Clinical exome sequencing efficacy and phenotypic expansions involving anomalous pulmonary venous return.

Anomalous pulmonary venous return (APVR) frequently occurs with other congenital heart defects (CHDs) or extra-cardiac anomalies. While some genetic causes have been identified, the optimal approach to genetic testing in individuals with APVR remains uncertain, and the etiology of most cases of APVR is unclear. Here, we analyzed molecular data from 49 individuals to determine the diagnostic yield of clinical exome sequencing (ES) for non-isolated APVR. A definitive or probable diagnosis was made for 8 of those individuals yielding a diagnostic efficacy rate of 16.3%. We then analyzed molecular data from 62 individuals with APVR accrued from three databases to identify novel APVR genes. Based on data from this analysis, published case reports, mouse models, and/or similarity to known APVR genes as revealed by a machine learning algorithm, we identified 3 genes-EFTUD2, NAA15, and NKX2-1-for which there is sufficient evidence to support phenotypic expansion to include APVR. We also provide evidence that 3 recurrent copy number variants contribute to the development of APVR: proximal 1q21.1 microdeletions involving RBM8A and PDZK1, recurrent BP1-BP2 15q11.2 deletions, and central 22q11.2 deletions involving CRKL. Our results suggest that ES and chromosomal microarray analysis (or genome sequencing) should be considered for individuals with non-isolated APVR for whom a genetic etiology has not been identified, and that genetic testing to identify an independent genetic etiology of APVR is not warranted in individuals with EFTUD2-, NAA15-, and NKX2-1-related disorders.

Persistent Markers of Kidney Injury in Children Who Developed Acute Kidney Injury After Pediatric Cardiac Surgery: A Prospective Cohort Study.

Background Acute kidney injury (AKI) after pediatric cardiac surgery is common. Longer-term outcomes and the incidence of chronic kidney disease after AKI are not well-known. Methods and Results All eligible children (aged <16 years) who had developed AKI following cardiac surgery at our tertiary referral hospital were prospectively invited for a formal kidney assessment ≈5 years after AKI, including measurements of estimated glomerular filtration rate, proteinuria, α1-microglobulin, blood pressure, and kidney ultrasound. Longer-term follow-up data on kidney function were collected at the latest available visit. Among 571 patients who underwent surgery, AKI occurred in 113 (19.7%) over a 4-year period. Fifteen of these (13.3%) died at a median of 31 days (interquartile range [IQR], 9-57) after surgery. A total of 66 patients participated in the kidney assessment at a median of 4.8 years (IQR, 3.9-5.7) after the index AKI episode. Thirty-nine patients (59.1%) had at least 1 marker of kidney injury, including estimated glomerular filtration rate <90 mL/min per 1.73 m2 in 9 (13.6%), proteinuria in 27 (40.9%), α1-microglobinuria in 5 (7.6%), hypertension in 13 (19.7%), and abnormalities on kidney ultrasound in 9 (13.6%). Stages 1 to 5 chronic kidney disease were present in 18 (27.3%) patients. Patients with CKD were more likely to have an associated syndrome (55.6% versus 20.8%, P=0.015). At 13.1 years (IQR, 11.2-14.0) follow-up, estimated glomerular filtration rate <90 mL/min per 1.73 m² was present in 18 of 49 patients (36.7%), suggesting an average estimated glomerular filtration rate decline rate of -1.81 mL/min per 1.73 m² per year. Conclusions Children who developed AKI after pediatric cardiac surgery showed persistent markers of kidney injury. As chronic kidney disease is a risk factor for cardiovascular comorbidity, long-term kidney follow-up in this population is warranted.

Percutaneous embolization of lymphatic fistulae as treatment for protein-losing enteropathy and plastic bronchitis in patients with failing Fontan circulation.

BACKGROUND: To determine the feasibility and clinical result of selective embolization of hepatoduodenal or paratracheal lymphatics in Fontan patients with protein-losing enteropathy (PLE) or plastic bronchitis (PB). METHODS: Dilated lymph vessels in periportal (PLE) or paratracheal (PB) position were percutaneously punctured with a 22G Chiba needle. Intralymphatic position was confirmed by water soluble contrast injection with drainage to hepatoduodenal or tracheal fistulae. After flushing with 10% glucose solution, occlusion of hepatoduodenal or paratreacheal lymphatics was effected by injection of 1-4 cc mixture 4/1 of Lipiodol/n-butyl cyanoacrylate (n-BCA; Histoacryl). RESULTS: Seven patients with proven PLE were treated with periportal lymphatic embolization 10.7 (range: 6.6-13.5) years after the Fontan operation. The Fontan operation was performed at a median age of 3.7 (range: 2.9-5.7) years and PLE started a median of 3.1 (range: 0.9-4.7) years later. Five patients required a second procedure 2-8 months later. Complications were limited (spillage of glue in portal branch, transient cholangitis, and caustic duodenal bleeding). Six of seven patients reported significant improvement in quality of life and normalization of albumin levels after limited follow-up (p < .01). One patient (Fontan at 2.9 years; age 16.4 years) had PB for 2 years. Selective transthoracic cone-beam-directed puncture of left and right paratracheal lymphatics with n-BCA embolization of distal lymphatic fistulae resulted in lasting absence of tracheal casts (11 months). CONCLUSIONS: Embolization of periportal/peritracheal lymphatics is a promising technique in Fontan patients with PLE/PB. Larger series are required to determine incidence and reasons of success/failure, with long-term results and effects on liver function.

Clinical Characteristics of Infective Endocarditis in Children.

BACKGROUND: Infective endocarditis (IE) remains a diagnostic and therapeutic challenge associated with high morbidity and mortality. We evaluated the microbial profile and clinical manifestation of IE in children. METHODS: A retrospective study examining pediatric IE cases treated between 2000 and 2017 at the Department of Pediatric Cardiology, KU Leuven, was conducted. Clinical presentation, treatment, complications, outcome of IE, underlying microorganisms and congenital heart defects were reviewed. RESULTS: Fifty-three patients were diagnosed with IE. Overall, 19 patients (36%) required cardiac surgery. Seven patients (13%) died. Eighty-seven percent of patients had an underlying congenital cardiac defect. Eighteen (34%) children presented with prosthetic graft IE. A causative organism was found in 49 (92%) cases: viridans group streptococci were identified in 17 (32%), Staphylococcus aureus in 13 (25%) and coagulase-negative staphylococci in 11 (20%) children. Community-acquired (CA) IE increased significantly from 8 (33%) cases in 2000-2007 to 20 (74%) cases in 2008-2017 (P < 0.01). Even with viridans streptococci being significantly more prevalent in the CA group (P < 0.01), we did not observe an increase of streptococcal IE from 2008 to 2017. Seventeen (32%) patients presented with hospital-acquired IE during the first year of life with 14 (82%) children after surgery and a prevalence of coagulase-negative staphylococci (53%). CONCLUSIONS: The incidence of pediatric IE was similar over the investigated time period with a shift toward CA IE. Streptococci and staphylococci accounted for the majority of cases in both periods. Awareness of IE and its prevention is crucial in patients after implantation of prosthetic grafts.

Compound heterozygous loss-of-function mutations in KIF20A are associated with a novel lethal congenital cardiomyopathy in two siblings.

Congenital or neonatal cardiomyopathies are commonly associated with a poor prognosis and have multiple etiologies. In two siblings, a male and female, we identified an undescribed type of lethal congenital restrictive cardiomyopathy affecting the right ventricle. We hypothesized a novel autosomal recessive condition. To identify the cause, we performed genetic, in vitro and in vivo studies. Genome-wide SNP typing and parametric linkage analysis was done in a recessive model to identify candidate regions. Exome sequencing analysis was done in unaffected and affected siblings. In the linkage regions, we selected candidate genes that harbor two rare variants with predicted functional effects in the patients and for which the unaffected sibling is either heterozygous or homozygous reference. We identified two compound heterozygous variants in KIF20A; a maternal missense variant (c.544C>T: p.R182W) and a paternal frameshift mutation (c.1905delT: p.S635Tfs*15). Functional studies confirmed that the R182W mutation creates an ATPase defective form of KIF20A which is not able to support efficient transport of Aurora B as part of the chromosomal passenger complex. Due to this, Aurora B remains trapped on chromatin in dividing cells and fails to translocate to the spindle midzone during cytokinesis. Translational blocking of KIF20A in a zebrafish model resulted in a cardiomyopathy phenotype. We identified a novel autosomal recessive congenital restrictive cardiomyopathy, caused by a near complete loss-of-function of KIF20A. This finding further illustrates the relationship of cytokinesis and congenital cardiomyopathy.

Distinct genetic architectures for syndromic and nonsyndromic congenital heart defects identified by exome sequencing.

Congenital heart defects (CHDs) have a neonatal incidence of 0.8-1% (refs. 1,2). Despite abundant examples of monogenic CHD in humans and mice, CHD has a low absolute sibling recurrence risk (∼2.7%), suggesting a considerable role for de novo mutations (DNMs) and/or incomplete penetrance. De novo protein-truncating variants (PTVs) have been shown to be enriched among the 10% of 'syndromic' patients with extra-cardiac manifestations. We exome sequenced 1,891 probands, including both syndromic CHD (S-CHD, n = 610) and nonsyndromic CHD (NS-CHD, n = 1,281). In S-CHD, we confirmed a significant enrichment of de novo PTVs but not inherited PTVs in known CHD-associated genes, consistent with recent findings. Conversely, in NS-CHD we observed significant enrichment of PTVs inherited from unaffected parents in CHD-associated genes. We identified three genome-wide significant S-CHD disorders caused by DNMs in CHD4, CDK13 and PRKD1. Our study finds evidence for distinct genetic architectures underlying the low sibling recurrence risk in S-CHD and NS-CHD.

Can a volume challenge pinpoint the limiting factor in a Fontan circulation?

OBJECTIVE: It is difficult to indicate whether the limitation in a failing Fontan circulation lies within the pulmonary vasculature or the heart. Such differentiation is crucial to direct adequate therapy. This study was set out to determine if a volume challenge could identify the limiting factor. METHODS AND STUDY POPULATION: Thirty-two catheterizations in 28 patients with a Fontan circulation were included. Pressures and oxygen saturations were measured before and after volume challenge (NaCl 0.9%; 15 cc/Kg). The changes in data were grouped based on the location of the major pressure increase. Ventricular function was measured in the resting state. RESULTS: The majority of the patients showed an increase in aortic oxygen saturation, mixed venous oxygen saturation, systolic, pulmonary and systemic venous pressures. The arterio-venous oxygen gradient decreased, suggesting an increase in cardiac output. Different patterns in pressure changes were observed. Most (n=17) showed a similar increase of ventricular end-diastolic pressure and mean venous pressure (MVP); some (n=7) showed a lower increase of MVP, suggesting pulmonary reserve and recruitment; others (n=8) showed a significant higher increase in MVP, suggesting increased pulmonary vascular resistance. All volume challenge was well tolerated. CONCLUSION: Most patients were preload-responsive. The pressure changes following volume load showed patterns with a potential of differentiating between patients with a major pulmonary or cardiac limiting factor.

The diagnostic value of next generation sequencing in familial nonsyndromic congenital heart defects.

To determine the diagnostic value of massive parallel sequencing of a panel of known cardiac genes in familial nonsyndromic congenital heart defects (CHD), targeted sequencing of the coding regions of 57 genes previously implicated in CHD was performed in 36 patients from 13 nonsyndromic CHD families with probable autosomal dominant inheritance. Following variant analysis and Sanger validation, we identified six potential disease causing variants in three genes (MYH6, NOTCH1, and TBX5), which may explain the defects in six families. Several problematic situations were encountered when performing genotype-phenotype correlations in the families to confirm the causality of these variants. In conclusion, by screening known CHD-associated genes in well-selected nonsyndromic CHD families and cautious variant interpretation, potential causative variants were identified in less than half of the families (6 out of 13; 46%). Variant interpretation remains a major challenge reflecting the complex genetic cause of CHD.

MEIS2 involvement in cardiac development, cleft palate, and intellectual disability.

MEIS2 has been associated with cleft palate and cardiac septal defects as well as varying degrees of intellectual disability. We present a female patient with a more severe phenotype compared to previous reported patients. She has multiple congenital malformations; cleft palate and congenital heart defect characterized by septal defects and aortic coarctation. She has severe feeding problems, facial dysmorphism, severely delayed gross motor and verbal development, and autism spectrum disorder. Facial dysmorphism consisting of bitemporal narrowing, arched and laterally extended eyebrows, mild upslanting palpebral fissures, deep-set eyes, a tented upper lip, thin upper vermilion, full lower vermilion, broad first ray of hands and feet, a gap between the first and second toes, and syndactyly of toe II-III. Exome sequencing revealed a non-frameshift deletion (c.998_1000del:p.Arg333del) of three base pairs in the MEIS2 homeodomain. The more severe phenotype is most probably due to dominant-negative mechanisms. This is the first report showing a de novo small intragenic mutation in MEIS2 and further confirms the important role of this gene in normal development.

Homozygous loss-of-function mutation in ALMS1 causes the lethal disorder mitogenic cardiomyopathy in two siblings.

BACKGROUND: Two siblings from consanguineous parents of Turkish descent presented with isolated dilated cardiomyopathy, leading to early death in infancy. The diagnosis of mitogenic cardiomyopathy was made histologically. METHODS AND RESULTS: Linkage analysis combined with exome sequencing identified a homozygous deleterious mutation in the ALMS1 gene as the cause of this phenotype. CONCLUSIONS: Alström syndrome is characterized by a typically transient dilating cardiomyopathy in infancy, suggesting that mitogenic cardiomyopathy represents the extreme phenotype, resulting in demise before the other clinical symptoms become evident. This observation further illustrates the role of ALMS1 and cell cycle regulation.

Use of covered Cheatham-Platinum stents in congenital heart disease.

BACKGROUND: Controversy remains regarding the use of covered stents in congenital heart disease (CHD). We evaluate the possibilities and safety of covered Cheatham-Platinum (CCP) stents in CHD. METHODS: Single-center retrospective CHD-database study of all CCP stents, 2003-2012. Three study groups: aortic coarctation (CoA), right ventricular outflow tract pre-stenting for percutaneous revalvulation (RVOT), and miscellaneous. Continuous data expressed as median (range). RESULTS: 114 CCP stents in 105 patients, age 16.8 years (4.2-71.2). CoA group: 54 CCP stents in 51 patients: 3/54 for aneurysm exclusion, in 51/54 covering used "prophylactically" because of increased risk for vessel tear. Overall, CCP stenting increased the coarctation diameter from 6mm (0-15) to 15 mm (10-20) (p<0.001). RVOT group: 39 CCP stents in 37 patients (34 with RVOT graft, 3 with transannular patch): the graft lumen had shrunken from nominal 21 mm (10-26) to 13 mm (5-22); with the CCP stent the RVOT was redilated to 22 mm (16-26, p<0.001 vs stenosis). Miscellaneous group: 21 CCP stents in 17 patients: closure of Fontan-circuit fenestration (n=5), restoration of superior caval vein (n=2) or pulmonary artery (n=3) patency, relief of supra-pulmonary stenosis (n=2), exclusion of aberrant pulmonary arteries (n=1), cavopulmonary conduit expansion (n=2), Blalock-Taussig shunt flow reduction (n=1), and defibrillator lead protection from sharp stents (n=1). Hybrid procedures performed in 3/17 patients. CCP stent was used as rescue treatment in 2/patients to seal iatrogenic bleeding. CONCLUSION: CCP stents can safely be applied in CHD patients. The covering allows adequate sealing of existing or expected tears, thereby increasing the safety margin with more complete dilation.

Rare variants in NR2F2 cause congenital heart defects in humans.

Congenital heart defects (CHDs) are the most common birth defect worldwide and are a leading cause of neonatal mortality. Nonsyndromic atrioventricular septal defects (AVSDs) are an important subtype of CHDs for which the genetic architecture is poorly understood. We performed exome sequencing in 13 parent-offspring trios and 112 unrelated individuals with nonsyndromic AVSDs and identified five rare missense variants (two of which arose de novo) in the highly conserved gene NR2F2, a very significant enrichment (p = 7.7 × 10(-7)) compared to 5,194 control subjects. We identified three additional CHD-affected families with other variants in NR2F2 including a de novo balanced chromosomal translocation, a de novo substitution disrupting a splice donor site, and a 3 bp duplication that cosegregated in a multiplex family. NR2F2 encodes a pleiotropic developmental transcription factor, and decreased dosage of NR2F2 in mice has been shown to result in abnormal development of atrioventricular septa. Via luciferase assays, we showed that all six coding sequence variants observed in individuals significantly alter the activity of NR2F2 on target promoters.

Neonatal circulatory failure due to acute hypertensive crisis: clinical and echocardiographic clues.

OBJECTIVE: Circulatory failure due to acute arterial hypertension in the neonatal period is rare. This study was undertaken to assess the clinical and echocardiographic manifestations of circulatory failure resulting from acute neonatal hypertensive crisis. METHODS: Neonatal and cardiology databases from 2007 to 2010 were reviewed. An established diagnosis of circulatory failure due to neonatal hypertension before the age of 14 days was required for inclusion. Six patients were identified. RESULTS: Five patients presented with circulatory failure due to an acute hypertensive crisis. The median age at presentation was 8.5 days (range: 6.0-11.0) with a median body weight of 3.58 kg (range: 0.86-4.70). Echocardiography demonstrated mild left ventricular dysfunction [median shortening fraction (SF) 25%, range 10-30] and mild aortic regurgitation in 83% (5/6) of patients. One patient with left ventricular dysfunction (SF = 17%) had a large apical thrombus. Two patients were hypotensive, and hypertension only became evident after restoration of cardiac output. Administration of intravenous milrinone was successful, with rapid improvement of the clinical condition. Left ventricular function normalised in all survivors. CONCLUSION: Early neonatal circulatory collapse due to arterial hypertension is a rare but potentially life-threatening condition. At presentation, hypotension, especially in the presence of a dysfunctional left ventricle, does not exclude a hypertensive crisis being the cause of circulatory failure. The echocardiographic presence of mild aortic regurgitation combined with left ventricular hypocontractility in a structurally normal heart should alert the physician to the presence of underlying hypertension.

Pulmonary artery banding as 'open end' palliation of systemic right ventricles: an interim analysis.

OBJECTIVES: A morphological right ventricle (RV) is not ideally suited for the long-term maintenance of the systemic circulation. The aim of this analysis was to evaluate the intermediate results and outcome of pulmonary artery banding (PAB) in an open-ended strategy. METHODS: This is a retrospective review of patients with systemic RVs who had undergone PAB in our institution from April 1985 to January 2011. PAB was placed in 5 patients late after the Senning operation and in 15 patients with corrected transposition; of whom, 6 had a large ventricular septal defect. RESULTS: PAB was performed at a median age of 4.3 years (range: 0.9-14.9), median follow-up of 86 months (range: 0.5-379). All 20 patients are alive and are being followed up. Tricuspid regurgitation (TR), RV function and dilation showed no deterioration after banding (P = 0.9). Ninety per cent (18/20) have adequate ongoing palliation with PAB. One patient underwent a double-switch operation and one received an additional bidirectional Glenn shunt. A dilatable band was redilated with improvement in percutaneous saturation and in another the procedure was abandoned due to development of transient atrioventricular block. Functional class remained either unchanged or improved. CONCLUSIONS: PAB was performed with no mortality and low morbidity. PAB in these heterogeneous patients provides true 'open ended palliation' by allowing left ventricular training in those going for anatomical repair, stabilizing or improving RV function and TR in others, thereby delaying surgery. It can also be left in place as long-term palliation. The addition of a dilatable band allows manipulation of pulmonary flows, but longer follow-up is required to provide data on best management strategies for these complex patients.

Treatment strategies for pulmonary sequestration in childhood: resection, embolization, observation?

BACKGROUND: The ideal treatment strategy for pulmonary sequestration whether resection or embolization in childhood is not clearly defined. Our institution has no clear policy, therefore both therapies are performed. OBJECTIVE: The aim of this study was to assess local management strategies of children presenting with pulmonary sequestrations. METHODS: This is a retrospective, single-institutional review. The main inclusion criterion was the established diagnosis of a pulmonary sequestration. Forty-eight patients were divided into three groups based on treatment received: conservative management (n = 5), surgery (n = 22) and embolization (n = 21). RESULTS: The median age at treatment was 8.0 months (range 1.2- 166.0) in the surgical, 4.0 months (range 0.2 - 166.0) in the embolization and 8 months (range 0.3 - 197.0) in the conservatively managed groups, respectively. Age at treatment was similar in the surgical and embolization groups (P = 0.9). Recurrent chest infections were the most common clinical presentation in the surgical group, whilst cardiac failure was the most frequent symptom in the embolization group (P < 0.01; 95% CI: 0.3 to 0.9). There were six complications in the surgical group and one in the embolization group (P = 0.1). In one patient embolization was not possible. Outcomes in both groups were comparable with good results on follow-up. CONCLUSION: Both surgery and endovascular embolization are effective and safe treatments for pulmonary sequestration. The presenting symptoms dictate therapy: surgery if there is infection and embolization if a shunt needs to be abolished. Our institutional policy remains unchanged.

Serum procalcitonin is not an early marker of pulmonary exacerbation in children with cystic fibrosis.

UNLABELLED: Serum procalcitonin (PCT) has been proposed as a marker to identify bacterial infection in children. For optimal management of cystic fibrosis (CF) patients, early recognition of pulmonary exacerbations is necessary, but sensitive biomarkers to do so are lacking. Our study was done to establish baseline values for PCT in children with CF and to compare these to values at onset of a pulmonary exacerbation. Serum PCT values were determined in CF children during an outpatient clinic visit and at onset of treatment with intravenous (IV) antibiotics for a pulmonary exacerbation. Serum PCT was measured using a quantitative immunoassay (BRAHMS Kryptor PCTsensitive, Henningsdorf, Germany). In 92 outpatients (mean age 10.0 years, SD 4.8 years; mean forced expiratory volume in 1 s 91%, SD 18; 9 chronically colonized with Pseudomonas aeruginosa), mean baseline PCT was 0.05 ng/ml (SD 0.07). Mean PCT on admission for IV treatment of pulmonary exacerbation was 0.07 ng/ml (SD 0.06) (n = 22) and not different from the baseline value. PCT values were markedly higher in two CF patients with an acute nonrespiratory infection (central venous catheter-associated bloodstream infection, acute gastroenteritis), demonstrating that they can mount a PCT response. CONCLUSION: PCT values in CF children are not different from values reported in healthy children. In CF children, PCT values do not rise significantly at the onset of a respiratory exacerbation and thus hold no promise as an early marker to identify a pulmonary exacerbation.