Paolo Versacci

New mutations in ZFPM2/FOG2 gene in tetralogy of Fallot and double outlet right ventricle

De Luca A, Sarkozy A, Ferese R, Consoli F, Lepri F, Dentici ML, Vergara P, De Zorzi A, Versacci P, Digilio MC, Marino B, Dallapiccola B. New mutations in ZFPM2/FOG2 gene in tetralogy of Fallot and double outlet right ventricle.

RASopathies: Clinical Diagnosis in the First Year of Life

Diagnosis within Noonan syndrome and related disorders (RASopathies) still presents a challenge during the first months of life, since most clinical features used to differentiate these conditions become manifest later in childhood. Here, we retrospectively reviewed the clinical records referred to the first year of life of 57 subjects with molecularly confirmed diagnosis of RASopathy, to define the early clinical features characterizing these disorders and improve our knowledge on natural history. Mildly or markedly expressed facial features were invariably present. Congenital heart defects were the clinical issue leading to medical attention in patients with Noonan syndrome and LEOPARD syndrome. Feeding difficulties and developmental motor delay represented the most recurrent features occurring in subjects with cardiofaciocutaneous syndrome and Costello syndrome. Thin hair was prevalent among SHOC2 and BRAF mutation-positive infants. Café-au-lait spots were found in patients with LS and PTPN11 mutations, while keratosis pilaris was more common in individuals with SOS1, SHOC2 and BRAF mutations. In conclusion, some characteristics can be used as hints for suspecting a RASopathy during the first months of life, and individual RASopathies may be suspected by analysis of specific clinical signs. In the first year of life, these include congenital heart defects, severity of feeding difficulties and delay of developmental milestones, hair and skin anomalies, which may help to distinguish different entities, for their subsequent molecular confirmation and appropriate clinical management.

Transposition of Great Arteries: New Insights into the Pathogenesis

Transposition of great arteries (TGA) is one of the most common and severe congenital heart diseases (CHD). It is also one of the most mysterious CHD because it has no precedent in phylogenetic and ontogenetic development, it does not represent an alternative physiological model of blood circulation and its etiology and morphogenesis are still largely unknown. However, recent epidemiologic, experimental, and genetic data suggest new insights into the pathogenesis. TGA is very rarely associated with the most frequent genetic syndromes, such as Turner, Noonan, Williams or Marfan syndromes, and in Down syndrome, it is virtually absent. The only genetic syndrome with a strong relation with TGA is Heterotaxy. In lateralization defects TGA is frequently associated with asplenia syndrome. Moreover, TGA is rather frequent in cases of isolated dextrocardia with situs solitus, showing link with defect of visceral situs. Nowadays, the most reliable method to induce TGA consists in treating pregnant mice with retinoic acid or with retinoic acid inhibitors. Following such treatment not only cases of TGA with d-ventricular loop have been registered, but also some cases of congenitally corrected transposition of great arteries (CCTGA). In another experiment, the embryos of mice treated with retinoic acid in day 6.5 presented Heterotaxy, suggesting a relationship among these morphologically different CHD. In humans, some families, beside TGA cases, present first-degree relatives with CCTGA. This data suggest that monogenic inheritance with a variable phenotypic expression could explain the familial aggregation of TGA and CCTGA. In some of these families we previously found multiple mutations in laterality genes including Nodal and ZIC3, confirming a pathogenetic relation between TGA and Heterotaxy. These overall data suggest to include TGA in the pathogenetic group of laterality defects instead of conotruncal abnormalities due to ectomesenchymal tissue migration.

Association of Nonalcoholic Fatty Liver Disease with Subclinical Cardiovascular Changes: A Systematic Review and Meta-Analysis.

In the last 20 years, nonalcoholic fatty liver disease (NAFLD) has become the leading cause of chronic liver disease worldwide, primarily as a result of the epidemic of obesity. NAFLD is strongly associated with insulin resistance, glucose intolerance, and dyslipidemia and is currently regarded as the liver manifestation of the metabolic syndrome, a highly atherogenic condition even at a very early age. Patients with NAFLD including pediatric subjects have a higher prevalence of subclinical atherosclerosis, as shown by impaired flow-mediated vasodilation, increased carotid artery intima-media thickness, and arterial stiffness, which are independent of obesity and other established risk factors. More recent work has identified NAFLD as a risk factor not only for premature coronary heart disease and cardiovascular events, but also for early subclinical abnormalities in myocardial structure and function. Thus, we conducted a systematic review and meta-analysis to test the hypothesis that NAFLD is associated with evidence of subclinical cardiac structural and functional abnormalities.

Ebstein anomaly: Genetic heterogeneity and association with microdeletions 1p36 and 8p23.1.

Ebstein anomaly is an uncommon congenital heart defect (CHD), characterized by downward displacement of the tricuspid valve into the right ventricle. To uncover the genetic associations with Ebstein anomaly, we have searched chromosomal imbalances using standard cytogenetic and array‐CGH analysis, and single gene conditions associated with syndromic Ebstein anomaly (with extracardiac anomalies), and screened GATA4 and NKX2.5 mutations in nonsyndromic patients (without extracardiac anomalies). Between January 1997 and September 2009, 44 consecutive patients with Ebstein anomaly were evaluated in two centers of Pediatric Cardiology. Ebstein anomaly was syndromic in 12 (27%) patients, and nonsyndromic in 32 (73%). A recognizable syndrome or complex was diagnosed by clinical criteria in seven patients. In one syndromic patient an 18q deletion was diagnosed by standard cytogenetic analysis. Array‐CGH analysis performed in 10 of the 12 syndromic patients detected an interstitial deletion of about 4 Mb at 8p23.1 in one patient, and a deletion 1pter > 1p36.32/dup Xpter‐ > Xp22.32 in another patient. In the 28 of 32 nonsyndromic patients who underwent molecular testing, no mutation in GATA4 and NKX2.5 genes were detected. We conclude that Ebstein anomaly is a genetically heterogeneous defect, and that deletion 1p36 and deletion 8p23.1 are the most frequent chromosomal imbalances associated with Ebstein anomaly. Candidate genes include the GATA4 gene (in patients with del 8p23.1), NKX2.5 (based on published patients with isolated Ebstein anomaly) and a hypothetical gene in patients with del 1p36).

Shells and heart: Are human laterality and chirality of snails controlled by the same maternal genes?†

The body of most animals display left–right asymmetry of internal organs. Alteration of such asymmetry results in severe congenital defects particularly affecting the cardiovascular system. The earliest known genes involved in asymmetry, the Nodal signalling cascade, are expressed asymmetrically during embryonic development. Nodal was discovered in the mouse, but orthologs (also involved in left‐right specification) were reported in ascidians, sea‐urchins, and snails. Mutations in Nodal‐pathway genes cause alteration of several aspects of chirality, but not entirely mirror phenotypes of the body. Other factors upstream of nodal must be involved in the generation of left–right asymmetry. In snails, breeding experiments have demonstrated that chirality is controlled by a nuclear gene with maternal effect. Given the available evidence, we propose that an evolutionarily conserved genetic basis of chirality (the same that controls left–right asymmetry in snails) is a major synapomorphy of the Bilateria. This hypothesis fits with the observation that: (a) the proportion of patients with heterotaxy and a detected mutation in a gene of the Nodal cascade is actually low, and (b) horizontal recurrence of laterality defects is remarkably more frequent than vertical recurrence, and includes a notable number of affected sibs and/or repeated abortions from unaffected mothers. Identification of the maternal gene(s) involved will allow for the identification of homozygous females at risk of having affected children and spontaneous abortions, and would provide a general medical framework for understanding the genetics of most alterations of chirality.

3q29 Microdeletion: a mental retardation disorder unassociated with a recognizable phenotype in two mother-daughter pairs.

The 3q29 microdeletion syndrome (del 3q29) is a novel genomic disorder identified after the introduction of microarray‐based technology. The phenotype of the reported patients is variable, including mental retardation and subtle facial anomalies. We report on two mother–daughter pairs, heterozygous for 3q29, and review clinical features of all known affected individuals. Del 3q29 syndrome is associated with nonspecific clinical features, including mild‐to‐moderate developmental delay, microcephaly, and mild facial dysmorphisms such as short philtrum and high nasal bridge. Facial anomalies were nonoverlapping and nondistinct, also within each mother–daughter pair. Parental transmission of del 3q29 could be more frequent than previously considered. Malformations are rare, occurring only in single subjects. The phenotypic diversity of affected patients and the lack of distinct dysmorphisms suggest that this disorder cannot be recognized on clinical ground alone. Del 3q29 should be searched in subjects with unexplained mild/moderate mental retardation, microcephaly, and minor nonspecific facial anomalies.

Absent pulmonary valve with intact ventricular septum and patent ductus arteriosus: A specific cardiac phenotype associated with deletion 18q syndrome

Research Letter Absent Pulmonary Valve With Intact Ventricular Septum and Patent Ductus Arteriosus: A Specific Cardiac Phenotype Associated With Deletion 18q Syndrome Paolo Versacci, M. Cristina Digilio, Ursula Sauer, Bruno Dallapiccola, and Bruno Marino* Pediatric Cardiology, Department of Pediatrics, University ‘‘La Sapienza’’, Rome, Italy Medical Genetics, Bambino Gesù Hospital, Rome, Italy Deutsches Herzzentrum, München, Germany CSS-Mendel Institute and University ‘‘La Sapienza’’, Rome, Italy

Syndromic non-compaction of the left ventricle: Associated chromosomal anomalies

Non‐compaction of the left ventricle (NCLV) is a cardiomyopathy characterized by prominent left ventricular trabeculae and deep intertrabecular recesses. Associated extracardiac anomalies occur in 14–66% of patients of different series, while chromosomal anomalies were reported in sporadic cases. We investigated the prevalence of chromosomal imbalances in 25 syndromic patients with NCLV, using standard cytogenetic, subtelomeric fluorescent in situ hybridization, and array‐comparative genomic hybridization (CGH) analyses. Standard chromosome analysis disclosed an abnormality in three (12%) patients, including a 45,X/46,XX mosaic, a 45,X/46,X,i(Y)(p11) mosaic, and a de novo Robertsonian 13;14 translocation in a child affected by hypomelanosis of Ito. Cryptic chromosome anomalies were found in six (24%) cases, including 1p36 deletion in two patients, 7p14.3p14.1 deletion, 18p subtelomeric deletion, 22q11.2 deletion associated with velo‐cardio‐facial syndrome, and distal 22q11.2 deletion, each in one case. These results recommend accurate clinical evaluation of patients with NCLV, and suggest that chromosome anomalies occur in about one third of syndromic NCLV individuals, without metabolic/neuromuscular disorder. Array‐CGH analysis should be included in the diagnostic protocol of these patients, because different submicroscopic imbalances are causally associated with this disorder and can pinpoint candidate genes for this cardiomyopathy.

The role of terlipressin in the management of severe pulmonary hypertension in congenital diaphragmatic hernia.

SIR—Infants with congenital diaphragmatic hernia (CDH) are prone to develop profound hypoxemia related to lung hypoplasia and persistent pulmonary hypertension (PPH) despite optimized ventilatory management and selective pulmonary vasodilator drugs. Terlipressin (tricyl-lysinevasopressin), a long-acting vasopressin analogue, is a potent vasopressor drug that has been used to treat hypotension in various conditions, especially catecholamine-resistant shock (1). The case we report of a newborn infant with CDH in whom severe PPH refractory to inhaled NO (iNO) promptly responded to terlipressin draws attention to this drug as an effective alternative to treat hypoxemia associated with PPH when pulmonary vasodilators fail. A baby girl weighing 2.7 kg, with a left-sided diaphragmatic hernia and severe pulmonary hypoplasia confirmed by magnetic resonance imaging at 22 weeks gestation, was born at 38 weeks via cesarean section. The baby was intubated in the delivery room, sedated, and manually ventilated (Apgar scores 1¢:2; 5¢:5, 10¢:8). Despite aggressive mechanical ventilation settings, the baby remained poorly ventilated and oxygenated (oxygenation index=34, pCO2 = 11.9 kPa). High frequency oscillatory ventilation [HFOV; mean airway pressure (MAP) = 21 cmH2O, F = 13 Hz, DP = 70 cmH2O] reduced hypercapnia (pCO2 = 5.8 kPa) and improved oxygenation. At the same time, she was empirically started on 20 ppm iNO, and a single surfactant dose was administered. After the first 12 h of life, because oxygen requirements increased and hypercapnia developed, HFOV parameters were gradually adjusted (MAP = 28, F = 7 Hz, DP = 70 cmH2O), and iNO was increased to 34 ppm. Echocardiographic studies indicated right ventricular dysfunction and a bidirectional shunt through the ductus arteriosus with a pulmonary artery pressure (PAP) of 70 mmHg estimated on tricuspidal regurgitation, suggesting severe pulmonary hypertension. Inotropic agents at increasing doses (dobutamine up to 10 lgÆkgÆmin and dopamine up to 20 lgÆkgÆmin) and appropriate fluid therapy were given to increase the baby’s blood pressure that was measured by femoral artery catheterization. At 48 h of life, profound hypoxemia and hypotension (Figure 1) led to cardiac arrest. Adrenaline added to the inotropic regimen transiently improved circulatory failure. The baby’s condition nevertheless worsened again and despite therapy with fluids and frusemide marked oliguria (<0.5 mlÆkgÆh) developed, accompanied by hypotension and hypoxemia (pH=6.97, postductal pO2 = 4.9 kPa, pCO2 = 15.5 kPa, base excess = )8.4). After obtaining approval from the parents and hospital committee, as rescue therapy to reverse catecholamine-resistant shock, we used intravenous terlipressin (5 lgÆkg as a bolus) that simultaneously normalized systemic arterial pressure and improved oxygenation. Terlipressin infusion (5 lgÆkgÆh) was then maintained to keep the systemic blood pressure higher than the PAP. Echocardiographic examination showed a slight decrease in PAP (65 mmHg) and a reversed right-to-left shunt. Terlipressin induced no evident adverse effects such as ischemic tissue injury, intestinal ischemia, myocardial ischemia, or ventricular arrhythmias. On days 3–4, the baby’s renal function improved and increased oxygenation allowed HFOV parameters to be reduced (MAP from 28 to 20 cmH2O). Echocardiographic indices of pulmonary hypertension progressively improved from day 3 to day 6 (PAP 35 mmHg on day 5 of life). Terlipressin was weaned off on day 5 of life and suspended on day 6. At 8 days of age, the baby girl underwent surgery. On followup, the child appeared developmentally normal and thrived well. There are no previous reports describing the use of terlipressin in the management of pulmonary hypertension with or without circulatory shock in newborn infants. Our case thus represents the first instance of the use of terlipressin to relieve severe hypoxemia developing as a consequence of PPH and circulatory shock after failure of conventional treatments. In our case, severe hypotension prevented us from using any of the standard alternatives to iNO because they would have dilated the pulmonary circulation but further decreased systemic blood pressure (2). We therefore used a systemic vasopressor that increased the ratio of systemic blood pressure to pulmonary arterial 0 20 40 60 80 100 120