryk A, Schimmenti LA, Brunner HG, Ekker SC, Lohr JL. 171. Char F. Peculiar facies with short philtrum, duck-bill lips, ptosis
WNT5A mutations in patients with autosomal dominant Robinow syn- and low-set ears–a new syndrome? Birth Defects Orig Artic Ser.
drome. Dev Dyn. 2010;239:327–337. doi: 10.1002/dvdy.22156 1978;14(6B):303–305.
153. Chun K, Teebi AS, Jung JH, Kennedy S, Laframboise R, Meschino 172. Gelb BD. Char syndrome. In: Pagon RA, Adam MP, Ardinger HH, Wallace
WS, Nakabayashi K, Scherer SW, Ray PN, Teshima I. Genetic analysis SE, Amemiya A, Bean LJH, Bird TD, Ledbetter N, Mefford HC, Smith RJH,
of patients with the Saethre-Chotzen phenotype. Am J Med Genet. Stephens K, eds. GeneReviews®. Seattle, WA: University of Washington,
2002;110:136–143. doi: 10.1002/ajmg.10400 Seattle; 1993.

173. Chen YW, Zhao W, Zhang ZF, Fu Q, Shen J, Zhang Z, Ji W, Wang J, K, Ogura S, Furumae T, Yoshino M, Tsuji Y, Kondoh T, Matsumoto T, Abe
CLINICAL STATEMENTS
Li F. Familial nonsyndromic patent ductus arteriosus caused by K, Harada N, Miike T, Ohdo S, Naritomi K, Abushwereb AK, Braun OH,
AND GUIDELINES
mutations in TFAP2B. Pediatr Cardiol. 2011;32:958–965. doi: Schmid E, Opitz JM, Reynolds JF. Kabuki make-up (Niikawa-Kuroki) syn-
10.1007/s00246-011-0024-7 drome: a study of 62 patients. Am J Med Genet. 1988;31:565–589. doi:
174. Hanemann JA, de Carvalho BC, Franco EC. Oral manifestations in Ellis- 10.1002/ajmg.1320310312
van Creveld syndrome: report of a case and review of the literature. J Oral 195. White SM, Thompson EM, Kidd A, Savarirayan R, Turner A, Amor D,
Maxillofac Surg. 2010;68:456–460. doi: 10.1016/j.joms.2009.07.026 Delatycki MB, Fahey M, Baxendale A, White S, Haan E, Gibson K, Halliday
175. Baujat G, Le Merrer M. Ellis-van Creveld syndrome. Orphanet J Rare Dis. JL, Bankier A. Growth, behavior, and clinical findings in 27 patients with
2007;2:27. doi: 10.1186/1750-1172-2-27 Kabuki (Niikawa-Kuroki) syndrome. Am J Med Genet A. 2004;127A:118–
176. Huber C, Cormier-Daire V. Ciliary disorder of the skeleton. Am J Med Genet 127. doi: 10.1002/ajmg.a.20674
C Semin Med Genet. 2012;160C:165–174. doi: 10.1002/ajmg.c.31336 196. Digilio MC, Gnazzo M, Lepri F, Dentici ML, Pisaneschi E, Baban A, Passarelli
177. Jones KL, Jones MC and Campo Md. Smith’s Recognizable Patterns of C, Capolino R, Angioni A, Novelli A, Marino B, Dallapiccola B. Congenital
Human Malformation. 7th ed. Philadelphia, PA: Elsevier Saunders; 2013. heart defects in molecularly proven Kabuki syndrome patients. Am J Med
178. Digilio MC, Marino B, Ammirati A, Borzaga U, Giannotti A, Dallapiccola Genet A. 2017;173:2912–2922. doi: 10.1002/ajmg.a.38417
B. Cardiac malformations in patients with oral-facial-skeletal syndromes: 197. Paulussen AD, Stegmann AP, Blok MJ, Tserpelis D, Posma-Velter C,
clinical similarities with heterotaxia. Am J Med Genet. 1999;84:350–356. Detisch Y, Smeets EE, Wagemans A, Schrander JJ, van den Boogaard MJ,
179. Galdzicka M, Patnala S, Hirshman MG, Cai JF, Nitowsky H, Egeland JA, van der Smagt J, van Haeringen A, Stolte-Dijkstra I, Kerstjens-Frederikse
Ginns EI. A new gene, EVC2, is mutated in Ellis-van Creveld syndrome. WS, Mancini GM, Wessels MW, Hennekam RC, Vreeburg M, Geraedts J,
Mol Genet Metab. 2002;77:291–295. de Ravel T, Fryns JP, Smeets HJ, Devriendt K, Schrander-Stumpel CT. MLL2
180. Blair HJ, Tompson S, Liu YN, Campbell J, MacArthur K, Ponting CP, Ruiz- mutation spectrum in 45 patients with Kabuki syndrome. Hum Mutat.
Perez VL, Goodship JA. Evc2 is a positive modulator of Hedgehog signal- 2011;32:E2018–E2025. doi: 10.1002/humu.21416
ling that interacts with Evc at the cilia membrane and is also found in the 198. Banka S, Lederer D, Benoit V, Jenkins E, Howard E, Bunstone S, Kerr
nucleus. BMC Biol. 2011;9:14. doi: 10.1186/1741-7007-9-14 B, McKee S, Lloyd IC, Shears D, Stewart H, White SM, Savarirayan R,
181. Zapata HH, Sletten LJ, Pierpont ME. Congenital cardiac malformations in Mancini GM, Beysen D, Cohn RD, Grisart B, Maystadt I, Donnai D.
Adams-Oliver syndrome. Clin Genet. 1995;47:80–84. Novel KDM6A (UTX) mutations and a clinical and molecular review of
182. Lehman A, Stittrich AB, Glusman G, Zong Z, Li H, Eydoux P, Senger C, the X-linked Kabuki syndrome (KS2). Clin Genet. 2015;87:252–258. doi:
Lyons C, Roach JC, Patel M. Diffuse angiopathy in Adams-Oliver syn- 10.1111/cge.12363
drome associated with truncating DOCK6 mutations. Am J Med Genet 199. Dentici ML, Barresi S, Niceta M, Pantaleoni F, Pizzi S, Dallapiccola B,
A. 2014;164A:2656–2662. doi: 10.1002/ajmg.a.36685 Tartaglia M, Digilio MC. Clinical spectrum of Kabuki-like syndrome
183. Martínez-Frías ML, Arroyo Carrera I, Muñoz-Delgado NJ, Nieto Conde caused by HNRNPK haploinsufficiency. Clin Genet. 2018;93:401–407.
C, Rodríguez-Pinilla E, Urioste Azcorra M, Omeñaca Teres F, García Alix doi: 10.1111/cge.13029
A. The Adams-Oliver syndrome in Spain: the epidemiological aspects [in 200. Badalato L, Farhan SM, Dilliott AA, Bulman DE, Hegele RA, Goobie SL;
Spanish]. An Esp Pediatr. 1996;45:57–61. Care4Rare Canada Consortium. KMT2D p.Gln3575His segregating in a
184. Southgate L, Sukalo M, Karountzos ASV, Taylor EJ, Collinson CS, family with autosomal dominant choanal atresia strengthens the Kabuki/
Ruddy D, Snape KM, Dallapiccola B, Tolmie JL, Joss S, Brancati F, Digilio CHARGE connection. Am J Med Genet A. 2017;173:183–189. doi:
MC, Graul-Neumann LM, Salviati L, Coerdt W, Jacquemin E, Wuyts 10.1002/ajmg.a.38010
W, Zenker M, Machado RD, Trembath RC. Haploinsufficiency of the 201. Verloes A. Updated diagnostic criteria for CHARGE syndrome: a
NOTCH1 receptor as a cause of Adams-Oliver syndrome with vari- proposal. Am J Med Genet A. 2005;133A:306–308. doi: 10.1002/
able cardiac anomalies. Circ Cardiovasc Genet. 2015;8:572–581. doi: ajmg.a.30559

10.1161/CIRCGENETICS.115.001086 202. Raqbi F, Le Bihan C, Morisseau-Durand MP, Dureau P, Lyonnet S, Abadie
185. Garg V, Muth AN, Ransom JF, Schluterman MK, Barnes R, King IN, V. Early prognostic factors for intellectual outcome in CHARGE syn-
Grossfeld PD, Srivastava D. Mutations in NOTCH1 cause aortic valve dis- drome. Dev Med Child Neurol. 2003;45:483–488.
ease. Nature. 2005;437:270–274. doi: 10.1038/nature03940 203. Zentner GE, Layman WS, Martin DM, Scacheri PC. Molecular and pheno-
186. Foffa I, Ait Alì L, Panesi P, Mariani M, Festa P, Botto N, Vecoli C, Andreassi typic aspects of CHD7 mutation in CHARGE syndrome. Am J Med Genet
MG. Sequencing of NOTCH1, GATA5, TGFBR1 and TGFBR2 genes in fa- A. 2010;152A:674–686. doi: 10.1002/ajmg.a.33323
milial cases of bicuspid aortic valve. BMC Med Genet. 2013;14:44. doi: 204. Lalani SR, Hefner MA, Belmont JW, Davenport SLH. CHARGE syndrome.
10.1186/1471-2350-14-44 In: Pagon RA, Adam MP, Ardinger HH, Wallace SE, Amemiya A, Bean
187. Dentici ML, Di Pede A, Lepri FR, Gnazzo M, Lombardi MH, Auriti C, LJH, Bird TD, Ledbetter N, Mefford HC, Smith RJH, Stephens K, eds.
Petrocchi S, Pisaneschi E, Bellacchio E, Capolino R, Braguglia A, Angioni GeneReviews®. Seattle, WA: University of Washington, Seattle; 1993.
A, Dotta A, Digilio MC, Dallapiccola B. Kabuki syndrome: clinical and mo- 205. Corsten-Janssen N, Kerstjens-Frederikse WS, du Marchie Sarvaas
lecular diagnosis in the first year of life. Arch Dis Child. 2015;100:158– GJ, Baardman ME, Bakker MK, Bergman JE, Hove HD, Heimdal
164. doi: 10.1136/archdischild-2013-305858 KR, Rustad CF, Hennekam RC, Hofstra RM, Hoefsloot LH, Van
188. Adam MP, Hudgins L, Hannibal M. Kabuki syndrome. In: Pagon RA, Ravenswaaij-Arts CM, Kapusta L. The cardiac phenotype in patients
Adam MP, Ardinger HH, Wallace SE, Amemiya A, Bean LJH, Bird TD, with a CHD7 mutation. Circ Cardiovasc Genet. 2013;6:248–254. doi:
Ledbetter N, Mefford HC, Smith RJH, Stephens K, eds. GeneReviews®. 10.1161/CIRCGENETICS.113.000054
Seattle, WA: University of Washington, Seattle; 1993. 206. Corsten-Janssen N, van Ravenswaaij-Arts CMA, Kapusta L. Congenital
189. Matsumoto N, Niikawa N. Kabuki make-up syndrome: a review. arch vessel anomalies in CHARGE syndrome: a frequent feature with
Am J Med Genet C Semin Med Genet. 2003;117C:57–65. doi: risk for co-morbidity. Int J Cardiol Heart Vasc. 2016;12:21–25. doi:
10.1002/ajmg.c.10020 10.1016/j.ijcha.2016.05.015
190. Yuan SM. Congenital heart defects in Kabuki syndrome. Cardiol J. 207. Issekutz KA, Graham JM Jr, Prasad C, Smith IM, Blake KD. An epide-
2013;20:121–124. doi: 10.5603/CJ.2013.0023 miological analysis of CHARGE syndrome: preliminary results from
191. Digilio MC, Marino B, Toscano A, Giannotti A, Dallapiccola B. Congenital a Canadian study. Am J Med Genet A. 2005;133A:309–317. doi:
heart defects in Kabuki syndrome. Am J Med Genet. 2001;100:269–274. 10.1002/ajmg.a.30560
192. Digilio MC, Baban A, Marino B, Dallapiccola B. Hypoplastic left heart syn- 208. Vuorela P, Ala-Mello S, Saloranta C, Penttinen M, Pöyhönen M, Huoponen
drome in patients with Kabuki syndrome. Pediatr Cardiol. 2010;31:1111– K, Borozdin W, Bausch B, Botzenhart EM, Wilhelm C, Kääriäinen H,
1113. doi: 10.1007/s00246-010-9773-y Kohlhase J. Molecular analysis of the CHD7 gene in CHARGE syndrome:
193. Yoon JK, Ahn KJ, Kwon BS, Kim GB, Bae EJ, Noh CI, Ko JM. The strong identification of 22 novel mutations and evidence for a low contribution
association of left-side heart anomalies with Kabuki syndrome. Korean J of large CHD7 deletions. Genet Med. 2007;9:690–694. doi: 10.1097GI
Pediatr. 2015;58:256–262. doi: 10.3345/kjp.2015.58.7.256 M.0b013e318156e68e
194. Niikawa N, Kuroki Y, Kajii T, Matsuura N, Ishikiriyama S, Tonoki H, 209. Jongmans MC, Hoefsloot LH, van der Donk KP, Admiraal RJ, Magee
Ishikawa N, Yamada Y, Fujita M, Umemoto H, Iwama Y, Kondoh I, A, van de Laar I, Hendriks Y, Verheij JB, Walpole I, Brunner HG, van
Fukushima Y, Naka Y, Matusui I, Urakami T, Aritaki S, Hara M, Suzuki Ravenswaaij CM. Familial CHARGE syndrome and the CHD7 gene: a re-
Y, Chyo H, Sugio Y, Hasegawa T, Yamanaka T, Tsukino R, Yoshida A, current missense mutation, intrafamilial recurrence and variability. Am J
Nomoto N, Kawahito S, Aihara R, Toyota S, Ieshima A, Funaki H, Ishitobi Med Genet A. 2008;146A:43–50. doi: 10.1002/ajmg.a.31921

210. Bergman JE, Janssen N, Hoefsloot LH, Jongmans MC, Hofstra RM, 231. Ramond F, Duband S, Croisille P, Cavé H, Teyssier G, Adouard V, Touraine
CLINICAL STATEMENTS
van Ravenswaaij-Arts CM. CHD7 mutations and CHARGE syndrome: R. Expanding the cardiac spectrum of Noonan syndrome with RIT1 vari-
AND GUIDELINES
the clinical implications of an expanding phenotype. J Med Genet. ant: left main coronary artery atresia causing sudden death. Eur J Med
2011;48:334–342. doi: 10.1136/jmg.2010.087106 Genet. 2017;60:299–302. doi: 10.1016/j.ejmg.2017.03.009
211. Lin AE, Birch PH, Korf BR, Tenconi R, Niimura M, Poyhonen M, Armfield 232. Mendez HM, Opitz JM. Noonan syndrome: a review. Am J Med Genet.
Uhas K, Sigorini M, Virdis R, Romano C, Bonioli E, Wolkenstein P, Pivnick 1985;21:493–506. doi: 10.1002/ajmg.1320210312
EK, Lawrence M, Friedman JM. Cardiovascular malformations and other 233. Tartaglia M, Mehler EL, Goldberg R, Zampino G, Brunner HG, Kremer
cardiovascular abnormalities in neurofibromatosis 1. Am J Med Genet. H, van der Burgt I, Crosby AH, Ion A, Jeffery S, Kalidas K, Patton MA,
2000;95:108–117. Kucherlapati RS, Gelb BD. Mutations in PTPN11, encoding the protein
212. Allanson JE, Hall JG, Hughes HE, Preus M, Witt RD. Noonan syndrome: tyrosine phosphatase SHP-2, cause Noonan syndrome [published correc-
the changing phenotype. Am J Med Genet. 1985;21:507–514. doi: tions appear in Nat Genet. 2002;30:123 and Nat Genet. 2001;29:491].
10.1002/ajmg.1320210313 Nat Genet. 2001;29:465–468. doi: 10.1038/ng772
213. Marin L da R, da Silva FT, de Sá LC, Brasil AS, Pereira A, Furquim IM, Kim 234. Tartaglia M, Kalidas K, Shaw A, Song X, Musat DL, van der Burgt I,
CA, Bertola DR. Ocular manifestations of Noonan syndrome. Ophthalmic Brunner HG, Bertola DR, Crosby A, Ion A, Kucherlapati RS, Jeffery S,
Genet. 2012;33:1–5. doi: 10.3109/13816810.2011.593606 Patton MA, Gelb BD. PTPN11 mutations in Noonan syndrome: molecular
214. van Trier DC, van Nierop J, Draaisma JM, van der Burgt I, Kunst H, spectrum, genotype-phenotype correlation, and phenotypic heterogene-
Croonen EA, Admiraal RJ. External ear anomalies and hearing impair- ity. Am J Hum Genet. 2002;70:1555–1563. doi: 10.1086/340847
ment in Noonan Syndrome. Int J Pediatr Otorhinolaryngol. 2015;79:874– 235. Tidyman WE, Rauen KA. Expansion of the RASopathies. Curr Genet Med
878. doi: 10.1016/j.ijporl.2015.03.021 Rep. 2016;4:57–64. doi: 10.1007/s40142-016-0100-7
215. Shah N, Rodriguez M, Louis DS, Lindley K, Milla PJ. Feeding difficul- 236. Tartaglia M, Cordeddu V, Chang H, Shaw A, Kalidas K, Crosby A, Patton
ties and foregut dysmotility in Noonan’s syndrome. Arch Dis Child. MA, Sorcini M, van der Burgt I, Jeffery S, Gelb BD. Paternal germline origin
1999;81:28–31. and sex-ratio distortion in transmission of PTPN11 mutations in Noonan
216. Noordam C, van der Burgt I, Sweep CG, Delemarre-van de Waal HA, syndrome. Am J Hum Genet. 2004;75:492–497. doi: 10.1086/423493
Sengers RC, Otten BJ. Growth hormone (GH) secretion in children with 237. Roberts AE, Araki T, Swanson KD, Montgomery KT, Schiripo TA, Joshi
Noonan syndrome: frequently abnormal without consequences for growth VA, Li L, Yassin Y, Tamburino AM, Neel BG, Kucherlapati RS. Germline
or response to GH treatment. Clin Endocrinol (Oxf). 2001;54:53–59. gain-of-function mutations in SOS1 cause Noonan syndrome. Nat Genet.
217. Şıklar Z, Genens M, Poyrazoğlu Ş, Baş F, Darendeliler F, Bundak R, Aycan 2007;39:70–74. doi: 10.1038/ng1926
Z, Savaş Erdeve Ş, Çetinkaya S, Güven A, Abalı S, Atay Z, Turan S, Kara 238. Razzaque MA, Nishizawa T, Komoike Y, Yagi H, Furutani M, Amo
C, Can Yılmaz G, Akyürek N, Abacı A, Çelmeli G, Sarı E, Bolu S, Korkmaz R, Kamisago M, Momma K, Katayama H, Nakagawa M, Fujiwara
HA, Şimşek E, Çatlı G, Büyükinan M, Çayır A, Evliyaoğlu O, İşgüven P, Y, Matsushima M, Mizuno K, Tokuyama M, Hirota H, Muneuchi J,
Özgen T, Hatipoğlu N, Elhan AH, Berberoğlu M. The growth characteris- Higashinakagawa T, Matsuoka R. Germline gain-of-function mutations
tics of patients with noonan syndrome: results of three years of growth in RAF1 cause Noonan syndrome. Nat Genet. 2007;39:1013–1017. doi:
hormone treatment: a nationwide multicenter study. J Clin Res Pediatr 10.1038/ng2078
Endocrinol. 2016;8:305–312. doi: 10.4274/jcrpe.3013 239. Yaoita M, Niihori T, Mizuno S, Okamoto N, Hayashi S, Watanabe
218. Briggs BJ, Dickerman JD. Bleeding disorders in Noonan syndrome. Pediatr A, Yokozawa M, Suzumura H, Nakahara A, Nakano Y, Hokosaki T,
Blood Cancer. 2012;58:167–172. doi: 10.1002/pbc.23358 Ohmori A, Sawada H, Migita O, Mima A, Lapunzina P, Santos-Simarro
219. Perez Botero J, Ho TP, Rodriguez V, Khan SP, Pruthi RK, Patnaik MM. F, García-Miñaúr S, Ogata T, Kawame H, Kurosawa K, Ohashi H, Inoue
Coagulation abnormalities and haemostatic surgical outcomes in 142 S, Matsubara Y, Kure S, Aoki Y. Spectrum of mutations and genotype-
patients with Noonan syndrome. Haemophilia. 2017;23:e237–e240. doi: phenotype analysis in Noonan syndrome patients with RIT1 mutations.
10.1111/hae.13225 Hum Genet. 2016;135:209–222. doi: 10.1007/s00439-015-1627-5.
220. Kratz CP, Rapisuwon S, Reed H, Hasle H, Rosenberg PS. Cancer in 240. Siegel DH, McKenzie J, Frieden IJ, Rauen KA. Dermatological findings in 61
Noonan, Costello, cardiofaciocutaneous and LEOPARD syndromes. mutation-positive individuals with cardiofaciocutaneous syndrome. Br J
Am J Med Genet C Semin Med Genet. 2011;157C:83–89. doi: Dermatol. 2011;164:521–529. doi: 10.1111/j.1365-2133.2010.10122.x
10.1002/ajmg.c.30300 241. Abe Y, Aoki Y, Kuriyama S, Kawame H, Okamoto N, Kurosawa K, Ohashi
221. White SW. Lymphedema in Noonan’s syndrome. Int J Dermatol. H, Mizuno S, Ogata T, Kure S, Niihori T, Matsubara Y; Costello and
1984;23:656–657. CFC Syndrome Study Group in Japan. Prevalence and clinical features
222. Roberts AE, Allanson JE, Tartaglia M, Gelb BD. Noonan syndrome. of Costello syndrome and cardio-facio-cutaneous syndrome in Japan:
Lancet. 2013;381:333–342. doi: 10.1016/S0140-6736(12)61023-X findings from a nationwide epidemiological survey. Am J Med Genet A.
223. Shaw AC, Kalidas K, Crosby AH, Jeffery S, Patton MA. The natural his- 2012;158A:1083–1094. doi: 10.1002/ajmg.a.35292
tory of Noonan syndrome: a long-term follow-up study. Arch Dis Child. 242. Gripp KW, Lin AE. Costello syndrome. In: Pagon RA, Adam MP, Ardinger
2007;92:128–132. doi: 10.1136/adc.2006.104547 HH, Wallace SE, Amemiya A, Bean LJH, Bird TD, Ledbetter N, Mefford
224. Smpokou P, Tworog-Dube E, Kucherlapati RS, Roberts AE. Medical com- HC, Smith RJH, Stephens K, eds. GeneReviews®. Seattle, WA: University
plications, clinical findings, and educational outcomes in adults with of Washington, Seattle; 1993.
Noonan syndrome. Am J Med Genet A. 2012;158A:3106–3111. doi: 243. Martínez-Quintana E, Rodríguez-González F. LEOPARD syndrome: clini-
10.1002/ajmg.a.35639 cal features and gene mutations. Mol Syndromol. 2012;3:145–157. doi:
225. Tartaglia M, Gelb BD, Zenker M. Noonan syndrome and clinically related 10.1159/000342251
disorders. Best Pract Res Clin Endocrinol Metab. 2011;25:161–179. doi: 244. Sarkozy A, Digilio MC, Dallapiccola B. Leopard syndrome. Orphanet J
10.1016/j.beem.2010.09.002 Rare Dis. 2008;3:13. doi: 10.1186/1750-1172-3-13
226. Pierpont EI. Neuropsychological functioning in individuals with Noonan 245. Jhang WK, Choi JH, Lee BH, Kim GH, Yoo HW. Cardiac manifes-
syndrome: a systematic literature review with educational and treatment tations and associations with gene mutations in patients diag-
recommendations. J Pediatr Neuropsychol. 2016;2:14–33. nosed with RASopathies. Pediatr Cardiol. 2016;37:1539–1547. doi:
227. Reinker KA, Stevenson DA, Tsung A. Orthopaedic conditions in Ras/ 10.1007/s00246-016-1468-6
MAPK related disorders. J Pediatr Orthop. 2011;31:599–605. doi: 246. Limongelli G, Pacileo G, Marino B, Digilio MC, Sarkozy A, Elliott P,
10.1097/BPO.0b013e318220396e Versacci P, Calabro P, De Zorzi A, Di Salvo G, Syrris P, Patton M, McKenna
228. Marino B, Digilio MC, Toscano A, Giannotti A, Dallapiccola B. Congenital WJ, Dallapiccola B, Calabro R. Prevalence and clinical significance of car-
heart diseases in children with Noonan syndrome: an expanded cardiovascular abnormalities in patients with the LEOPARD syndrome. Am J
diac spectrum with high prevalence of atrioventricular canal. J Pediatr. Cardiol. 2007;100:736–741. doi: 10.1016/j.amjcard.2007.03.093
1999;135:703–706. 247. Sol-Church K, Gripp KW. The molecular basis of the Costello syndrome.
229. Gelb BD, Roberts AE, Tartaglia M. Cardiomyopathies in Noonan syn- In: Zenker M, ed. Noonan Syndrome and Related Disorders. Basel,
drome and the other RASopathies. Prog Pediatr Cardiol. 2015;39:13–19. Switzerland: Karger; 2009(17):94–103.
doi: 10.1016/j.ppedcard.2015.01.002 248. Kontaridis MI, Swanson KD, David FS, Barford D, Neel BG. PTPN11
230. Cornwall JW, Green RS, Nielsen JC, Gelb BD. Frequency of aortic di- (Shp2) mutations in LEOPARD syndrome have dominant nega-
lation in Noonan syndrome. Am J Cardiol. 2014;113:368–371. doi: tive, not activating, effects. J Biol Chem. 2006;281:6785–6792. doi:
10.1016/j.amjcard.2013.09.034 10.1074/jbc.M513068200

249. Yoshiba S, Hamada H. Roles of cilia, fluid flow, and Ca2+ signaling in comparison of intrauterine, postnatal and postmortem diagnoses.
CLINICAL STATEMENTS
breaking of left-right symmetry. Trends Genet. 2014;30:10–17. doi: Ultrasound Obstet Gynecol. 2009;33:552–559. doi: 10.1002/uog.6309
AND GUIDELINES
10.1016/j.tig.2013.09.001 268. Cowan JR, Tariq M, Shaw C, Rao M, Belmont JW, Lalani SR, Smolarek TA,
250. Burnicka-Turek O, Steimle JD, Huang W, Felker L, Kamp A, Kweon J, Ware SM. Copy number variation as a genetic basis for heterotaxy and
Peterson M, Reeves RH, Maslen CL, Gruber PJ, Yang XH, Shendure J, heterotaxy-spectrum congenital heart defects. Philos Trans R Soc Lond B
Moskowitz IP. Cilia gene mutations cause atrioventricular septal defects Biol Sci. 2016;371.
by multiple mechanisms. Hum Mol Genet. 2016;25:3011–3028. doi: 269. Rigler SL, Kay DM, Sicko RJ, Fan R, Liu A, Caggana M, Browne ML,
10.1093/hmg/ddw155 Druschel CM, Romitti PA, Brody LC, Mills JL. Novel copy-number variants
251. Li Y, Klena NT, Gabriel GC, Liu X, Kim AJ, Lemke K, Chen Y, Chatterjee in a population-based investigation of classic heterotaxy. Genet Med.
B, Devine W, Damerla RR, Chang C, Yagi H, San Agustin JT, Thahir M, 2015;17:348–357. doi: 10.1038/gim.2014.112
Anderton S, Lawhead C, Vescovi A, Pratt H, Morgan J, Haynes L, Smith 270. Lander J, Ware SM. Copy number variation in congenital heart defects.
CL, Eppig JT, Reinholdt L, Francis R, Leatherbury L, Ganapathiraju MK, Curr Genet Med Rep. 2014;2:168–178.
Tobita K, Pazour GJ, Lo CW. Global genetic analysis in mice unveils cen- 271. Fakhro KA, Choi M, Ware SM, Belmont JW, Towbin JA, Lifton RP, Khokha
tral role for cilia in congenital heart disease. Nature. 2015;521:520–524. MK, Brueckner M. Rare copy number variations in congenital heart dis-
doi: 10.1038/nature14269 ease patients identify unique genes in left-right patterning. Proc Natl
252. Fliegauf M, Benzing T, Omran H. When cilia go bad: cilia defects and ciliop- Acad Sci U S A. 2011;108:2915–2920. doi: 10.1073/pnas.1019645108
athies [published correction appears in Nat Rev Mol Cell Biol. 2008;9:88]. 272. Hagen EM, Sicko RJ, Kay DM, Rigler SL, Dimopoulos A, Ahmad S, Doleman
Nat Rev Mol Cell Biol. 2007;8:880–893. doi: 10.1038/nrm2278 MH, Fan R, Romitti PA, Browne ML, Caggana M, Brody LC, Shaw GM,
253. Essner JJ, Vogan KJ, Wagner MK, Tabin CJ, Yost HJ, Brueckner M. Jelliffe-Pawlowski LL, Mills JL. Copy-number variant analysis of classic
Conserved function for embryonic nodal cilia. Nature. 2002;418:37–38. heterotaxy highlights the importance of body patterning pathways. Hum
doi: 10.1038/418037a Genet. 2016;135:1355–1364. doi: 10.1007/s00439-016-1727-x
254. Nonaka S, Tanaka Y, Okada Y, Takeda S, Harada A, Kanai Y, Kido M, 273. Øyen N, Poulsen G, Boyd HA, Wohlfahrt J, Jensen PK, Melbye M.
Hirokawa N. Randomization of left-right asymmetry due to loss of nodal Recurrence of congenital heart defects in families. Circulation.
cilia generating leftward flow of extraembryonic fluid in mice lacking 2009;120:295–301. doi: 10.1161/CIRCULATIONAHA.109.857987
KIF3B motor protein [published correction appears in Cell. 1999;99:117]. 274. Homsy J, Zaidi S, Shen Y, Ware JS, Samocha KE, Karczewski KJ, DePalma
Cell. 1998;95:829–837. SR, McKean D, Wakimoto H, Gorham J, Jin SC, Deanfield J, Giardini A,
255. McGrath J, Somlo S, Makova S, Tian X, Brueckner M. Two popula- Porter GA Jr, Kim R, Bilguvar K, López-Giráldez F, Tikhonova I, Mane S,
tions of node monocilia initiate left-right asymmetry in the mouse. Cell. Romano-Adesman A, Qi H, Vardarajan B, Ma L, Daly M, Roberts AE,
2003;114:61–73. Russell MW, Mital S, Newburger JW, Gaynor JW, Breitbart RE, Iossifov
256. Yoshiba S, Shiratori H, Kuo IY, Kawasumi A, Shinohara K, Nonaka S, I, Ronemus M, Sanders SJ, Kaltman JR, Seidman JG, Brueckner M,
Asai Y, Sasaki G, Belo JA, Sasaki H, Nakai J, Dworniczak B, Ehrlich BE, Gelb BD, Goldmuntz E, Lifton RP, Seidman CE, Chung WK. De novo
Pennekamp P, Hamada H. Cilia at the node of mouse embryos sense fluid mutations in congenital heart disease with neurodevelopmental and
flow for left-right determination via Pkd2. Science. 2012;338:226–231. other congenital anomalies. Science. 2015;350:1262–1266. doi:
doi: 10.1126/science.1222538 10.1126/science.aac9396
257. Hamada H, Tam PP. Mechanisms of left-right asymmetry and pattern- 275. Zaidi S, Choi M, Wakimoto H, Ma L, Jiang J, Overton JD, Romano-
ing: driver, mediator and responder. F1000Prime Rep. 2014;6:110. doi: Adesman A, Bjornson RD, Breitbart RE, Brown KK, Carriero NJ, Cheung
10.12703/P6-110 YH, Deanfield J, DePalma S, Fakhro KA, Glessner J, Hakonarson H, Italia
258. Stone DL, Slavotinek A, Bouffard GG, Banerjee-Basu S, Baxevanis AD, MJ, Kaltman JR, Kaski J, Kim R, Kline JK, Lee T, Leipzig J, Lopez A, Mane
Barr M, Biesecker LG. Mutation of a gene encoding a putative chapero- SM, Mitchell LE, Newburger JW, Parfenov M, Pe’er I, Porter G, Roberts
nin causes McKusick-Kaufman syndrome. Nat Genet. 2000;25:79–82. AE, Sachidanandam R, Sanders SJ, Seiden HS, State MW, Subramanian
doi: 10.1038/75637 S, Tikhonova IR, Wang W, Warburton D, White PS, Williams IA, Zhao H,
259. Sund KL, Roelker S, Ramachandran V, Durbin L, Benson DW. Analysis of Seidman JG, Brueckner M, Chung WK, Gelb BD, Goldmuntz E, Seidman
Ellis van Creveld syndrome gene products: implications for cardiovascular CE, Lifton RP. De novo mutations in histone-modifying genes in congeni-
development and disease. Hum Mol Genet. 2009;18:1813–1824. doi: tal heart disease. Nature. 2013;498:220–223. doi: 10.1038/nature12141
10.1093/hmg/ddp098 276. Sutherland MJ, Wang S, Quinn ME, Haaning A, Ware SM. Zic3 is re-
260. Tompson SW, Ruiz-Perez VL, Blair HJ, Barton S, Navarro V, Robson JL, quired in the migrating primitive streak for node morphogenesis and
Wright MJ, Goodship JA. Sequencing EVC and EVC2 identifies muta- left-right patterning. Hum Mol Genet. 2013;22:1913–1923. doi:
tions in two-thirds of Ellis-van Creveld syndrome patients. Hum Genet. 10.1093/hmg/ddt001
2007;120:663–670. doi: 10.1007/s00439-006-0237-7 277. Bedard JE, Haaning AM, Ware SM. Identification of a novel ZIC3 isoform
261. Slough J, Cooney L, Brueckner M. Monocilia in the embryonic mouse and mutation screening in patients with heterotaxy and congenital heart
heart suggest a direct role for cilia in cardiac morphogenesis. Dev Dyn. disease. PLoS One. 2011;6:e23755. doi: 10.1371/journal.pone.0023755
2008;237:2304–2314. doi: 10.1002/dvdy.21669 278. Cowan J, Tariq M, Ware SM. Genetic and functional analyses of ZIC3
262. Goetz JG, Steed E, Ferreira RR, Roth S, Ramspacher C, Boselli F, Charvin variants in congenital heart disease. Hum Mutat. 2014;35:66–75. doi:
G, Liebling M, Wyart C, Schwab Y, Vermot J. Endothelial cilia medi- 10.1002/humu.22457
ate low flow sensing during zebrafish vascular development. Cell Rep. 279. Ware SM, Peng J, Zhu L, Fernbach S, Colicos S, Casey B, Towbin J,
2014;6:799–808. doi: 10.1016/j.celrep.2014.01.032 Belmont JW. Identification and functional analysis of ZIC3 mutations
263. Sutherland MJ, Ware SM. Disorders of left-right asymmetry: het- in heterotaxy and related congenital heart defects. Am J Hum Genet.
erotaxy and situs inversus. Am J Med Genet C Semin Med Genet. 2004;74:93–105. doi: 10.1086/380998
2009;151C:307–317. doi: 10.1002/ajmg.c.30228 280. Gebbia M, Ferrero GB, Pilia G, Bassi MT, Aylsworth A, Penman-Splitt
264. Ticho BS, Goldstein AM, Van Praagh R. Extracardiac anomalies in the M, Bird LM, Bamforth JS, Burn J, Schlessinger D, Nelson DL, Casey B.
heterotaxy syndromes with focus on anomalies of midline-associated X-linked situs abnormalities result from mutations in ZIC3. Nat Genet.
structures. Am J Cardiol. 2000;85:729–734 1997;17:305–308. doi: 10.1038/ng1197-305
265. Lin AE, Krikov S, Riehle-Colarusso T, Frías JL, Belmont J, Anderka M, 281. Paulussen AD, Steyls A, Vanoevelen J, van Tienen FH, Krapels IP, Claes GR,
Geva T, Getz KD, Botto LD; National Birth Defects Prevention Study. Chocron S, Velter C, Tan-Sindhunata GM, Lundin C, Valenzuela I, Nagy B,
Laterality defects in the national birth defects prevention study (1998- Bache I, Maroun LL, Avela K, Brunner HG, Smeets HJ, Bakkers J, van den
2007): birth prevalence and descriptive epidemiology. Am J Med Genet Wijngaard A. Rare novel variants in the ZIC3 gene cause X-linked hetero-
A. 2014;164A:2581–2591. doi: 10.1002/ajmg.a.36695 taxy. Eur J Hum Genet. 2016;24:1783–1791. doi: 10.1038/ejhg.2016.91
266. Shapiro AJ, Tolleson-Rinehart S, Zariwala MA, Knowles MR, Leigh MW. 282. Mégarbané A, Salem N, Stephan E, Ashoush R, Lenoir D, Delague V,
The prevalence of clinical features associated with primary ciliary dyski- Kassab R, Loiselet J, Bouvagnet P. X-linked transposition of the great arter-
nesia in a heterotaxy population: results of a web-based survey. Cardiol ies and incomplete penetrance among males with a nonsense mutation in
Young. 2015;25:752–759. doi: 10.1017/S1047951114000912 ZIC3. Eur J Hum Genet. 2000;8:704–708. doi: 10.1038/sj.ejhg.5200526
267. Song MS, Hu A, Dyamenahalli U, Chitayat D, Winsor EJ, Ryan G, 283. Mohapatra B, Casey B, Li H, Ho-Dawson T, Smith L, Fernbach SD,
Smallhorn J, Barrett J, Yoo SJ, Hornberger LK. Extracardiac lesions and Molinari L, Niesh SR, Jefferies JL, Craigen WJ, Towbin JA, Belmont JW,
chromosomal abnormalities associated with major fetal heart defects: Ware SM. Identification and functional characterization of NODAL rare

variants in heterotaxy and isolated cardiovascular malformations. Hum 298. Otto EA, Schermer B, Obara T, O’Toole JF, Hiller KS, Mueller AM, Ruf RG,
CLINICAL STATEMENTS
Mol Genet. 2009;18:861–871. doi: 10.1093/hmg/ddn411 Hoefele J, Beekmann F, Landau D, Foreman JW, Goodship JA, Strachan
AND GUIDELINES
284. Goldmuntz E, Bamford R, Karkera JD, dela Cruz J, Roessler E, Muenke M. T, Kispert A, Wolf MT, Gagnadoux MF, Nivet H, Antignac C, Walz G,
CFC1 mutations in patients with transposition of the great arteries and Drummond IA, Benzing T, Hildebrandt F. Mutations in INVS encoding
double-outlet right ventricle. Am J Hum Genet. 2002;70:776–780. doi: inversin cause nephronophthisis type 2, linking renal cystic disease to
10.1086/339079 the function of primary cilia and left-right axis determination. Nat Genet.
285. Roessler E, Ouspenskaia MV, Karkera JD, Vélez JI, Kantipong A, 2003;34:413–420. doi: 10.1038/ng1217
Lacbawan F, Bowers P, Belmont JW, Towbin JA, Goldmuntz E, Feldman 299. Okada M, Sugimoto K, Shimada Y, Fujita S, Yanagida H, Yagi K, Takemura
B, Muenke M. Reduced NODAL signaling strength via mutation of sev- T. Association of INVS (NPHP2) mutation in an adolescent exhibit-
eral pathway members including FOXH1 is linked to human heart de- ing nephronophthisis (NPH) and complete situs inversus. Clin Nephrol.
fects and holoprosencephaly. Am J Hum Genet. 2008;83:18–29. doi: 2008;69:135–141.
10.1016/j.ajhg.2008.05.012 300. van Bon BW, Koolen DA, Pfundt R, van der Burgt I, de Leeuw N, de
286. Afzelius BA. A human syndrome caused by immotile cilia. Science. Vries BB. Transposition of the great vessels in a patient with a 2.9 Mb
1976;193:317–319. interstitial deletion of 9q31.1 encompassing the inversin gene: clinical
287. Lucas JS, Barbato A, Collins SA, Goutaki M, Behan L, Caudri D, Dell report and review. Am J Med Genet A. 2008;146A:1225–1229. doi:
S, Eber E, Escudier E, Hirst RA, Hogg C, Jorissen M, Latzin P, Legendre 10.1002/ajmg.a.32289
M, Leigh MW, Midulla F, Nielsen KG, Omran H, Papon JF, Pohunek P, 301. Chaki M, Hoefele J, Allen SJ, Ramaswami G, Janssen S, Bergmann C,
Redfern B, Rigau D, Rindlisbacher B, Santamaria F, Shoemark A, Snijders Heckenlively JR, Otto EA, Hildebrandt F. Genotype-phenotype cor-
D, Tonia T, Titieni A, Walker WT, Werner C, Bush A, Kuehni CE. European relation in 440 patients with NPHP-related ciliopathies. Kidney Int.
Respiratory Society guidelines for the diagnosis of primary ciliary dyskine- 2011;80:1239–1245. doi: 10.1038/ki.2011.284
sia. Eur Respir J. 2017;49:1601090. 302. Bergmann C, Fliegauf M, Brüchle NO, Frank V, Olbrich H, Kirschner J,
288. Kennedy MP, Omran H, Leigh MW, Dell S, Morgan L, Molina PL, Schermer B, Schmedding I, Kispert A, Kränzlin B, Nürnberg G, Becker
Robinson BV, Minnix SL, Olbrich H, Severin T, Ahrens P, Lange L, C, Grimm T, Girschick G, Lynch SA, Kelehan P, Senderek J, Neuhaus TJ,
Morillas HN, Noone PG, Zariwala MA, Knowles MR. Congenital heart Stallmach T, Zentgraf H, Nürnberg P, Gretz N, Lo C, Lienkamp S, Schäfer
disease and other heterotaxic defects in a large cohort of patients T, Walz G, Benzing T, Zerres K, Omran H. Loss of nephrocystin-3 func-
with primary ciliary dyskinesia. Circulation. 2007;115:2814–2821. doi: tion can cause embryonic lethality, Meckel-Gruber-like syndrome, situs
10.1161/CIRCULATIONAHA.106.649038 inversus, and renal-hepatic-pancreatic dysplasia. Am J Hum Genet.
289. Shapiro AJ, Davis SD, Ferkol T, Dell SD, Rosenfeld M, Olivier KN, 2008;82:959–970. doi: 10.1016/j.ajhg.2008.02.017
Sagel SD, Milla C, Zariwala MA, Wolf W, Carson JL, Hazucha MJ, 303. Hoff S, Halbritter J, Epting D, Frank V, Nguyen TM, van Reeuwijk J,
Burns K, Robinson B, Knowles MR, Leigh MW; Genetic Disorders of Boehlke C, Schell C, Yasunaga T, Helmstädter M, Mergen M, Filhol E,
Mucociliary Clearance Consortium. Laterality defects other than situs Boldt K, Horn N, Ueffing M, Otto EA, Eisenberger T, Elting MW, van Wijk
inversus totalis in primary ciliary dyskinesia: insights into situs am- JA, Bockenhauer D, Sebire NJ, Rittig S, Vyberg M, Ring T, Pohl M, Pape L,
biguus and heterotaxy. Chest. 2014;146:1176–1186. doi: 10.1378/ Neuhaus TJ, Elshakhs NA, Koon SJ, Harris PC, Grahammer F, Huber TB,
chest.13-1704 Kuehn EW, Kramer-Zucker A, Bolz HJ, Roepman R, Saunier S, Walz G,
290. Paff T, Loges NT, Aprea I, Wu K, Bakey Z, Haarman EG, Daniels JMA, Hildebrandt F, Bergmann C, Lienkamp SS. ANKS6 is a central component
Sistermans EA, Bogunovic N, Dougherty GW, Höben IM, Große- of a nephronophthisis module linking NEK8 to INVS and NPHP3. Nat
Onnebrink J, Matter A, Olbrich H, Werner C, Pals G, Schmidts M, Genet. 2013;45:951–956. doi: 10.1038/ng.2681
Omran H, Micha D. Mutations in PIH1D3 cause X-linked primary ciliary 304. Frank V, Habbig S, Bartram MP, Eisenberger T, Veenstra-Knol HE, Decker
dyskinesia with outer and inner dynein arm defects. Am J Hum Genet. C, Boorsma RA, Göbel H, Nürnberg G, Griessmann A, Franke M, Borgal
2017;100:160–168. doi: 10.1016/j.ajhg.2016.11.019 L, Kohli P, Völker LA, Dötsch J, Nürnberg P, Benzing T, Bolz HJ, Johnson C,
291. Bachmann-Gagescu R, Dempsey JC, Phelps IG, O’Roak BJ, Knutzen DM, Gerkes EH, Schermer B, Bergmann C. Mutations in NEK8 link multiple or-
Rue TC, Ishak GE, Isabella CR, Gorden N, Adkins J, Boyle EA, de Lacy N, gan dysplasia with altered Hippo signalling and increased c-MYC expres-
O’Day D, Alswaid A, Ramadevi A R, Lingappa L, Lourenço C, Martorell sion. Hum Mol Genet. 2013;22:2177–2185. doi: 10.1093/hmg/ddt070
L, Garcia-Cazorla À, Ozyürek H, Haliloğlu G, Tuysuz B, Topçu M, Chance 305. Mitchison HM, Schmidts M, Loges NT, Freshour J, Dritsoula A, Hirst
P, Parisi MA, Glass IA, Shendure J, Doherty D; University of Washington RA, O’Callaghan C, Blau H, Al Dabbagh M, Olbrich H, Beales PL, Yagi
Center for Mendelian Genomics. Joubert syndrome: a model for un- T, Mussaffi H, Chung EM, Omran H, Mitchell DR. Mutations in axone-
tangling recessive disorders with extreme genetic heterogeneity. J Med mal dynein assembly factor DNAAF3 cause primary ciliary dyskinesia. Nat
Genet. 2015;52:514–522. doi: 10.1136/jmedgenet-2015-103087 Genet. 2012;44:381–9, S1. doi: 10.1038/ng.1106
292. Oud MM, Lamers IJ, Arts HH. Ciliopathies: genetics in pediatric medicine. 306. Merveille AC, Davis EE, Becker-Heck A, Legendre M, Amirav I, Bataille
J Pediatr Genet. 2017;6:18–29. doi: 10.1055/s-0036-1593841 G, Belmont J, Beydon N, Billen F, Clément A, Clercx C, Coste A, Crosbie
293. Reiter JF, Leroux MR. Genes and molecular pathways underpin- R, de Blic J, Deleuze S, Duquesnoy P, Escalier D, Escudier E, Fliegauf M,
ning ciliopathies. Nat Rev Mol Cell Biol. 2017;18:533–547. doi: Horvath J, Hill K, Jorissen M, Just J, Kispert A, Lathrop M, Loges NT,
10.1038/nrm.2017.60 Marthin JK, Momozawa Y, Montantin G, Nielsen KG, Olbrich H, Papon JF,
294. Bruel AL, Franco B, Duffourd Y, Thevenon J, Jego L, Lopez E, Deleuze JF, Rayet I, Roger G, Schmidts M, Tenreiro H, Towbin JA, Zelenika D, Zentgraf
Doummar D, Giles RH, Johnson CA, Huynen MA, Chevrier V, Burglen H, Georges M, Lequarré AS, Katsanis N, Omran H, Amselem S. CCDC39
L, Morleo M, Desguerres I, Pierquin G, Doray B, Gilbert-Dussardier B, is required for assembly of inner dynein arms and the dynein regulatory
Reversade B, Steichen-Gersdorf E, Baumann C, Panigrahi I, Fargeot- complex and for normal ciliary motility in humans and dogs. Nat Genet.
Espaliat A, Dieux A, David A, Goldenberg A, Bongers E, Gaillard D, 2011;43:72–78. doi: 10.1038/ng.726
Argente J, Aral B, Gigot N, St-Onge J, Birnbaum D, Phadke SR, Cormier- 307. Becker-Heck A, Zohn IE, Okabe N, Pollock A, Lenhart KB, Sullivan-Brown
Daire V, Eguether T, Pazour GJ, Herranz-Pérez V, Goldstein JS, Pasquier J, McSheene J, Loges NT, Olbrich H, Haeffner K, Fliegauf M, Horvath J,
L, Loget P, Saunier S, Mégarbané A, Rosnet O, Leroux MR, Wallingford Reinhardt R, Nielsen KG, Marthin JK, Baktai G, Anderson KV, Geisler R,
JB, Blacque OE, Nachury MV, Attie-Bitach T, Rivière JB, Faivre L, Thauvin- Niswander L, Omran H, Burdine RD. The coiled-coil domain containing
Robinet C. Fifteen years of research on oral-facial-digital syndromes: protein CCDC40 is essential for motile cilia function and left-right axis
from 1 to 16 causal genes. J Med Genet. 2017;54:371–380. doi: formation. Nat Genet. 2011;43:79–84. doi: 10.1038/ng.727
10.1136/jmedgenet-2016-104436 308. Panizzi JR, Becker-Heck A, Castleman VH, Al-Mutairi DA, Liu Y, Loges NT,
295. Franco B, Thauvin-Robinet C. Update on oral-facial-digital syndromes Pathak N, Austin-Tse C, Sheridan E, Schmidts M, Olbrich H, Werner C,
(OFDS). Cilia. 2016;5:12. doi: 10.1186/s13630-016-0034-4 Häffner K, Hellman N, Chodhari R, Gupta A, Kramer-Zucker A, Olale F,
296. Parisi MA. Clinical and molecular features of Joubert syndrome and re- Burdine RD, Schier AF, O’Callaghan C, Chung EM, Reinhardt R, Mitchison
lated disorders. Am J Med Genet C Semin Med Genet. 2009;151C:326– HM, King SM, Omran H, Drummond IA. CCDC103 mutations cause pri-
340. doi: 10.1002/ajmg.c.30229 mary ciliary dyskinesia by disrupting assembly of ciliary dynein arms. Nat
297. Kaasinen E, Aittomäki K, Eronen M, Vahteristo P, Karhu A, Mecklin JP, Genet. 2012;44:714–719. doi: 10.1038/ng.2277
Kajantie E, Aaltonen LA, Lehtonen R. Recessively inherited right atrial 309. Horani A, Druley TE, Zariwala MA, Patel AC, Levinson BT, Van Arendonk
isomerism caused by mutations in growth/differentiation factor 1 (GDF1). LG, Thornton KC, Giacalone JC, Albee AJ, Wilson KS, Turner EH,
Hum Mol Genet. 2010;19:2747–2753. doi: 10.1093/hmg/ddq164 Nickerson DA, Shendure J, Bayly PV, Leigh MW, Knowles MR, Brody SL,

Dutcher SK, Ferkol TW. Whole-exome capture and sequencing identifies primary ciliary dyskinesia with outer dynein arm defects. Am J Respir Crit
CLINICAL STATEMENTS
HEATR2 mutation as a cause of primary ciliary dyskinesia. Am J Hum Care Med. 2006;174:120–126. doi: 10.1164/rccm.200601-084OC
AND GUIDELINES
Genet. 2012;91:685–693. doi: 10.1016/j.ajhg.2012.08.022 319. Duriez B, Duquesnoy P, Escudier E, Bridoux AM, Escalier D, Rayet I,
310. Hjeij R, Lindstrand A, Francis R, Zariwala MA, Liu X, Li Y, Damerla R, Marcos E, Vojtek AM, Bercher JF, Amselem S. A common variant in
Dougherty GW, Abouhamed M, Olbrich H, Loges NT, Pennekamp combination with a nonsense mutation in a member of the thioredoxin
P, Davis EE, Carvalho CM, Pehlivan D, Werner C, Raidt J, Köhler G, family causes primary ciliary dyskinesia [published correction appears in
Häffner K, Reyes-Mugica M, Lupski JR, Leigh MW, Rosenfeld M, Proc Natl Acad Sci U S A. 2007;104:6490.]. Proc Natl Acad Sci U S A.
Morgan LC, Knowles MR, Lo CW, Katsanis N, Omran H. ARMC4 mu- 2007;104:3336–3341. doi: 10.1073/pnas.0611405104
tations cause primary ciliary dyskinesia with randomization of left/ 320. Wallmeier J, Shiratori H, Dougherty GW, Edelbusch C, Hjeij R, Loges
right body asymmetry. Am J Hum Genet. 2013;93:357–367. doi: NT, Menchen T, Olbrich H, Pennekamp P, Raidt J, Werner C, Minegishi
10.1016/j.ajhg.2013.06.009 K, Shinohara K, Asai Y, Takaoka K, Lee C, Griese M, Memari Y, Durbin
311. Tarkar A, Loges NT, Slagle CE, Francis R, Dougherty GW, Tamayo JV, R, Kolb-Kokocinski A, Sauer S, Wallingford JB, Hamada H, Omran H.
Shook B, Cantino M, Schwartz D, Jahnke C, Olbrich H, Werner C, TTC25 deficiency results in defects of the outer dynein arm docking
Raidt J, Pennekamp P, Abouhamed M, Hjeij R, Köhler G, Griese M, Li machinery and primary ciliary dyskinesia with left-right body asym-
Y, Lemke K, Klena N, Liu X, Gabriel G, Tobita K, Jaspers M, Morgan metry randomization. Am J Hum Genet. 2016;99:460–469. doi:
LC, Shapiro AJ, Letteboer SJ, Mans DA, Carson JL, Leigh MW, Wolf 10.1016/j.ajhg.2016.06.014
WE, Chen S, Lucas JS, Onoufriadis A, Plagnol V, Schmidts M, Boldt K, 321. Knowles MR, Leigh MW, Carson JL, Davis SD, Dell SD, Ferkol TW, Olivier
Roepman R, Zariwala MA, Lo CW, Mitchison HM, Knowles MR, Burdine KN, Sagel SD, Rosenfeld M, Burns KA, Minnix SL, Armstrong MC, Lori A,
RD, Loturco JJ, Omran H; UK10K. DYX1C1 is required for axonemal Hazucha MJ, Loges NT, Olbrich H, Becker-Heck A, Schmidts M, Werner
dynein assembly and ciliary motility. Nat Genet. 2013;45:995–1003. C, Omran H, Zariwala MA; Genetic Disorders of Mucociliary Clearance
doi: 10.1038/ng.2707 Consortium. Mutations of DNAH11 in patients with primary ciliary dys-
312. Austin-Tse C, Halbritter J, Zariwala MA, Gilberti RM, Gee HY, Hellman N, kinesia with normal ciliary ultrastructure. Thorax. 2012;67:433–441. doi:
Pathak N, Liu Y, Panizzi JR, Patel-King RS, Tritschler D, Bower R, O’Toole 10.1136/thoraxjnl-2011-200301
E, Porath JD, Hurd TW, Chaki M, Diaz KA, Kohl S, Lovric S, Hwang DY, 322. Bartoloni L, Blouin JL, Pan Y, Gehrig C, Maiti AK, Scamuffa N, Rossier C,
Braun DA, Schueler M, Airik R, Otto EA, Leigh MW, Noone PG, Carson JL, Jorissen M, Armengot M, Meeks M, Mitchison HM, Chung EM, Delozier-
Davis SD, Pittman JE, Ferkol TW, Atkinson JJ, Olivier KN, Sagel SD, Dell SD, Blanchet CD, Craigen WJ, Antonarakis SE. Mutations in the DNAH11
Rosenfeld M, Milla CE, Loges NT, Omran H, Porter ME, King SM, Knowles (axonemal heavy chain dynein type 11) gene cause one form of situs
MR, Drummond IA, Hildebrandt F. Zebrafish ciliopathy screen plus hu- inversus totalis and most likely primary ciliary dyskinesia. Proc Natl Acad
man mutational analysis identifies C21orf59 and CCDC65 defects as Sci U S A. 2002;99:10282–10286. doi: 10.1073/pnas.152337699
causing primary ciliary dyskinesia. Am J Hum Genet. 2013;93:672–686. 323. Zariwala MA, Leigh MW, Ceppa F, Kennedy MP, Noone PG, Carson
doi: 10.1016/j.ajhg.2013.08.015 JL, Hazucha MJ, Lori A, Horvath J, Olbrich H, Loges NT, Bridoux AM,
313. Knowles MR, Ostrowski LE, Loges NT, Hurd T, Leigh MW, Huang L, Pennarun G, Duriez B, Escudier E, Mitchison HM, Chodhari R, Chung
Wolf WE, Carson JL, Hazucha MJ, Yin W, Davis SD, Dell SD, Ferkol EM, Morgan LC, de Iongh RU, Rutland J, Pradal U, Omran H, Amselem S,
TW, Sagel SD, Olivier KN, Jahnke C, Olbrich H, Werner C, Raidt J, Knowles MR. Mutations of DNAI1 in primary ciliary dyskinesia: evidence
Wallmeier J, Pennekamp P, Dougherty GW, Hjeij R, Gee HY, Otto of founder effect in a common mutation. Am J Respir Crit Care Med.
EA, Halbritter J, Chaki M, Diaz KA, Braun DA, Porath JD, Schueler 2006;174:858–866. doi: 10.1164/rccm.200603-370OC
M, Baktai G, Griese M, Turner EH, Lewis AP, Bamshad MJ, Nickerson 324. Guichard C, Harricane MC, Lafitte JJ, Godard P, Zaegel M, Tack V, Lalau
DA, Hildebrandt F, Shendure J, Omran H, Zariwala MA. Mutations in G, Bouvagnet P. Axonemal dynein intermediate-chain gene (DNAI1) mu-
SPAG1 cause primary ciliary dyskinesia associated with defective outer tations result in situs inversus and primary ciliary dyskinesia (Kartagener
and inner dynein arms. Am J Hum Genet. 2013;93:711–720. doi: syndrome). Am J Hum Genet. 2001;68:1030–1035. doi: 10.1086/319511
10.1016/j.ajhg.2013.07.025 325. Mazor M, Alkrinawi S, Chalifa-Caspi V, Manor E, Sheffield VC, Aviram M,
314. Hjeij R, Onoufriadis A, Watson CM, Slagle CE, Klena NT, Dougherty Parvari R. Primary ciliary dyskinesia caused by homozygous mutation in
GW, Kurkowiak M, Loges NT, Diggle CP, Morante NF, Gabriel GC, DNAL1, encoding dynein light chain 1. Am J Hum Genet. 2011;88:599–
Lemke KL, Li Y, Pennekamp P, Menchen T, Konert F, Marthin JK, 607. doi: 10.1016/j.ajhg.2011.03.018
Mans DA, Letteboer SJ, Werner C, Burgoyne T, Westermann C, 326. Onoufriadis A, Paff T, Antony D, Shoemark A, Micha D, Kuyt B, Schmidts
Rutman A, Carr IM, O’Callaghan C, Moya E, Chung EM, Sheridan E, M, Petridi S, Dankert-Roelse JE, Haarman EG, Daniels JM, Emes RD,
Nielsen KG, Roepman R, Bartscherer K, Burdine RD, Lo CW, Omran Wilson R, Hogg C, Scambler PJ, Chung EM, Pals G, Mitchison HM;
H, Mitchison HM; UK10K Consortium. CCDC151 mutations cause UK10K. Splice-site mutations in the axonemal outer dynein arm dock-
primary ciliary dyskinesia by disruption of the outer dynein arm docking complex gene CCDC114 cause primary ciliary dyskinesia. Am J Hum
ing complex formation. Am J Hum Genet. 2014;95:257–274. doi: Genet. 2013;92:88–98. doi: 10.1016/j.ajhg.2012.11.002
10.1016/j.ajhg.2014.08.005 327. Kott E, Duquesnoy P, Copin B, Legendre M, Dastot-Le Moal F, Montantin
315. Duquesnoy P, Escudier E, Vincensini L, Freshour J, Bridoux AM, Coste G, Jeanson L, Tamalet A, Papon JF, Siffroi JP, Rives N, Mitchell V, de Blic J,
A, Deschildre A, de Blic J, Legendre M, Montantin G, Tenreiro H, Coste A, Clement A, Escalier D, Touré A, Escudier E, Amselem S. Loss-of-
Vojtek AM, Loussert C, Clément A, Escalier D, Bastin P, Mitchell DR, function mutations in LRRC6, a gene essential for proper axonemal as-
Amselem S. Loss-of-function mutations in the human ortholog of sembly of inner and outer dynein arms, cause primary ciliary dyskinesia.
Chlamydomonas reinhardtii ODA7 disrupt dynein arm assembly and Am J Hum Genet. 2012;91:958–964. doi: 10.1016/j.ajhg.2012.10.003
cause primary ciliary dyskinesia. Am J Hum Genet. 2009;85:890–896. 328. Zariwala MA, Gee HY, Kurkowiak M, Al-Mutairi DA, Leigh MW, Hurd
doi: 10.1016/j.ajhg.2009.11.008 TW, Hjeij R, Dell SD, Chaki M, Dougherty GW, Adan M, Spear PC, Esteve-
316. Loges NT, Olbrich H, Becker-Heck A, Häffner K, Heer A, Reinhard C, Rudd J, Loges NT, Rosenfeld M, Diaz KA, Olbrich H, Wolf WE, Sheridan
Schmidts M, Kispert A, Zariwala MA, Leigh MW, Knowles MR, Zentgraf E, Batten TF, Halbritter J, Porath JD, Kohl S, Lovric S, Hwang DY, Pittman
H, Seithe H, Nürnberg G, Nürnberg P, Reinhardt R, Omran H. Deletions JE, Burns KA, Ferkol TW, Sagel SD, Olivier KN, Morgan LC, Werner C,
and point mutations of LRRC50 cause primary ciliary dyskinesia due Raidt J, Pennekamp P, Sun Z, Zhou W, Airik R, Natarajan S, Allen SJ,
to dynein arm defects. Am J Hum Genet. 2009;85:883–889. doi: Amirav I, Wieczorek D, Landwehr K, Nielsen K, Schwerk N, Sertic J,
10.1016/j.ajhg.2009.10.018 Köhler G, Washburn J, Levy S, Fan S, Koerner-Rettberg C, Amselem S,
317. Omran H, Kobayashi D, Olbrich H, Tsukahara T, Loges NT, Hagiwara H, Williams DS, Mitchell BJ, Drummond IA, Otto EA, Omran H, Knowles
Zhang Q, Leblond G, O’Toole E, Hara C, Mizuno H, Kawano H, Fliegauf MR, Hildebrandt F. ZMYND10 is mutated in primary ciliary dyskinesia
M, Yagi T, Koshida S, Miyawaki A, Zentgraf H, Seithe H, Reinhardt R, and interacts with LRRC6. Am J Hum Genet. 2013;93:336–345. doi:
Watanabe Y, Kamiya R, Mitchell DR, Takeda H. Ktu/PF13 is required for 10.1016/j.ajhg.2013.06.007
cytoplasmic pre-assembly of axonemal dyneins. Nature. 2008;456:611– 329. Moore DJ, Onoufriadis A, Shoemark A, Simpson MA, zur Lage PI, de
616. doi: 10.1038/nature07471 Castro SC, Bartoloni L, Gallone G, Petridi S, Woollard WJ, Antony D,
318. Hornef N, Olbrich H, Horvath J, Zariwala MA, Fliegauf M, Loges NT, Schmidts M, Didonna T, Makrythanasis P, Bevillard J, Mongan NP, Djakow
Wildhaber J, Noone PG, Kennedy M, Antonarakis SE, Blouin JL, Bartoloni J, Pals G, Lucas JS, Marthin JK, Nielsen KG, Santoni F, Guipponi M, Hogg
L, Nüsslein T, Ahrens P, Griese M, Kuhl H, Sudbrak R, Knowles MR, C, Antonarakis SE, Emes RD, Chung EM, Greene ND, Blouin JL, Jarman
Reinhardt R, Omran H. DNAH5 mutations are a common cause of AP, Mitchison HM. Mutations in ZMYND10, a gene essential for proper

axonemal assembly of inner and outer dynein arms in humans and flies, 347. Rajagopal SK, Ma Q, Obler D, Shen J, Manichaikul A, Tomita-Mitchell A,
CLINICAL STATEMENTS
cause primary ciliary dyskinesia. Am J Hum Genet. 2013;93:346–356. Boardman K, Briggs C, Garg V, Srivastava D, Goldmuntz E, Broman KW,
AND GUIDELINES
doi: 10.1016/j.ajhg.2013.07.009 Benson DW, Smoot LB, Pu WT. Spectrum of heart disease associated with
330. Perles Z, Cinnamon Y, Ta-Shma A, Shaag A, Einbinder T, Rein AJ, Elpeleg O. murine and human GATA4 mutation. J Mol Cell Cardiol. 2007;43:677–
A human laterality disorder associated with recessive CCDC11 mutation. 685. doi: 10.1016/j.yjmcc.2007.06.004
J Med Genet. 2012;49:386–390. doi: 10.1136/jmedgenet-2011-100457 348. Chen Y, Han ZQ, Yan WD, Tang CZ, Xie JY, Chen H, Hu DY. A novel
331. Bataille S, Demoulin N, Devuyst O, Audrézet MP, Dahan K, Godin M, mutation in GATA4 gene associated with dominant inherited familial
Fontès M, Pirson Y, Burtey S. Association of PKD2 (polycystin 2) muta- atrial septal defect. J Thorac Cardiovasc Surg. 2010;140:684–687. doi:
tions with left-right laterality defects. Am J Kidney Dis. 2011;58:456– 10.1016/j.jtcvs.2010.01.013
460. doi: 10.1053/j.ajkd.2011.05.015 349. Xiang R, Fan LL, Huang H, Cao BB, Li XP, Peng DQ, Xia K. A novel
332. Vetrini F, D’Alessandro LC, Akdemir ZC, Braxton A, Azamian MS, Eldomery mutation of GATA4 (K319E) is responsible for familial atrial septal de-
MK, Miller K, Kois C, Sack V, Shur N, Rijhsinghani A, Chandarana J, Ding fect and pulmonary valve stenosis. Gene. 2014;534:320–323. doi:
Y, Holtzman J, Jhangiani SN, Muzny DM, Gibbs RA, Eng CM, Hanchard 10.1016/j.gene.2013.10.028
NA, Harel T, Rosenfeld JA, Belmont JW, Lupski JR, Yang Y. Bi-allelic muta- 350. Chen J, Qi B, Zhao J, Liu W, Duan R, Zhang M. A novel mutation of
tions in PKD1L1 are associated with laterality defects in humans. Am J GATA4 (K300T) associated with familial atrial septal defect. Gene.
Hum Genet. 2016;99:886–893. doi: 10.1016/j.ajhg.2016.07.011 2016;575(pt 2):473–477. doi: 10.1016/j.gene.2015.09.021
333. Durst R, Sauls K, Peal DS, deVlaming A, Toomer K, Leyne M, Salani 351. Kodo K, Nishizawa T, Furutani M, Arai S, Yamamura E, Joo K, Takahashi T,
M, Talkowski ME, Brand H, Perrocheau M, Simpson C, Jett C, Stone Matsuoka R, Yamagishi H. GATA6 mutations cause human cardiac outflow
MR, Charles F, Chiang C, Lynch SN, Bouatia-Naji N, Delling FN, Freed tract defects by disrupting semaphorin-plexin signaling. Proc Natl Acad
LA, Tribouilloy C, Le Tourneau T, LeMarec H, Fernandez-Friera L, Solis Sci U S A. 2009;106:13933–13938. doi: 10.1073/pnas.0904744106
J, Trujillano D, Ossowski S, Estivill X, Dina C, Bruneval P, Chester A, 352. Maitra M, Koenig SN, Srivastava D, Garg V. Identification of GATA6 se-
Schott JJ, Irvine KD, Mao Y, Wessels A, Motiwala T, Puceat M, Tsukasaki quence variants in patients with congenital heart defects. Pediatr Res.
Y, Menick DR, Kasiganesan H, Nie X, Broome AM, Williams K, Johnson 2010;68:281–285. doi: 10.1203/PDR.0b013e3181ed17e4
A, Markwald RR, Jeunemaitre X, Hagege A, Levine RA, Milan DJ, Norris 353. Lin X, Huo Z, Liu X, Zhang Y, Li L, Zhao H, Yan B, Liu Y, Yang Y, Chen YH.
RA, Slaugenhaupt SA. Mutations in DCHS1 cause mitral valve prolapse. A novel GATA6 mutation in patients with tetralogy of Fallot or atrial sep-
Nature. 2015;525:109–113. doi: 10.1038/nature14670 tal defect. J Hum Genet. 2010;55:662–667. doi: 10.1038/jhg.2010.84
334. Dau C, Fliegauf M, Omran H, Schlensog M, Dahl E, van Roeyen CR, Kriz 354. Allen HL, Flanagan SE, Shaw-Smith C, De Franco E, Akerman I, Caswell
W, Moeller MJ, Braun GS. The atypical cadherin Dachsous1 localizes to R, Ferrer J, Hattersley AT, Ellard S; International Pancreatic Agenesis
the base of the ciliary apparatus in airway epithelia. Biochem Biophys Res Consortium. GATA6 haploinsufficiency causes pancreatic agenesis in hu-
Commun. 2016;473:1177–1184. doi: 10.1016/j.bbrc.2016.04.036 mans. Nat Genet. 2011;44:20–22. doi: 10.1038/ng.1035
335. Harden B, Tian X, Giese R, Nakhleh N, Kureshi S, Francis R, 355. Yorifuji T, Kawakita R, Hosokawa Y, Fujimaru R, Yamaguchi E, Tamagawa
Hanumanthaiah S, Li Y, Swisher M, Kuehl K, Sami I, Olivier K, Jonas R, N. Dominantly inherited diabetes mellitus caused by GATA6 haploinsuf-
Lo CW, Leatherbury L. Increased postoperative respiratory complications ficiency: variable intrafamilial presentation. J Med Genet. 2012;49:642–
in heterotaxy congenital heart disease patients with respiratory ciliary 643. doi: 10.1136/jmedgenet-2012-101161
dysfunction. J Thorac Cardiovasc Surg. 2014;147:1291–1298.e2. doi: 356. Muncke N, Jung C, Rüdiger H, Ulmer H, Roeth R, Hubert A,
10.1016/j.jtcvs.2013.06.018 Goldmuntz E, Driscoll D, Goodship J, Schön K, Rappold G. Missense
336. Horani A, Ferkol TW, Dutcher SK, Brody SL. Genetics and biology of mutations and gene interruption in PROSIT240, a novel TRAP240-
primary ciliary dyskinesia. Paediatr Respir Rev. 2016;18:18–24. doi: like gene, in patients with congenital heart defect (transposi-
10.1016/j.prrv.2015.09.001 tion of the great arteries). Circulation. 2003;108:2843–2850. doi:

337. Wang S, Dong Z. Primary cilia and kidney injury: current research status 10.1161/01.CIR.0000103684.77636.CD
and future perspectives. Am J Physiol Renal Physiol. 2013;305:F1085– 357. Al Turki S, Manickaraj AK, Mercer CL, Gerety SS, Hitz MP, Lindsay S,
F1098. doi: 10.1152/ajprenal.00399.2013 D’Alessandro LC, Swaminathan GJ, Bentham J, Arndt AK, Louw J,
338. Panigrahy A, Lee V, Ceschin R, Zuccoli G, Beluk N, Khalifa O, Votava- Breckpot J, Gewillig M, Thienpont B, Abdul-Khaliq H, Harnack C, Hoff
Smith JK, DeBrunner M, Munoz R, Domnina Y, Morell V, Wearden P, K, Kramer HH, Schubert S, Siebert R, Toka O, Cosgrove C, Watkins H,
Sanchez De Toledo J, Devine W, Zahid M, Lo CW. Brain dysplasia associ- Lucassen AM, O’Kelly IM, Salmon AP, Bu’lock FA, Granados-Riveron
ated with ciliary dysfunction in infants with congenital heart disease. J J, Setchfield K, Thornborough C, Brook JD, Mulder B, Klaassen S,
Pediatr. 2016;178:141–148.e1. doi: 10.1016/j.jpeds.2016.07.041 Bhattacharya S, Devriendt K, Fitzpatrick DF, Wilson DI, Mital S, Hurles
339. Volta F, Gerdes JM. The role of primary cilia in obesity and diabetes. Ann ME; UK10K Consortium. Rare variants in NR2F2 cause congenital
N Y Acad Sci. 2017;1391:71–84. doi: 10.1111/nyas.13216 heart defects in humans [published correction appears in Am J Hum
340. Andersen TA, Troelsen Kde L, Larsen LA. Of mice and men: molecular ge- Genet. 2014;95:126]. Am J Hum Genet. 2014;94:574–585. doi:
netics of congenital heart disease. Cell Mol Life Sci. 2014;71:1327–1352. 10.1016/j.ajhg.2014.03.007
doi: 10.1007/s00018-013-1430-1 358. Schott JJ, Benson DW, Basson CT, Pease W, Silberbach GM, Moak
341. Fahed AC, Gelb BD, Seidman JG, Seidman CE. Genetics of con- JP, Maron BJ, Seidman CE, Seidman JG. Congenital heart disease
genital heart disease: the glass half empty [published correction ap- caused by mutations in the transcription factor NKX2-5. Science.
pears in Circ Res. 2013;112:e182]. Circ Res. 2013;112:707–720. doi: 1998;281:108–111.
10.1161/CIRCRESAHA.112.300853 359. Benson DW, Silberbach GM, Kavanaugh-McHugh A, Cottrill C, Zhang
342. Sperling S, Grimm CH, Dunkel I, Mebus S, Sperling HP, Ebner A, Galli R, Y, Riggs S, Smalls O, Johnson MC, Watson MS, Seidman JG, Seidman
Lehrach H, Fusch C, Berger F, Hammer S. Identification and functional CE, Plowden J, Kugler JD. Mutations in the cardiac transcription factor
analysis of CITED2 mutations in patients with congenital heart defects. NKX2.5 affect diverse cardiac developmental pathways. J Clin Invest.
Hum Mutat. 2005;26:575–582. doi: 10.1002/humu.20262 1999;104:1567–1573. doi: 10.1172/JCI8154
343. Okubo A, Miyoshi O, Baba K, Takagi M, Tsukamoto K, Kinoshita A, 360. Goldmuntz E, Geiger E, Benson DW. NKX2.5 mutations in patients with
Yoshiura K, Kishino T, Ohta T, Niikawa N, Matsumoto N. A novel GATA4 tetralogy of Fallot. Circulation. 2001;104:2565–2568.
mutation completely segregated with atrial septal defect in a large 361. McElhinney DB, Geiger E, Blinder J, Benson DW, Goldmuntz E. NKX2.5
Japanese family. J Med Genet. 2004;41:e97. mutations in patients with congenital heart disease. J Am Coll Cardiol.
344. Hirayama-Yamada K, Kamisago M, Akimoto K, Aotsuka H, Nakamura Y, 2003;42:1650–1655.
Tomita H, Furutani M, Imamura S, Takao A, Nakazawa M, Matsuoka R. 362. Stallmeyer B, Fenge H, Nowak-Göttl U, Schulze-Bahr E. Mutational
Phenotypes with GATA4 or NKX2.5 mutations in familial atrial septal de- spectrum in the cardiac transcription factor gene NKX2.5 (CSX) associ-
fect. Am J Med Genet A. 2005;135:47–52. doi: 10.1002/ajmg.a.30684 ated with congenital heart disease. Clin Genet. 2010;78:533–540. doi:
345. Sarkozy A, Conti E, Neri C, D’Agostino R, Digilio MC, Esposito G, Toscano 10.1111/j.1399-0004.2010.01422.x
A, Marino B, Pizzuti A, Dallapiccola B. Spectrum of atrial septal defects 363. Ellesøe SG, Johansen MM, Bjerre JV, Hjortdal VE, Brunak S, Larsen LA.
associated with mutations of NKX2.5 and GATA4 transcription factors. J Familial atrial septal defect and sudden cardiac death: identification of
Med Genet. 2005;42:e16. doi: 10.1136/jmg.2004.026740 a novel NKX2-5 mutation and a review of the literature. Congenit Heart
346. Tomita-Mitchell A, Maslen CL, Morris CD, Garg V, Goldmuntz E. GATA4 Dis. 2016;11:283–290. doi: 10.1111/chd.12317
sequence variants in patients with congenital heart disease. J Med Genet. 364. Heathcote K, Braybrook C, Abushaban L, Guy M, Khetyar ME, Patton MA,
2007;44:779–783. doi: 10.1136/jmg.2007.052183 Carter ND, Scambler PJ, Syrris P. Common arterial trunk associated with

a homeodomain mutation of NKX2.6. Hum Mol Genet. 2005;14:585– in the human Jagged1 gene are responsible for Alagille syndrome. Nat
CLINICAL STATEMENTS
593. doi: 10.1093/hmg/ddi055 Genet. 1997;16:235–242. doi: 10.1038/ng0797-235

AND GUIDELINES
365. Ta-Shma A, El-lahham N, Edvardson S, Stepensky P, Nir A, Perles Z, 382. Eldadah ZA, Hamosh A, Biery NJ, Montgomery RA, Duke M, Elkins R,
Gavri S, Golender J, Yaakobi-Simhayoff N, Shaag A, Rein AJ, Elpeleg Dietz HC. Familial tetralogy of Fallot caused by mutation in the jagged1
O. Conotruncal malformations and absent thymus due to a del- gene. Hum Mol Genet. 2001;10:163–169.
eterious NKX2-6 mutation. J Med Genet. 2014;51:268–270. doi: 383. Kerstjens-Frederikse WS, van de Laar IM, Vos YJ, Verhagen JM, Berger
10.1136/jmedgenet-2013-102100 RM, Lichtenbelt KD, Klein Wassink-Ruiter JS, van der Zwaag PA, du
366. Kirk EP, Sunde M, Costa MW, Rankin SA, Wolstein O, Castro ML, Butler Marchie Sarvaas GJ, Bergman KA, Bilardo CM, Roos-Hesselink JW,
TL, Hyun C, Guo G, Otway R, Mackay JP, Waddell LB, Cole AD, Hayward Janssen JH, Frohn-Mulder IM, van Spaendonck-Zwarts KY, van Melle
C, Keogh A, Macdonald P, Griffiths L, Fatkin D, Sholler GF, Zorn AM, JP, Hofstra RM, Wessels MW. Cardiovascular malformations caused
Feneley MP, Winlaw DS, Harvey RP. Mutations in cardiac T-box factor by NOTCH1 mutations do not keep left: data on 428 probands with
gene TBX20 are associated with diverse cardiac pathologies, including left-sided CHD and their families. Genet Med. 2016;18:914–923. doi:
defects of septation and valvulogenesis and cardiomyopathy. Am J Hum 10.1038/gim.2015.193
Genet. 2007;81:280–291. doi: 10.1086/519530 384. Preuss C, Capredon M, Wünnemann F, Chetaille P, Prince A, Godard
367. Pan Y, Geng R, Zhou N, Zheng GF, Zhao H, Wang J, Zhao CM, Qiu B, Leclerc S, Sobreira N, Ling H, Awadalla P, Thibeault M, Khairy P,
XB, Yang YQ, Liu XY. TBX20 loss-of-function mutation contributes to Samuels ME, Andelfinger G; MIBAVA Leducq Consortium. Family based
double outlet right ventricle. Int J Mol Med. 2015;35:1058–1066. doi: whole exome sequencing reveals the multifaceted role of Notch signal-
10.3892/ijmm.2015.2077 ing in congenital heart disease. PLoS Genet. 2016;12:e1006335. doi:
368. Zhou YM, Dai XY, Huang RT, Xue S, Xu YJ, Qiu XB, Yang YQ. A nov- 10.1371/journal.pgen.1006335
el TBX20 loss‑of‑function mutation contributes to adult‑onset di- 385. Zahavich L, Bowdin S, Mital S. Use of clinical exome sequencing in iso-
lated cardiomyopathy or congenital atrial septal defect. Mol Med Rep. lated congenital heart disease. Circ Cardiovasc Genet. 2017;10. doi:
2016;14:3307–3314. doi: 10.3892/mmr.2016.5609 10.1161/CIRCGENETICS.116.001581
369. Huang RT, Wang J, Xue S, Qiu XB, Shi HY, Li RG, Qu XK, Yang XX, Liu H, 386. Bleyl SB, Saijoh Y, Bax NA, Gittenberger-de Groot AC, Wisse LJ, Chapman
Li N, Li YJ, Xu YJ, Yang YQ. TBX20 loss-of-function mutation responsible SC, Hunter J, Shiratori H, Hamada H, Yamada S, Shiota K, Klewer SE,
for familial tetralogy of Fallot or sporadic persistent truncus arteriosus. Int Leppert MF, Schoenwolf GC. Dysregulation of the PDGFRA gene causes
J Med Sci. 2017;14:323–332. doi: 10.7150/ijms.17834 inflow tract anomalies including TAPVR: integrating evidence from hu-
370. Pizzuti A, Sarkozy A, Newton AL, Conti E, Flex E, Digilio MC, Amati F, man genetics and model organisms. Hum Mol Genet. 2010;19:1286–
Gianni D, Tandoi C, Marino B, Crossley M, Dallapiccola B. Mutations of 1301. doi: 10.1093/hmg/ddq005
ZFPM2/FOG2 gene in sporadic cases of tetralogy of Fallot. Hum Mutat. 387. Tan HL, Glen E, Töpf A, Hall D, O’Sullivan JJ, Sneddon L, Wren C,
Avery P, Lewis RJ, ten Dijke P, Arthur HM, Goodship JA, Keavney BD.
2003;22:372–377. doi: 10.1002/humu.10261
Nonsynonymous variants in the SMAD6 gene predispose to congeni-
371. De Luca A, Sarkozy A, Ferese R, Consoli F, Lepri F, Dentici ML,
tal cardiovascular malformation. Hum Mutat. 2012;33:720–727. doi:
Vergara P, De Zorzi A, Versacci P, Digilio MC, Marino B, Dallapiccola
10.1002/humu.22030
B. New mutations in ZFPM2/FOG2 gene in tetralogy of Fallot and
388. Thienpont B, Zhang L, Postma AV, Breckpot J, Tranchevent LC, Van Loo
double outlet right ventricle. Clin Genet. 2011;80:184–190. doi:
P, Møllgård K, Tommerup N, Bache I, Tümer Z, van Engelen K, Menten B,
10.1111/j.1399-0004.2010.01523.x
Mortier G, Waggoner D, Gewillig M, Moreau Y, Devriendt K, Larsen LA.
372. Tan ZP, Huang C, Xu ZB, Yang JF, Yang YF. Novel ZFPM2/FOG2 variants
Haploinsufficiency of TAB2 causes congenital heart defects in humans.
in patients with double outlet right ventricle. Clin Genet. 2012;82:466–
Am J Hum Genet. 2010;86:839–849. doi: 10.1016/j.ajhg.2010.04.011
471. doi: 10.1111/j.1399-0004.2011.01787.x

389. Matsson H, Eason J, Bookwalter CS, Klar J, Gustavsson P, Sunnegårdh J,
373. Smith KA, Joziasse IC, Chocron S, van Dinther M, Guryev V, Verhoeven
Enell H, Jonzon A, Vikkula M, Gutierrez I, Granados-Riveron J, Pope M,
MC, Rehmann H, van der Smagt JJ, Doevendans PA, Cuppen E, Mulder
Bu’Lock F, Cox J, Robinson TE, Song F, Brook DJ, Marston S, Trybus KM,
BJ, Ten Dijke P, Bakkers J. Dominant-negative ALK2 allele associates
Dahl N. Alpha-cardiac actin mutations produce atrial septal defects. Hum
with congenital heart defects. Circulation. 2009;119:3062–3069. doi:
Mol Genet. 2008;17:256–265. doi: 10.1093/hmg/ddm302
10.1161/CIRCULATIONAHA.108.843714
390. Greenway SC, McLeod R, Hume S, Roslin NM, Alvarez N, Giuffre M, Zhan
374. Robinson SW, Morris CD, Goldmuntz E, Reller MD, Jones MA, Steiner RD,
SH, Shen Y, Preuss C, Andelfinger G, Jones SJ, Gerull B; FORGE Canada
Maslen CL. Missense mutations in CRELD1 are associated with cardiac
Consortium. Exome sequencing identifies a novel variant in ACTC1 asso-
atrioventricular septal defects. Am J Hum Genet. 2003;72:1047–1052. ciated with familial atrial septal defect. Can J Cardiol. 2014;30:181–187.
doi: 10.1086/374319 doi: 10.1016/j.cjca.2013.12.003
375. Zatyka M, Priestley M, Ladusans EJ, Fryer AE, Mason J, Latif F, 391. Li DY, Toland AE, Boak BB, Atkinson DL, Ensing GJ, Morris CA, Keating
Maher ER. Analysis of CRELD1 as a candidate 3p25 atrioventicu- MT. Elastin point mutations cause an obstructive vascular disease, supra-
lar septal defect locus (AVSD2). Clin Genet. 2005;67:526–528. doi: valvular aortic stenosis. Hum Mol Genet. 1997;6:1021–1028.
10.1111/j.1399-0004.2005.00435.x 392. Metcalfe K, Rucka AK, Smoot L, Hofstadler G, Tuzler G, McKeown P, Siu
376. Maslen CL, Babcock D, Robinson SW, Bean LJ, Dooley KJ, Willour VL, V, Rauch A, Dean J, Dennis N, Ellis I, Reardon W, Cytrynbaum C, Osborne
Sherman SL. CRELD1 mutations contribute to the occurrence of cardiac L, Yates JR, Read AP, Donnai D, Tassabehji M. Elastin: mutational spec-
atrioventricular septal defects in Down syndrome. Am J Med Genet A. trum in supravalvular aortic stenosis. Eur J Hum Genet. 2000;8:955–963.
2006;140:2501–2505. doi: 10.1002/ajmg.a.31494 doi: 10.1038/sj.ejhg.5200564
377. Dasgupta C, Martinez AM, Zuppan CW, Shah MM, Bailey LL, Fletcher 393. Micale L, Turturo MG, Fusco C, Augello B, Jurado LA, Izzi C, Digilio MC,
WH. Identification of connexin43 (alpha1) gap junction gene mutations Milani D, Lapi E, Zelante L, Merla G. Identification and characterization of
in patients with hypoplastic left heart syndrome by denaturing gradient seven novel mutations of elastin gene in a cohort of patients affected by
gel electrophoresis (DGGE). Mutat Res. 2001;479:173–186. supravalvular aortic stenosis. Eur J Hum Genet. 2010;18:317–323. doi:
378. Wang B, Wen Q, Xie X, Liu S, Liu M, Tao Y, Li Z, Suo P, Shen A, Wang 10.1038/ejhg.2009.181
J, Ma X. Mutation analysis of Connexon43 gene in Chinese patients 394. Ching YH, Ghosh TK, Cross SJ, Packham EA, Honeyman L, Loughna S,
with congenital heart defects. Int J Cardiol. 2010;145:487–489. doi: Robinson TE, Dearlove AM, Ribas G, Bonser AJ, Thomas NR, Scotter AJ,
10.1016/j.ijcard.2009.06.026 Caves LS, Tyrrell GP, Newbury-Ecob RA, Munnich A, Bonnet D, Brook JD.
379. Izumi K, Lippa AM, Wilkens A, Feret HA, McDonald-McGinn DM, Mutation in myosin heavy chain 6 causes atrial septal defect. Nat Genet.
Zackai EH. Congenital heart defects in oculodentodigital dysplasia: re- 2005;37:423–428. doi: 10.1038/ng1526
port of two cases. Am J Med Genet A. 2013;161A:3150–3154. doi: 395. Posch MG, Waldmuller S, Müller M, Scheffold T, Fournier D, Andrade-
10.1002/ajmg.a.36159 Navarro MA, De Geeter B, Guillaumont S, Dauphin C, Yousseff D,
380. Li L, Krantz ID, Deng Y, Genin A, Banta AB, Collins CC, Qi M, Trask BJ, Schmitt KR, Perrot A, Berger F, Hetzer R, Bouvagnet P, Özcelik C.
Kuo WL, Cochran J, Costa T, Pierpont ME, Rand EB, Piccoli DA, Hood L, Cardiac alpha-myosin (MYH6) is the predominant sarcomeric disease
Spinner NB. Alagille syndrome is caused by mutations in human Jagged1, gene for familial atrial septal defects. PLoS One. 2011;6:e28872. doi:
which encodes a ligand for Notch1. Nat Genet. 1997;16:243–251. doi: 10.1371/journal.pone.0028872
10.1038/ng0797-243 396. Granados-Riveron JT, Ghosh TK, Pope M, Bu’Lock F, Thornborough C,
381. Oda T, Elkahloun AG, Pike BL, Okajima K, Krantz ID, Genin A, Piccoli DA, Eason J, Kirk EP, Fatkin D, Feneley MP, Harvey RP, Armour JA, David
Meltzer PS, Spinner NB, Collins FS, Chandrasekharappa SC. Mutations Brook J. Alpha-cardiac myosin heavy chain (MYH6) mutations affecting

myofibril formation are associated with congenital heart defects. Hum L, Roberts DJ, Sambrook J, Setchfield K, Stiller B, Thornborough C, Toka
CLINICAL STATEMENTS
Mol Genet. 2010;19:4007–4016. doi: 10.1093/hmg/ddq315 O, Watkins H, Williams D, Wright M, Mital S, Daubeney PE, Keavney B,
AND GUIDELINES
397. Budde BS, Binner P, Waldmüller S, Höhne W, Blankenfeldt W, Hassfeld S, Goodship J, Abu-Sulaiman RM, Klaassen S, Wright CF, Firth HV, Barrett
Brömsen J, Dermintzoglou A, Wieczorek M, May E, Kirst E, Selignow C, JC, Devriendt K, FitzPatrick DR, Brook JD, Hurles ME; INTERVAL Study;
Rackebrandt K, Müller M, Goody RS, Vosberg HP, Nürnberg P, Scheffold UK10K Consortium; Deciphering Developmental Disorders Study. Distinct
T. Noncompaction of the ventricular myocardium is associated with genetic architectures for syndromic and nonsyndromic congenital heart
a de novo mutation in the beta-myosin heavy chain gene. PLoS One. defects identified by exome sequencing. Nat Genet. 2016;48:1060–
2007;2:e1362. doi: 10.1371/journal.pone.0001362 1065. doi: 10.1038/ng.3627
398. Postma AV, van Engelen K, van de Meerakker J, Rahman T, Probst S, 412. D’Alessandro LC, Al Turki S, Manickaraj AK, Manase D, Mulder BJ,
Baars MJ, Bauer U, Pickardt T, Sperling SR, Berger F, Moorman AF, Bergin L, Rosenberg HC, Mondal T, Gordon E, Lougheed J, Smythe J,
Mulder BJ, Thierfelder L, Keavney B, Goodship J, Klaassen S. Mutations Devriendt K, Bhattacharya S, Watkins H, Bentham J, Bowdin S, Hurles
in the sarcomere gene MYH7 in Ebstein anomaly. Circ Cardiovasc Genet. ME, Mital S. Exome sequencing identifies rare variants in multiple genes
2011;4:43–50. doi: 10.1161/CIRCGENETICS.110.957985 in atrioventricular septal defect. Genet Med. 2016;18:189–198. doi:
399. Zhu L, Vranckx R, Khau Van Kien P, Lalande A, Boisset N, Mathieu F, 10.1038/gim.2015.60
Wegman M, Glancy L, Gasc JM, Brunotte F, Bruneval P, Wolf JE, Michel 413. Priest JR, Osoegawa K, Mohammed N, Nanda V, Kundu R, Schultz
JB, Jeunemaitre X. Mutations in myosin heavy chain 11 cause a syndrome K, Lammer EJ, Girirajan S, Scheetz T, Waggott D, Haddad F, Reddy S,
associating thoracic aortic aneurysm/aortic dissection and patent ductus Bernstein D, Burns T, Steimle JD, Yang XH, Moskowitz IP, Hurles M, Lifton
arteriosus. Nat Genet. 2006;38:343–349. doi: 10.1038/ng1721 RP, Nickerson D, Bamshad M, Eichler EE, Mital S, Sheffield V, Quertermous
400. LaHaye S, Corsmeier D, Basu M, Bowman JL, Fitzgerald-Butt S, T, Gelb BD, Portman M, Ashley EA. De novo and rare variants at multiple
Zender G, Bosse K, McBride KL, White P, Garg V. Utilization of whole loci support the oligogenic origins of atrioventricular septal heart defects.
exome sequencing to identify causative mutations in familial con- PLoS Genet. 2016;12:e1005963. doi: 10.1371/journal.pgen.1005963
genital heart disease. Circ Cardiovasc Genet. 2016;9:320–329. doi: 414. Liu X, Yagi H, Saeed S, Bais AS, Gabriel GC, Chen Z, Peterson KA, Li Y,
10.1161/CIRCGENETICS.115.001324 Schwartz MC, Reynolds WT, Saydmohammed M, Gibbs B, Wu Y, Devine
401. Olson EN. Gene regulatory networks in the evolution and development of W, Chatterjee B, Klena NT, Kostka D, de Mesy Bentley KL, Ganapathiraju
the heart. Science. 2006;313:1922–1927. doi: 10.1126/science.1132292 MK, Dexheimer P, Leatherbury L, Khalifa O, Bhagat A, Zahid M, Pu W,
402. Ashraf H, Pradhan L, Chang EI, Terada R, Ryan NJ, Briggs LE, Chowdhury Watkins S, Grossfeld P, Murray SA, Porter GA Jr, Tsang M, Martin LJ,
R, Zárate MA, Sugi Y, Nam HJ, Benson DW, Anderson RH, Kasahara H. Benson DW, Aronow BJ, Lo CW. The complex genetics of hypoplastic left
A mouse model of human congenital heart disease: high incidence of heart syndrome. Nat Genet. 2017;49:1152–1159. doi: 10.1038/ng.3870
diverse cardiac anomalies and ventricular noncompaction produced by
415. Brodwall K, Greve G, Leirgul E, Tell GS, Vollset SE, Øyen N. Recurrence of
heterozygous Nkx2-5 homeodomain missense mutation. Circ Cardiovasc
congenital heart defects among siblings-a nationwide study. Am J Med
Genet. 2014;7:423–433. doi: 10.1161/CIRCGENETICS.113.000281
Genet A. 2017;173:1575–1585. doi: 10.1002/ajmg.a.38237
403. Biben C, Weber R, Kesteven S, Stanley E, McDonald L, Elliott DA, Barnett
416. Mital S, Musunuru K, Garg V, Russell MW, Lanfear DE, Gupta RM, Hickey
L, Köentgen F, Robb L, Feneley M, Harvey RP. Cardiac septal and valvular
KT, Ackerman MJ, Perez MV, Roden DM, Woo D, Fox CS, Ware S; on behalf
dysmorphogenesis in mice heterozygous for mutations in the homeobox
of the American Heart Association Council on Functional Genomics and
gene Nkx2-5. Circ Res. 2000;87:888–895.
Translational Biology; Council on Cardiovascular Disease in the Young;
404. Chowdhury R, Ashraf H, Melanson M, Tanada Y, Nguyen M, Silberbach
Council on Cardiovascular and Stroke Nursing; Stroke Council; Council
M, Wakimoto H, Benson DW, Anderson RH, Kasahara H. Mouse
on Lifestyle and Cardiometabolic Health; Council on Quality of Care and
model of human congenital heart disease: progressive atrioventricu-
Outcomes Research. Enhancing literacy in cardiovascular genetics: a sci-

lar block induced by a heterozygous Nkx2-5 homeodomain missense
entific statement from the American Heart Association. Circ Cardiovasc
mutation. Circ Arrhythm Electrophysiol. 2015;8:1255–1264. doi:
Genet. 2016;9:448–467. doi: 10.1161/HCG.0000000000000031
10.1161/CIRCEP.115.002720
417. Zaidi S, Brueckner M. Genetics and genomics of congenital heart disease.
405. Prendiville T, Jay PY, Pu WT. Insights into the genetic structure of con-
Circ Res. 2017;120:923–940. doi: 10.1161/CIRCRESAHA.116.309140
genital heart disease from human and murine studies on monogenic
418. Karakikes I, Ameen M, Termglinchan V, Wu JC. Human induced plu-
disorders. Cold Spring Harb Perspect Med. 2014;4:a013946. doi:
ripotent stem cell-derived cardiomyocytes: insights into molecular,
10.1101/cshperspect.a013946
cellular, and functional phenotypes. Circ Res. 2015;117:80–88. doi:
406. Han H, Chen Y, Liu G, Han Z, Zhao Z, Tang Y. GATA4 transgenic
mice as an in vivo model of congenital heart disease. Int J Mol Med. 10.1161/CIRCRESAHA.117.305365
2015;35:1545–1553. doi: 10.3892/ijmm.2015.2178 419. Doetschman T, Georgieva T. Gene editing with CRISPR/Cas9 RNA-directed
407. Misra C, Sachan N, McNally CR, Koenig SN, Nichols HA, Guggilam A, nuclease. Circ Res. 2017;120:876–894. doi: 10.1161/CIRCRESAHA.
Lucchesi PA, Pu WT, Srivastava D, Garg V. Congenital heart disease- 116.309727
causing Gata4 mutation displays functional deficits in vivo. PLoS Genet. 420. Molkentin JD, Robbins J. With great power comes great responsibility:
2012;8:e1002690. doi: 10.1371/journal.pgen.1002690 using mouse genetics to study cardiac hypertrophy and failure. J Mol Cell
408. Griffin HR, Töpf A, Glen E, Zweier C, Stuart AG, Parsons J, Peart I, Cardiol. 2009;46:130–136. doi: 10.1016/j.yjmcc.2008.09.002
Deanfield J, O’Sullivan J, Rauch A, Scambler P, Burn J, Cordell HJ, Keavney 421. Blow MJ, McCulley DJ, Li Z, Zhang T, Akiyama JA, Holt A, Plajzer-Frick I,
B, Goodship JA. Systematic survey of variants in TBX1 in non-syndromic Shoukry M, Wright C, Chen F, Afzal V, Bristow J, Ren B, Black BL, Rubin
tetralogy of Fallot identifies a novel 57 base pair deletion that reduces EM, Visel A, Pennacchio LA. ChIP-Seq identification of weakly conserved
transcriptional activity but finds no evidence for association with common heart enhancers. Nat Genet. 2010;42:806–810. doi: 10.1038/ng.650
variants. Heart. 2010;96:1651–1655. doi: 10.1136/hrt.2010.200121 422. May D, Blow MJ, Kaplan T, McCulley DJ, Jensen BC, Akiyama JA, Holt
409. Smemo S, Campos LC, Moskowitz IP, Krieger JE, Pereira AC, Nobrega A, Plajzer-Frick I, Shoukry M, Wright C, Afzal V, Simpson PC, Rubin EM,
MA. Regulatory variation in a TBX5 enhancer leads to isolated con- Black BL, Bristow J, Pennacchio LA, Visel A. Large-scale discovery of
genital heart disease. Hum Mol Genet. 2012;21:3255–3263. doi: enhancers from human heart tissue. Nat Genet. 2011;44:89–93. doi:
10.1093/hmg/dds165 10.1038/ng.1006
410. Schulkey CE, Regmi SD, Magnan RA, Danzo MT, Luther H, Hutchinson 423. Dickel DE, Barozzi I, Zhu Y, Fukuda-Yuzawa Y, Osterwalder M, Mannion
AK, Panzer AA, Grady MM, Wilson DB, Jay PY. The maternal-age- BJ, May D, Spurrell CH, Plajzer-Frick I, Pickle CS, Lee E, Garvin TH, Kato
associated risk of congenital heart disease is modifiable. Nature. M, Akiyama JA, Afzal V, Lee AY, Gorkin DU, Ren B, Rubin EM, Visel
2015;520:230–233. doi: 10.1038/nature14361 A, Pennacchio LA. Genome-wide compendium and functional assess-
411. Sifrim A, Hitz MP, Wilsdon A, Breckpot J, Turki SH, Thienpont B, McRae ment of in vivo heart enhancers. Nat Commun. 2016;7:12923. doi:
J, Fitzgerald TW, Singh T, Swaminathan GJ, Prigmore E, Rajan D, Abdul- 10.1038/ncomms12923
Khaliq H, Banka S, Bauer UM, Bentham J, Berger F, Bhattacharya S, 424. Zhou P, Gu F, Zhang L, Akerberg BN, Ma Q, Li K, He A, Lin Z, Stevens SM,
Bu’Lock F, Canham N, Colgiu IG, Cosgrove C, Cox H, Daehnert I, Daly Zhou B, Pu WT. Mapping cell type-specific transcriptional enhancers using
A, Danesh J, Fryer A, Gewillig M, Hobson E, Hoff K, Homfray T, Kahlert high affinity, lineage-specific Ep300 bioChIP-seq. Elife. 2017;6:e22039.
AK, Ketley A, Kramer HH, Lachlan K, Lampe AK, Louw JJ, Manickara AK, doi: 10.7554/eLife.22039
Manase D, McCarthy KP, Metcalfe K, Moore C, Newbury-Ecob R, Omer 425. Papaioannou VE. Concepts of cell lineage in mammalian embryos. Curr
SO, Ouwehand WH, Park SM, Parker MJ, Pickardt T, Pollard MO, Robert Top Dev Biol. 2016;117:185–197. doi: 10.1016/bs.ctdb.2015.10.013

426. Cai CL, Liang X, Shi Y, Chu PH, Pfaff SL, Chen J, Evans S. Isl1 identi- underlies heart valve morphogenesis. Cell. 2004;118:649–663. doi:
CLINICAL STATEMENTS
fies a cardiac progenitor population that proliferates prior to differentia- 10.1016/j.cell.2004.08.010

AND GUIDELINES
tion and contributes a majority of cells to the heart. Dev Cell. 2003;5: 449. Shenje LT, Andersen P, Uosaki H, Fernandez L, Rainer PP, Cho GS, Lee DI,
877–889. Zhong W, Harvey RP, Kass DA, Kwon C. Precardiac deletion of Numb and
427. Snarr BS, Wirrig EE, Phelps AL, Trusk TC, Wessels A. A spatiotempo- Numblike reveals renewal of cardiac progenitors. Elife. 2014;3:e02164.
ral evaluation of the contribution of the dorsal mesenchymal protru- doi: 10.7554/eLife.02164
sion to cardiac development. Dev Dyn. 2007;236:1287–1294. doi: 450. Red-Horse K, Ueno H, Weissman IL, Krasnow MA. Coronary arter-
10.1002/dvdy.21074 ies form by developmental reprogramming of venous cells. Nature.
428. Xie L, Hoffmann AD, Burnicka-Turek O, Friedland-Little JM, Zhang K, 2010;464:549–553. doi: 10.1038/nature08873
Moskowitz IP. Tbx5-hedgehog molecular networks are essential in the 451. von Gise A, Pu WT. Endocardial and epicardial epithelial to mesenchymal
second heart field for atrial septation. Dev Cell. 2012;23:280–291. doi: transitions in heart development and disease. Circ Res. 2012;110:1628–
10.1016/j.devcel.2012.06.006 1645. doi: 10.1161/CIRCRESAHA.111.259960
429. Yagi H, Furutani Y, Hamada H, Sasaki T, Asakawa S, Minoshima S, 452. Molkentin JD, Lu JR, Antos CL, Markham B, Richardson J, Robbins J,
Ichida F, Joo K, Kimura M, Imamura S, Kamatani N, Momma K, Takao Grant SR, Olson EN. A calcineurin-dependent transcriptional pathway for
A, Nakazawa M, Shimizu N, Matsuoka R. Role of TBX1 in human cardiac hypertrophy. Cell. 1998;93:215–228.
del22q11.2 syndrome. Lancet. 2003;362:1366–1373. 453. Li P, Cavallero S, Gu Y, Chen TH, Hughes J, Hassan AB, Brüning JC,
430. Zhang Z, Baldini A. In vivo response to high-resolution variation Pashmforoush M, Sucov HM. IGF signaling directs ventricular cardiomyo-
of Tbx1 mRNA dosage. Hum Mol Genet. 2008;17:150–157. doi: cyte proliferation during embryonic heart development. Development.
10.1093/hmg/ddm291 2011;138:1795–1805. doi: 10.1242/dev.054338
431. Winston JB, Schulkey CE, Chen IB, Regmi SD, Efimova M, Erlich JM, 454. Zhou B, Honor LB, He H, Ma Q, Oh JH, Butterfield C, Lin RZ, Melero-
Green CA, Aluko A, Jay PY. Complex trait analysis of ventricular septal Martin JM, Dolmatova E, Duffy HS, Gise Av, Zhou P, Hu YW, Wang G,
defects caused by Nkx2-5 mutation. Circ Cardiovasc Genet. 2012;5:293– Zhang B, Wang L, Hall JL, Moses MA, McGowan FX, Pu WT. Adult mouse
300. doi: 10.1161/CIRCGENETICS.111.961136 epicardium modulates myocardial injury by secreting paracrine factors. J
432. Guo Y, VanDusen NJ, Zhang L, Gu W, Sethi I, Guatimosim S, Ma Q, Jardin Clin Invest. 2011;121:1894–1904. doi: 10.1172/JCI45529
BD, Ai Y, Zhang D, Chen B, Guo A, Yuan GC, Song LS, Pu WT. Analysis of 455. Wamstad JA, Alexander JM, Truty RM, Shrikumar A, Li F, Eilertson KE,
cardiac myocyte maturation using CASAAV, a platform for rapid dissec- Ding H, Wylie JN, Pico AR, Capra JA, Erwin G, Kattman SJ, Keller GM,
tion of cardiac myocyte gene function in vivo. Circ Res. 2017;120:1874– Srivastava D, Levine SS, Pollard KS, Holloway AK, Boyer LA, Bruneau
1888. doi: 10.1161/CIRCRESAHA.116.310283 BG. Dynamic and coordinated epigenetic regulation of developmen-
433. Stitelman DH, Brazelton T, Bora A, Traas J, Merianos D, Limberis M, Davey tal transitions in the cardiac lineage. Cell. 2012;151:206–220. doi:
M, Flake AW. Developmental stage determines efficiency of gene trans- 10.1016/j.cell.2012.07.035
fer to muscle satellite cells by in utero delivery of adeno-associated virus 456. Paige SL, Thomas S, Stoick-Cooper CL, Wang H, Maves L, Sandstrom R,
vector serotype 2/9. Mol Ther Methods Clin Dev. 2014;1:14040. doi: Pabon L, Reinecke H, Pratt G, Keller G, Moon RT, Stamatoyannopoulos
10.1038/mtm.2014.40 J, Murry CE. A temporal chromatin signature in human embryonic stem
434. Staudt D, Stainier D. Uncovering the molecular and cellular mecha- cells identifies regulators of cardiac development. Cell. 2012;151:221–
nisms of heart development using the zebrafish. Annu Rev Genet. 232. doi: 10.1016/j.cell.2012.08.027
2012;46:397–418. doi: 10.1146/annurev-genet-110711-155646 457. Ang YS, Rivas RN, Ribeiro AJS, Srivas R, Rivera J, Stone NR, Pratt K,
435. Grant MG, Patterson VL, Grimes DT, Burdine RD. Modeling syndromic Mohamed TMA, Fu JD, Spencer CI, Tippens ND, Li M, Narasimha A,
congenital heart defects in zebrafish. Curr Top Dev Biol. 2017;124:1–40. Radzinsky E, Moon-Grady AJ, Yu H, Pruitt BL, Snyder MP, Srivastava D.
doi: 10.1016/bs.ctdb.2016.11.010 Disease model of GATA4 mutation reveals transcription factor coop-
436. Blum M, De Robertis EM, Wallingford JB, Niehrs C. Morpholinos: an- erativity in human cardiogenesis. Cell. 2016;167:1734–1749.e22. doi:
tisense and sensibility. Dev Cell. 2015;35:145–149. doi: 10.1016/j. 10.1016/j.cell.2016.11.033
devcel.2015.09.017 458. Hinson JT, Chopra A, Nafissi N, Polacheck WJ, Benson CC, Swist S,
437. Hisano Y, Ota S, Kawahara A. Genome editing using artificial site-spe- Gorham J, Yang L, Schafer S, Sheng CC, Haghighi A, Homsy J, Hubner
cific nucleases in zebrafish. Dev Growth Differ. 2014;56:26–33. doi: N, Church G, Cook SA, Linke WA, Chen CS, Seidman JG, Seidman CE.
10.1111/dgd.12094 Heart disease: titin mutations in iPS cells define sarcomere insufficiency
438. Amores A, Force A, Yan YL, Joly L, Amemiya C, Fritz A, Ho RK, as a cause of dilated cardiomyopathy. Science. 2015;349:982–986. doi:
Langeland J, Prince V, Wang YL, Westerfield M, Ekker M, Postlethwait 10.1126/science.aaa5458
JH. Zebrafish hox clusters and vertebrate genome evolution. Science. 459. Lan F, Lee AS, Liang P, Sanchez-Freire V, Nguyen PK, Wang L, Han L, Yen
1998;282:1711–1714. M, Wang Y, Sun N, Abilez OJ, Hu S, Ebert AD, Navarrete EG, Simmons
439. Dai YJ, Jia YF, Chen N, Bian WP, Li QK, Ma YB, Chen YL, Pei DS. CS, Wheeler M, Pruitt B, Lewis R, Yamaguchi Y, Ashley EA, Bers DM,
Zebrafish as a model system to study toxicology. Environ Toxicol Chem. Robbins RC, Longaker MT, Wu JC. Abnormal calcium handling proper-
2014;33:11–17. doi: 10.1002/etc.2406 ties underlie familial hypertrophic cardiomyopathy pathology in patient-
440. Liu J, Stainier DY. Zebrafish in the study of early cardiac development. specific induced pluripotent stem cells. Cell Stem Cell. 2013;12:101–113.
Circ Res. 2012;110:870–874. doi: 10.1161/CIRCRESAHA.111.246504 doi: 10.1016/j.stem.2012.10.010
441. Halloran MC, Sato-Maeda M, Warren JT, Su F, Lele Z, Krone PH, Kuwada 460. Wang G, McCain ML, Yang L, He A, Pasqualini FS, Agarwal A, Yuan
JY, Shoji W. Laser-induced gene expression in specific cells of transgenic H, Jiang D, Zhang D, Zangi L, Geva J, Roberts AE, Ma Q, Ding J, Chen
zebrafish. Development. 2000;127:1953–1960. J, Wang DZ, Li K, Wang J, Wanders RJ, Kulik W, Vaz FM, Laflamme
442. Hatta K, Tsujii H, Omura T. Cell tracking using a photoconvertible fluores- MA, Murry CE, Chien KR, Kelley RI, Church GM, Parker KK, Pu WT.
cent protein. Nat Protoc. 2006;1:960–967. doi: 10.1038/nprot.2006.96 Modeling the mitochondrial cardiomyopathy of Barth syndrome with
443. Serbedzija GN, Chen JN, Fishman MC. Regulation in the heart field of induced pluripotent stem cell and heart-on-chip technologies. Nat Med.
zebrafish. Development. 1998;125:1095–1101. 2014;20:616–623. doi: 10.1038/nm.3545
444. Midgett M, Thornburg K, Rugonyi S. Blood flow patterns underlie devel- 461. Richards AA, Garg V. Genetics of congenital heart disease. Curr Cardiol
opmental heart defects. Am J Physiol Heart Circ Physiol. 2017;312:H632– Rev. 2010;6:91–97. doi: 10.2174/157340310791162703
H642. doi: 10.1152/ajpheart.00641.2016 462. Landis BJ, Ware SM. The current landscape of genetic testing in cardio-
445. Sedmera D, Hu N, Weiss KM, Keller BB, Denslow S, Thompson RP. Cellular vascular malformations: opportunities and challenges. Front Cardiovasc
changes in experimental left heart hypoplasia. Anat Rec. 2002;267:137– Med. 2016;3:22. doi: 10.3389/fcvm.2016.00022
145. doi: 10.1002/ar.10098 463. Fung A, Manlhiot C, Naik S, Rosenberg H, Smythe J, Lougheed J,
446. Vogler G, Bodmer R. Cellular mechanisms of Drosophila heart morpho- Mondal T, Chitayat D, McCrindle BW, Mital S. Impact of prenatal risk
genesis. J Cardiovasc Dev Dis. 2015;2:2–16. doi: 10.3390/jcdd2010002 factors on congenital heart disease in the current era. J Am Heart Assoc.
447. Zhu JY, Fu Y, Nettleton M, Richman A, Han Z. High throughput in vivo 2013;2:e000064. doi: 10.1161/JAHA.113.000064
functional validation of candidate congenital heart disease genes in 464. Blue GM, Kirk EP, Giannoulatou E, Sholler GF, Dunwoodie SL, Harvey
Drosophila. Elife. 2017;6:e22617. doi: 10.7554/eLife.22617 RP, Winlaw DS. Advances in the genetics of congenital heart dis-
448. Chang CP, Neilson JR, Bayle JH, Gestwicki JE, Kuo A, Stankunas K, ease: a clinician’s guide. J Am Coll Cardiol. 2017;69:859–870. doi:
Graef IA, Crabtree GR. A field of myocardial-endocardial NFAT signaling 10.1016/j.jacc.2016.11.060

465. Green RC, Berg JS, Grody WW, Kalia SS, Korf BR, Martin CL, McGuire with congenital heart disease. Pediatr Cardiol. 2017;38:1465–1470. doi:
CLINICAL STATEMENTS
AL, Nussbaum RL, O’Daniel JM, Ormond KE, Rehm HL, Watson MS, 10.1007/s00246-017-1685-7
AND GUIDELINES
Williams MS, Biesecker LG; American College of Medical Genetics and 484. van Engelen K, Baars MJ, van Rongen LT, van der Velde ET, Mulder BJ,
Genomics. ACMG recommendations for reporting of incidental findings Smets EM. Adults with congenital heart disease: patients’ knowledge
in clinical exome and genome sequencing [published correction ap- and concerns about inheritance. Am J Med Genet A. 2011;155A:1661–
pears in Genet Med. 2017;19:606]. Genet Med. 2013;15:565–574. doi: 1667. doi: 10.1002/ajmg.a.34068
10.1038/gim.2013.73 485. Jansen FA, Blumenfeld YJ, Fisher A, Cobben JM, Odibo AO, Borrell A,
466. Kalia SS, Adelman K, Bale SJ, Chung WK, Eng C, Evans JP, Herman GE, Haak MC. Array comparative genomic hybridization and fetal congenital
Hufnagel SB, Klein TE, Korf BR, McKelvey KD, Ormond KE, Richards CS, heart defects: a systematic review and meta-analysis. Ultrasound Obstet
Vlangos CN, Watson M, Martin CL, Miller DT. Recommendations for re- Gynecol. 2015;45:27–35. doi: 10.1002/uog.14695
porting of secondary findings in clinical exome and genome sequenc- 486. Morales A, Allain DC, Arscott P, James E, MacCarrick G, Murray B,
ing, 2016 update (ACMG SF v2.0): a policy statement of the American Tichnell C, Shikany AR, Spencer S, Fitzgerald-Butt SM, Kushner JD, Munn
College of Medical Genetics and Genomics [published correction ap- C, Smith E, Spoonamore KG, Tandri HS, Kay WA. At the heart of the
pears in Genet Med. 2017;19:484]. Genet Med. 2017;19:249–255. doi: pregnancy: what prenatal and cardiovascular genetic counselors need
10.1038/gim.2016.190 to know about maternal heart disease [published correction appears in
467. Andorno R. The right not to know: an autonomy based approach [pub- J Genet Couns. 2017;26:689]. J Genet Couns. 2017;26:669–688. doi:
lished correction appears in J Med Ethics. 2004;30:612]. J Med Ethics. 10.1007/s10897-017-0081-z
2004;30:435–439. doi: 10.1136/jme.2002.001578 487. van Engelen K, Baars MJ, Felix JP, Postma AV, Mulder BJ, Smets EM. The
468. American Society of Human Genetics Board of Directors; American value of the clinical geneticist caring for adults with congenital heart
College of Medical Genetics Board of Directors. Points to consider: ethi- disease: diagnostic yield and patients’ perspective. Am J Med Genet A.
cal, legal, and psychosocial implications of genetic testing in children and 2013;161A:1628–1637. doi: 10.1002/ajmg.a.35973
adolescents. Am J Hum Genet. 1995;57:1233–1241. 488. Ferencz C, Boughman JA, Neill CA, Brenner JI, Perry LW; Baltimore-
469. Ross LF, Saal HM, David KL, Anderson RR; American Academy of Washington Infant Study Group. Congenital cardiovascular malforma-
Pediatrics; American College of Medical Genetics and Genomics. tions: questions on inheritance. J Am Coll Cardiol. 1989;14:756–763.
Technical report: ethical and policy issues in genetic testing and screening 489. Ferencz C, Neill CA, Boughman JA, Rubin JD, Brenner JI, Perry LW.
of children. Genet Med. 2013;15:234–245. doi: 10.1038/gim.2012.176 Congenital cardiovascular malformations associated with chromosome
470. Davis DS. Genetic dilemmas and the child’s right to an open future. abnormalities: an epidemiologic study. J Pediatr. 1989;114:79–86.
Hastings Cent Rep. 1997;27:7–15. 490. Jenkins KJ, Correa A, Feinstein JA, Botto L, Britt AE, Daniels SR,
471. Wilfond BS, Fernandez CV, Green RC. Disclosing secondary findings from Elixson M, Warnes CA, Webb CL. Noninherited risk factors and con-
pediatric sequencing to families: considering the “benefit to families.” genital cardiovascular defects: current knowledge: a scientific state-
J Law Med Ethics. 2015;43:552–558. doi: 10.1111/jlme.12298 ment from the American Heart Association Council on Cardiovascular
472. Berkman BE, Hull SC. The “right not to know” in the genomic era: Disease in the Young. Circulation. 2007;115:2995–3014. doi:
time to break from tradition? Am J Bioeth. 2014;14:28–31. doi: 10.1161/CIRCULATIONAHA.106.183216
10.1080/15265161.2014.880313 491. Burn J, Brennan P, Little J, Holloway S, Coffey R, Somerville J, Dennis NR,
473. American Academy of Pediatrics Committee on Bioethics. Informed con- Allan L, Arnold R, Deanfield JE, Godman M, Houston A, Keeton B, Oakley
sent, parental permission, and assent in pediatric practice. Pediatrics. C, Scott O, Silove E, Wilkinson J, Pembrey M, Hunter AS. Recurrence risks
1995;95:314–317. in offspring of adults with major heart defects: results from first cohort
474. Heshka JT, Palleschi C, Howley H, Wilson B, Wells PS. A systematic of British collaborative study. Lancet. 1998;351:311–316.
review of perceived risks, psychological and behavioral impacts of 492. Gill HK, Splitt M, Sharland GK, Simpson JM. Patterns of recurrence of
genetic testing. Genet Med. 2008;10:19–32. doi: 10.1097/GIM. congenital heart disease: an analysis of 6,640 consecutive pregnan-
0b013e31815f524f cies evaluated by detailed fetal echocardiography. J Am Coll Cardiol.
475. Biesecker BB. Predictive genetic testing of minors: evidence and ex- 2003;42:923–929.
perience with families. Genet Med. 2016;18:763–764. doi: 10.1038/ 493. Cripe L, Andelfinger G, Martin LJ, Shooner K, Benson DW. Bicuspid
gim.2015.191 aortic valve is heritable. J Am Coll Cardiol. 2004;44:138–143. doi:
476. Wakefield CE, Hanlon LV, Tucker KM, Patenaude AF, Signorelli C, 10.1016/j.jacc.2004.03.050
McLoone JK, Cohn RJ. The psychological impact of genetic information 494. McBride KL, Pignatelli R, Lewin M, Ho T, Fernbach S, Menesses A, Lam W,
on children: a systematic review. Genet Med. 2016;18:755–762. doi: Leal SM, Kaplan N, Schliekelman P, Towbin JA, Belmont JW. Inheritance
10.1038/gim.2015.181 analysis of congenital left ventricular outflow tract obstruction malfor-
477. Green RC, Lautenbach D, McGuire AL. GINA, genetic discrimina- mations: Segregation, multiplex relative risk, and heritability. Am J Med
tion, and genomic medicine. N Engl J Med. 2015;372:397–399. doi: Genet A. 2005;134A:180–186. doi: 10.1002/ajmg.a.30602
10.1056/NEJMp1404776 495. Hinton RB Jr, Martin LJ, Tabangin ME, Mazwi ML, Cripe LH, Benson
478. Resta R, Biesecker BB, Bennett RL, Blum S, Hahn SE, Strecker MN, DW. Hypoplastic left heart syndrome is heritable. J Am Coll Cardiol.
Williams JL; National Society of Genetic Counselors’ Definition Task 2007;50:1590–1595. doi: 10.1016/j.jacc.2007.07.021
Force. A new definition of genetic counseling: National Society of 496. Oyen N, Poulsen G, Wohlfahrt J, Boyd HA, Jensen PK, Melbye M.
Genetic Counselors’ Task Force report. J Genet Couns. 2006;15:77–83. Recurrence of discordant congenital heart defects in families. Circ
doi: 10.1007/s10897-005-9014-3 Cardiovasc Genet. 2010;3:122–128. doi: 10.1161/CIRCGENETICS.
479. Somers AE, Ware SM, Collins K, Jefferies JL, He H, Miller EM. 109.890103
Provision of cardiovascular genetic counseling services: current prac- 497. Canfield MA, Honein MA, Yuskiv N, Xing J, Mai CT, Collins JS, Devine
tice and future directions. J Genet Couns. 2014;23:976–983. doi: O, Petrini J, Ramadhani TA, Hobbs CA, Kirby RS. National estimates
10.1007/s10897-014-9719-2 and race/ethnic-specific variation of selected birth defects in the United
480. Ahrens-Nicklas RC, Khan S, Garbarini J, Woyciechowski S, D’Alessandro States, 1999-2001. Birth Defects Res A Clin Mol Teratol. 2006;76:747–
L, Zackai EH, Deardorff MA, Goldmuntz E. Utility of genetic evalu- 756. doi: 10.1002/bdra.20294
ation in infants with congenital heart defects admitted to the cardiac 498. Pradat P, Francannet C, Harris JA, Robert E. The epidemiology of cardio-
intensive care unit. Am J Med Genet A. 2016;170:3090–3097. doi: vascular defects, part I: a study based on data from three large registries
10.1002/ajmg.a.37891 of congenital malformations. Pediatr Cardiol. 2003;24:195–221. doi:
481. Goldenberg PC, Adler BJ, Parrott A, Anixt J, Mason K, Phillips J, Cooper 10.1007/s00246-002-9401-6
DS, Ware SM, Marino BS. High burden of genetic conditions diagnosed 499. Calcagni G, Digilio MC, Sarkozy A, Dallapiccola B, Marino B. Familial re-
in a cardiac neurodevelopmental clinic. Cardiol Young. 2017;27:459– currence of congenital heart disease: an overview and review of the litera-
466. doi: 10.1017/S104795111600072X ture. Eur J Pediatr. 2007;166:111–116. doi: 10.1007/s00431-006-0295-9
482. Connor JA, Hinton RB, Miller EM, Sund KL, Ruschman JG, Ware SM. 500. Nora JJ. From generational studies to a multilevel genetic-environmental
Genetic testing practices in infants with congenital heart disease. interaction. J Am Coll Cardiol. 1994;23:1468–1471.
Congenit Heart Dis. 2014;9:158–167. doi: 10.1111/chd.12112 501. Nora JJ, Nora AH. Update on counseling the family with a first-degree
483. Geddes GC, Basel D, Frommelt P, Kinney A, Earing M. Genetic testing relative with a congenital heart defect. Am J Med Genet. 1988;29:137–
protocol reduces costs and increases rate of genetic diagnosis in infants 142. doi: 10.1002/ajmg.1320290117

502. Roos-Hesselink JW, Kerstjens-Frederikse WS, Meijboom FJ, Pieper PG. 520. Levitsky LL, Luria AH, Hayes FJ, Lin AE. Turner syndrome: update on biol-
CLINICAL STATEMENTS
Inheritance of congenital heart disease. Neth Heart J. 2005;13:88–91. ogy and management across the life span. Curr Opin Endocrinol Diabetes
AND GUIDELINES
503. Traeger-Synodinos J. Pre-implantation genetic diagnosis. Best Pract Obes. 2015;22:65–72. doi: 10.1097/MED.0000000000000128
Res Clin Obstet Gynaecol. 2017;39:74–88. doi: 10.1016/j.bpobgyn. 521. Nienhaus H, Mau U, Zang KD, Henn W. Pericentric inversion of chro-
2016.10.010 mosome 6 in a patient with cleidocranial dysplasia. Am J Med Genet.
504. Vermeesch JR, Voet T, Devriendt K. Prenatal and pre-implantation genetic 1993;46:630–631. doi: 10.1002/ajmg.1320460605
diagnosis. Nat Rev Genet. 2016;17:643–656. doi: 10.1038/nrg.2016.97 522. Battaglia A, Filippi T, Carey JC. Update on the clinical features and natural
505. Kuliev A, Pomerantseva E, Polling D, Verlinsky O, Rechitsky S. PGD for in- history of Wolf-Hirschhorn (4p-) syndrome: experience with 87 patients
herited cardiac diseases. Reprod Biomed Online. 2012;24:443–453. doi: and recommendations for routine health supervision. Am J Med Genet C
10.1016/j.rbmo.2011.12.009 Semin Med Genet. 2008;148C:246–251. doi: 10.1002/ajmg.c.30187
506. Gregg AR, Skotko BG, Benkendorf JL, Monaghan KG, Bajaj K, Best RG, 523. Xu W, Ahmad A, Dagenais S, Iyer RK, Innis JW. Chromosome 4q
Klugman S, Watson MS. Noninvasive prenatal screening for fetal aneu- deletion syndrome: narrowing the cardiovascular critical region
ploidy, 2016 update: a position statement of the American College of to 4q32.2-q34.3. Am J Med Genet A. 2012;158A:635–640. doi:
Medical Genetics and Genomics. Genet Med. 2016;18:1056–1065. doi: 10.1002/ajmg.a.34425
10.1038/gim.2016.97 524. Nguyen JM, Qualmann KJ, Okashah R, Reilly A, Alexeyev MF, Campbell DJ.
507. Skrzypek H, Hui L. Noninvasive prenatal testing for fetal aneuploidy and 5p deletions: current knowledge and future directions. Am J Med Genet
single gene disorders. Best Pract Res Clin Obstet Gynaecol. 2017;42:26– C Semin Med Genet. 2015;169:224–238. doi: 10.1002/ajmg.c.31444
38. doi: 10.1016/j.bpobgyn.2017.02.007 525. Kondoh T, Shimokawa O, Harada N, Doi T, Yun C, Gohda Y, Kinoshita
508. Taylor-Phillips S, Freeman K, Geppert J, Agbebiyi A, Uthman OA, F, Matsumoto T, Moriuchi H. Genotype-phenotype correlation of 5p-
Madan J, Clarke A, Quenby S, Clarke A. Accuracy of non-invasive pre- syndrome: pitfall of diagnosis. J Hum Genet. 2005;50:26–29. doi:
natal testing using cell-free DNA for detection of Down, Edwards and 10.1007/s10038-004-0213-9
Patau syndromes: a systematic review and meta-analysis. BMJ Open. 526. Swinkels ME, Simons A, Smeets DF, Vissers LE, Veltman JA, Pfundt R,
2016;6:e010002. doi: 10.1136/bmjopen-2015-010002 de Vries BB, Faas BH, Schrander-Stumpel CT, McCann E, Sweeney E,
509. Committee on Genetics and the Society for Maternal-Fetal Medicine. May P, Draaisma JM, Knoers NV, van Kessel AG, van Ravenswaaij-Arts
Committee Opinion No. 682: microarrays and next-generation se- CM. Clinical and cytogenetic characterization of 13 Dutch patients
quencing technology: the use of advanced genetic diagnostic tools in with deletion 9p syndrome: delineation of the critical region for a con-
obstetrics and gynecology. Obstet Gynecol. 2016;128:e262–e268. doi: sensus phenotype. Am J Med Genet A. 2008;146A:1430–1438. doi:
10.1097/AOG.0000000000001817 10.1002/ajmg.a.32310
510. Donofrio MT, Moon-Grady AJ, Hornberger LK, Copel JA, Sklansky 527. Lindstrand A, Malmgren H, Verri A, Benetti E, Eriksson M, Nordgren
MS, Abuhamad A, Cuneo BF, Huhta JC, Jonas RA, Krishnan A, Lacey A, Anderlid BM, Golovleva I, Schoumans J, Blennow E. Molecular and
S, Lee W, Michelfelder EC Sr, Rempel GR, Silverman NH, Spray TL, clinical characterization of patients with overlapping 10p deletions. Am J
Strasburger JF, Tworetzky W, Rychik J; on behalf of the American Heart Med Genet A. 2010;152A:1233–1243. doi: 10.1002/ajmg.a.33366
Association Adults With Congenital Heart Disease Joint Committee 528. Aglan MS, Kamel AK, Helmy NA. Partial trisomy of the distal part of 10q:
of the Council on Cardiovascular Disease in the Young and Council a report of two Egyptian cases. Genet Couns. 2008;19:199–209.
on Clinical Cardiology, Council on Cardiovascular Surgery and 529. Rosenfeld JA, Lacassie Y, El-Khechen D, Escobar LF, Reggin J, Heuer
Anesthesia, Council on Cardiovascular and Stroke Nursing. Diagnosis C, Chen E, Jenkins LS, Collins AT, Zinner S, Babcock M, Morrow B,
and treatment of fetal cardiac disease: a scientific statement from Schultz RA, Torchia BS, Ballif BC, Tsuchiya KD, Shaffer LG. New cases
the American Heart Association [published correction appears in and refinement of the critical region in the 1q41q42 microdeletion
Circulation. 2014;129:e512]. Circulation. 2014;129:2183–2242. doi: syndrome. Eur J Med Genet. 2011;54:42–49. doi: 10.1016/j.ejmg.
10.1161/01.cir.0000437597.44550.5d 2010.10.002
511. Copel JA, Pilu G, Kleinman CS. Congenital heart disease and extracardiac 530. van Bon BW, Koolen DA, Borgatti R, Magee A, Garcia-Minaur S, Rooms
anomalies: associations and indications for fetal echocardiography. Am J L, Reardon W, Zollino M, Bonaglia MC, De Gregori M, Novara F, Grasso
Obstet Gynecol. 1986;154:1121–1132. R, Ciccone R, van Duyvenvoorde HA, Aalbers AM, Guerrini R, Fazzi E,
512. Malik S, Cleves MA, Zhao W, Correa A, Hobbs CA; National Birth Nillesen WM, McCullough S, Kant SG, Marcelis CL, Pfundt R, de Leeuw
Defects Prevention Study. Association between congenital heart defects N, Smeets D, Sistermans EA, Wit JM, Hamel BC, Brunner HG, Kooy F,
and small for gestational age. Pediatrics. 2007;119:e976–e982. doi: Zuffardi O, de Vries BB. Clinical and molecular characteristics of 1qter
10.1542/peds.2006-2742 microdeletion syndrome: delineating a critical region for corpus cal-
513. Bilardo CM, Müller MA, Pajkrt E. Outcome of fetuses with increased nu- losum agenesis/hypogenesis. J Med Genet. 2008;45:346–354. doi:
chal translucency. Curr Opin Obstet Gynecol. 2001;13:169–174. 10.1136/jmg.2007.055830
514. Ali MM, Chasen ST, Norton ME. Testing for Noonan syndrome after 531. Mitter D, Chiaie BD, Lüdecke HJ, Gillessen-Kaesbach G, Bohring A,
increased nuchal translucency. Prenat Diagn. 2017;37:750–753. doi: Kohlhase J, Caliebe A, Siebert R, Roepke A, Ramos-Arroyo MA, Nieva B,
10.1002/pd.5076 Menten B, Loeys B, Mortier G, Wieczorek D. Genotype-phenotype cor-
515. Vigneswaran TV, Homfray T, Allan LD, Simpson JM, Zidere V. Persistently relation in eight new patients with a deletion encompassing 2q31.1. Am
elevated nuchal translucency and the fetal heart. J Matern Fetal Neonatal J Med Genet A. 2010;152A:1213–1224. doi: 10.1002/ajmg.a.33344
Med. 2018;31:2376–2380. doi: 10.1080/14767058.2017.1342804 532. Casas KA, Mononen TK, Mikail CN, Hassed SJ, Li S, Mulvihill JJ, Lin HJ,
516. Schinzel A. Catalogue of Unbalanced Chromosome Aberrations in Falk RE. Chromosome 2q terminal deletion: report of 6 new patients and
Man, 2nd Edition. Chromosome Res. 2002;10:1–4. doi: 10.1023/A: review of phenotype-breakpoint correlations in 66 individuals. Am J Med
1014274605979 Genet A. 2004;130A:331–339. doi: 10.1002/ajmg.a.30156
517. Bruns D. Presenting physical characteristics, medical conditions, and 533. Falk RE, Casas KA. Chromosome 2q37 deletion: clinical and molecular
developmental status of long-term survivors with trisomy 9 mosa- aspects. Am J Med Genet C Semin Med Genet. 2007;145C:357–371.
icism. Am J Med Genet A. 2011;155A:1033–1039. doi: 10.1002/ doi: 10.1002/ajmg.c.30153
ajmg.a.33928 534. Kleefstra T, Brunner HG, Amiel J, Oudakker AR, Nillesen WM, Magee A,
518. Springett A, Wellesley D, Greenlees R, Loane M, Addor MC, Arriola Geneviève D, Cormier-Daire V, van Esch H, Fryns JP, Hamel BC, Sistermans
L, Bergman J, Cavero-Carbonell C, Csaky-Szunyogh M, Draper ES, EA, de Vries BB, van Bokhoven H. Loss-of-function mutations in euchro-
Garne E, Gatt M, Haeusler M, Khoshnood B, Klungsoyr K, Lynch C, matin histone methyl transferase 1 (EHMT1) cause the 9q34 subtelo-
Dias CM, McDonnell R, Nelen V, O’Mahony M, Pierini A, Queisser- meric deletion syndrome. Am J Hum Genet. 2006;79:370–377. doi:
Luft A, Rankin J, Rissmann A, Rounding C, Stoianova S, Tuckerz D, 10.1086/505693
Zymak-Zakutnia N, Morris JK. Congenital anomalies associated with 535. Mefford HC, Rosenfeld JA, Shur N, Slavotinek AM, Cox VA, Hennekam
trisomy 18 or trisomy 13: a registry-based study in 16 European coun- RC, Firth HV, Willatt L, Wheeler P, Morrow EM, Cook J, Sullivan R, Oh
tries, 2000–2011. Am J Med Genet A. 2015;167A:3062–3069. doi: A, McDonald MT, Zonana J, Keller K, Hannibal MC, Ball S, Kussmann
10.1002/ajmg.a.37355 J, Gorski J, Zelewski S, Banks V, Smith W, Smith R, Paull L, Rosenbaum
519. Bruns D. Birth history, physical characteristics, and medical condi- KN, Amor DJ, Silva J, Lamb A, Eichler EE. Further clinical and molec-
tions in long-term survivors with full trisomy 13. Am J Med Genet A. ular delineation of the 15q24 microdeletion syndrome. J Med Genet.
2011;155A:2634–2640. doi: 10.1002/ajmg.a.34283 2012;49:110–118. doi: 10.1136/jmedgenet-2011-100499

536. Hempel M, Rivera Brugués N, Wagenstaller J, Lederer G, Weitensteiner C, Brunner HG, Wilkie AO, Veltman JA, Zuffardi O, Eichler EE, de Vries BB.
CLINICAL STATEMENTS
A, Seidel H, Meitinger T, Strom TM. Microdeletion syndrome 16p11.2- Clinical and molecular delineation of the 17q21.31 microdeletion syndrome
AND GUIDELINES
p12.2: clinical and molecular characterization. Am J Med Genet A. [published correction appears in J Med Genet. 2009;46:576]. J Med Genet.
2009;149A:2106–2112. doi: 10.1002/ajmg.a.33042 2008;45:710–720. doi: 10.1136/jmg.2008.058701
537. Koolen DA, Sharp AJ, Hurst JA, Firth HV, Knight SJ, Goldenberg A, Saugier- 538. McElhinney DB, Krantz ID, Bason L, Piccoli DA, Emerick KM, Spinner NB,
Veber P, Pfundt R, Vissers LE, Destrée A, Grisart B, Rooms L, Van der Aa N, Goldmuntz E. Analysis of cardiovascular phenotype and genotype-phe-
Field M, Hackett A, Bell K, Nowaczyk MJ, Mancini GM, Poddighe PJ, Schwartz notype correlation in individuals with a JAG1 mutation and/or Alagille
CE, Rossi E, De Gregori M, Antonacci-Fulton LL, McLellan MD 2nd, Garrett syndrome. Circulation. 2002;106:2567–2574.
JM, Wiechert MA, Miner TL, Crosby S, Ciccone R, Willatt L, Rauch A, Zenker 539. Phelan K, McDermid HE. The 22q13.3 deletion syndrome (Phelan-
M, Aradhya S, Manning MA, Strom TM, Wagenstaller J, Krepischi-Santos McDermid syndrome). Mol Syndromol. 2012;2:186–201. doi: 10.1159/
AC, Vianna-Morgante AM, Rosenberg C, Price SM, Stewart H, Shaw-Smith 000334260

Genetic Basis For Congenital Heart Disease: Revisited: Circulation

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Genetic Basis For Congenital Heart Disease: Revisited: Circulation

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Circulation

AHA SCIENTIFIC STATEMENT

Genetic Basis for Congenital Heart Disease:

number variants, syndromes, RASopathies, and heterotaxy/ciliopathies PhD

Key Words: AHA Scientific Statements

© 2018 American Heart Association, Inc.

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Table 1. Clinical Tests

≥1 genes or loci involved in disease.18 Many tests use, in

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euploidies such as Turner syndrome (Appendix). There is

an increased risk of many aneuploidies with increasing

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women, anovulation and infertility), lymphedema, Cardiovascular Genotype/Phenotype

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ment of other potential medical problems (Table 4).86

has been implicated in other manifestations of WS.72

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tion or deletion. Patients with JS require coordinated

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Molecular Genetics Alagille Syndrome

The condition is identified by CMA. The gene respon-

sible for congenital HD within the interval is possibly

hyperactivity and impulsivity, mild to moderate in- Ophthalmologic

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Table 5. Genes and Loci Associated With Congenital HD

limb defects more prominent on left

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Syndrome Gene(s) Loci Cardiac Disease HD Other Clinical Findings References

imperforate anus, renal anomalies

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Prevalence Holt-Oram Syndrome

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atrial isomerism.169 Cardiac conduction disease is seen Molecular Genetics

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Orthopedic Kabuki syndrome (KS) has both X-linked and autosomal

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Other Common Features

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Molecular Genetics Common Features

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cluding acute lymphoblastic leukemia and juvenile my- Molecular Genetics

The most commonly reported orthopedic complications Other RASopathies

Cardiac Features Common Features

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Figure. Ciliary structure.

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Table 6. Summary of Ciliopathies

unclassified) kidney disease

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from abnormalities of cilia within the heart. Cardiomy- genotype-phenotype correlations.

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TTC25 Dynein docking SI 326

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Table 8. Disease Genes for Nonsyndromic Congenital Cardiovascular Disease

ACTC1 ASD, HCM, DCM, LVNC NS 102540 389, 390

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ing the identification of NR2F2, a novel potentially phenotype.414

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FUNCTIONALITY OF CONGENITAL at a single specific site (eg, CRISPR/Cas9) have expe-

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teratogenic effects of environmental toxins439 or in-

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clude the frog (genus Xenopus), which has been very

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