Congenital heart disease (CHD) is the most common birth defect with an incidence of 0.4%–1.5% in the total newborn infants every year. The morbidity and mortality of CHD are the first place of non-infectious diseases of children in the world [
Genetic variants are closely associated with PAH-CHD [
Patients who were first diagnosed with PAH-CHD were consecutively enrolled at Fuwai Hospital of Chinese Academy of Medical Sciences in Beijing from October 31, 2018, to October 25, 2019. CHD was diagnosed by echocardiography or cardiac CT scanning and PAH was diagnosed by right heart catheterization (RHC) or echocardiography according to the guideline3. All PAH-CHD patients had a moderately increased pulmonary artery pressure (pulmonary artery systolic pressure greater than 40 mmHg). Seven patients were excluded because they were unwilling to undergo genetic testing (
CHD-PAH patients were screened by whole exome sequencing (WES) to detect the rare variants in the coding regions and the intron/exon boundaries of
The exome sequencing data was processed using the established bioinformatics pipeline [
Results were presented as percentages, median (interquartile range), or mean (standard error of mean or SD), as indicated. The frequency of rare variants was compared by χ2 test or Fisher exact test. All the statistical testing was 2 sided and considered statistically significant at a level of
Totally 142 PAH-CHD patients were recruited in our study eventually, including 54 atrial septal defects (ASD 38.0%), 66 ventricular septal defects (VSD 46.5%), 7 patent ductus arteriosus (PDA 4.9%), and 15 (10.6%) cases had complex CHD. Forty-three cases (30.3%) were men and 99 cases (69.7%) were women. The mean age was 29.8 ± 10.9 years old. The mean value of mPAP (mean Pulmonary Arterial Pressure) and sPAP (systolic Pulmonary Arterial Pressure) in the cohort were 65.2 ± 15.7mmHg and 97.1 ± 22.3 mmHg, respectively (see
Items | CHD-PAH (Mean ± SD) | (Median, IQR) |
---|---|---|
Gender | / | / |
Male (%) | 46 (31.29) | / |
Female (%) | 101 (68.71) | / |
Age (Year) | 29.84 ± 10.94 | (39.5, 12.8) |
mPAP (mmHg) | 65.15 ± 15.71 | (34, 23) |
sPAP (mmHg) | 97.12 ± 22.31 | (53, 26.6) |
CTR | 0.52 ± 0.09 | (0.49, 0.1) |
SiO2 (mmHg) | 92.08 ± 3.69 | (91.2, 4.7) |
PVR (WoodU) | 9.69 ± 5.76 | (3.12, 8.19) |
Note: INR, Interquartile range; mPAP, Mean pulmonary artery pressure; sPAP, systolic pulmonary artery pressure; CTR, Cardiac thoracic rate; SiO2, Oxygen saturation (arteria femoralis); PVR, Pulmonary vascular resistance.
Whole exome sequencing was performed in the 142 PAH-CHD patients. Pathogenic or likely pathogenic mutations of PAH and CHD related to pathogenic gene were not found in all patients. We identified 11 (7.7%) patients carrying rare
No. | Gender | Age (Years) | Clinical diagnosis | Revel scorea | 1000 Genomesb | gnomAD genome east asianc | Coding nucleotide | Amino acid change | Inheritance | ACMG grade |
---|---|---|---|---|---|---|---|---|---|---|
1 | Male | 29 | ASD, PAH | 0.054 | 0.000199681 | 0.001010 | c.4791T>A | p.Asn1597Lys | AD | Uncertain significance |
2 | Male | 41 | ASD, PAH | 0.574 | 0.000199681 | 0.003967 | c.1630C>T | p.Arg544Cys | AD | Pathogenic |
3 | Female | 38 | VSD, PAH | 0.421 | – | 0.001781 | c.224G>A | p.Arg75Gln | AD | Likely Pathogenic |
4 | Female | 27 | VSD, PAH | 0.173 | – | 0.001616 | c.4793A>T | p.Asp1598Val | AD | Likely benign |
5 | Female | 20 | VSD, PAH | 0.574 | 0.000199681 | 0.003967 | c.1630C>T | p.Arg544Cys | AD | Pathogenic |
0.893 | 0.00001652 | 0.0001658 | c.515G>A | p.Gly172Asp | AD | Uncertain significance | ||||
6 | Female | 50 | ASD, PAH | 0.29 | 0.000199681 | 0.001655 | c.3299G>A | p.Arg1100His | AD | Uncertain significance |
7 | Male | 39 | VSD, PAH | 0.753 | 0.0007987 | 0.002356 | c.709G>A | p.Val237Met | AD | Uncertain significance |
8 | Female | 31 | VSD, PAH | 0.574 | 0.000199681 | 0.003967 | c.1630C>T | p.Arg544Cys | AD | Pathogenic |
9 | Female | 21 | VSD, PDA, PAH | 0.334 | 0.000199681 | 0.001332 | c.4348G>A | p.Ala1450Thr | AD | Uncertain significance |
10 | Female | 32 | ASD, PAH | 0.173 | – | 0.001616 | c.4793A>T | p.Asp1598Val | AD | Likely benign |
11 | Female | 21 | PDA, PAH | 0.574 | 0.000199681 | 0.003967 | c.1630C>T | p.Arg544Cys | AD | Pathogenic |
Note: CHD, Congenital heart disease; ASD, Atrial septal defect; PAH, Pulmonary hypertension; VSD, Ventricular septal defect; PDA, Patent ductus arteriosus; AD, Autosomal dominant; ACMG, The American College of Medical Genetics and Genomics.
a REVEL is an ensemble method for predicting the pathogenicity of missense variants based on a combination of scores from 13 individual tools: MutPred, FATHMM v2.3, VEST 3.0, PolyPhen-2, SIFT, PROVEAN, MutationAssessor, MutationTaster, LRT, GERP++, SiPhy, phyloP, and phastCons. The REVEL score for an individual missense variant can range from 0 to 1, with higher scores reflecting greater likelihood that the variant is disease-causing. Protein prediction: REVEL>5 indicates harmful.
b Allele frequency in the 1000 Genomes Project Database.
c The Genome Aggregation Database (East Asian).
Five patients (ID: 2, 3, 5, 8, 11) carrying the pathogenic variants of NOTCH3 were suspected as CADASIL. To confirm the cerebral pathogenic phenotype, four patients (ID: 2, 5, 8, 11) undertook MRI. Patient 3 who had no neurologic symptoms refused to take the examination because of the short hospitalization time and the lack of MRI equipment in the local community. Although these patients denied suffering from Seizure, migraine and other neurological symptoms, Surprisingly, the cerebral MRI results of four cases showed that the presence of white matter changes, which conformed the CADASIL phenotype (
No. | sPAP | sPAPa | dPAP | dPAPa | mPAP | mPAPa | PA/BP | PA/BPa | QP:QS | QP:QSa | PVR | PVRa |
---|---|---|---|---|---|---|---|---|---|---|---|---|
2 | 55.5 | 49.5 | 34 | 31 | 43 | 39 | 0.44 | 0.41 | 1.095 | 1.64 | 6.805 | 4.54 |
3# | 97 | / | / | / | / | / | / | / | / | / | / | / |
5 | 96 | 95 | 67 | 54 | 79 | 72 | 0.89 | 0.96 | 0.91 | 1.71 | 19.37 | 12.16 |
8 | 127 | 110 | 62 | 57 | 86 | 77 | 0.98 | 0.95 | 1.22 | 1.73 | 10.16 | 4.69 |
11 | 109 | 106 | 42 | 40 | 73 | 66 | 1.04 | 1.08 | 1.36 | 1.75 | 6.47 | 2.09 |
Note: sPAP, Pulmonary arterial systolic pressure; dPAP, Diastolic pulmonary artery pressure; mPAP, Mean pulmonary artery pressure; PA/BP, Pulmonary artery pressure/blood pressure; QP/QS, Pulmonary blood flow/systemic blood flow; PVR, Pulmonary vascular resistance.
a After oxygen inhalation.
# For Patient 3, the average pulmonary artery pressure was estimated by echocardiogram. For Patients 2, 5, 8, 11, the pulmonary vascular hemodynamic were assessed by right heart catheterization.
# For Patient 3, the average pulmonary artery pressure was estimated by echocardiogram. For Patients 2, 5, 8, 11, the pulmonary vascular hemodynamic were assessed by right heart catheterization.
To our knowledge, the etiology of PAH-CHD is complicated and affected by many factors, and the phenotype is heterogeneous [
Genetic testing finds that the pathogenic mutation of
Three patients with p.Arg544Cys mutation were treated with surgery in this study. No neurological complications and abnormalities were found in the surgical patients, but the MRI results suggested that the CADASIL was indeed present. The reason might be that most patients with PAH-CHD were young, the onset time was not long for cerebrovascular disease and the condition was not serious in our study. Although the number of cases in this study was small, however, 11 (7.7%) PAH-CHD patients had
PAH-CHD patients undergoing the neurological examination before surgery is not a clinical routine requirement [
The results of this study suggest that the CADASIL has a relatively high incidence in CHD-PAH patients. Clinically, attention should be paid to investigate the nervous system problems of CHD-PAH patients, determine whether the patients are contraindicated in surgery, and reduce intraoperative neurological complications, especially for elder patients. The symptoms of headaches and dizziness originally caused by CHD-PAH should also be noted. It is crucial to avoid increasing the risk of surgery due to missed diagnosis of CADASIL in PAH-CHD patients. Nevertheless, the impact of postoperative drug use on CADASIL should also be concerned if surgical treatment is allowed in PAH-CHD patients with some obvious abnormal symptoms of CADASIL.
In this study, we first reported the relationship between
In conclusion, the
We thank patients for providing clinical examination data. Thanks to BestNovo (Beijing) Medical Laboratory for technical support and bioinformatics analysis of WES data. Professor Rui Jiang is responsible for enrolling patients with clinically characterizes, study design and perform surgery. Xiaojian Wang improved the study design and revised the manuscript. Jiangping Xu, Xiang Feng and Shaoye Wang collected the samples and clinical information. Kaisheng Lai and Zhe Liu analyzed and interpreted the data and wrote the manuscript. All authors contributed to and discussed the results and critically reviewed the manuscript. All authors read and approved the final manuscript.
No. | Gene | Coding nucleotide | ACMG grade |
---|---|---|---|
1 | c.3130C>A | Uncertain significance | |
c.2053G>A | Uncertain significance | ||
c.6662A>G | Uncertain significance | ||
c.7645C>T | Uncertain significance | ||
c.3622G>A | Uncertain significance | ||
c.4791T>A | Uncertain significance | ||
c.58A>G | Uncertain significance | ||
c.6050G>A | Uncertain significance | ||
c.1331C>A | Uncertain significance | ||
2 | c.1630C>T | Pathogenic | |
c.781A>G | Uncertain significance | ||
3 | c.224G>A | Likely Pathogenic | |
c.2104C>T | Uncertain significance | ||
c.2953C>T | Uncertain significance | ||
c.974A>G | Uncertain significance | ||
c.3088A>G | Uncertain significance | ||
c.290C>T | Uncertain significance | ||
4 | c.213C>G | Uncertain significance | |
c.7516G>A | Uncertain significance | ||
c.3143G>A | Uncertain significance | ||
c.4793A>T | Likely benign | ||
5 | c.1630C>T | Pathogenic | |
c.515G>A | Uncertain significance | ||
c.170T>C | Uncertain significance | ||
c.275A>G | Uncertain significance | ||
c.1541T>C | Uncertain significance | ||
6 | c.2743C>G | Uncertain significance | |
c.3299G>A | Uncertain significance | ||
c.1843A>T | Likely benign | ||
c.6013C>T | Uncertain significance | ||
c.9679C>T | Uncertain significance | ||
c.1202G>A | Uncertain significance | ||
c.1540G>A | Uncertain significance | ||
7 | c.2183C>T | Uncertain significance | |
c.844C>T | Uncertain significance | ||
c.516G>A | Uncertain significance | ||
c.3448T>C | Uncertain significance | ||
c.709G>A | Uncertain significance | ||
8 | c.1630C>T | Pathogenic | |
c.244G>A | Uncertain significance | ||
c.7544G>A | Uncertain significance | ||
c.2232T>A | Uncertain significance | ||
c.1358-6C>T | Uncertain significance | ||
9 | c.7327C>T | Uncertain significance | |
c.4682T>G | Likely benign | ||
c.1468G>A | Uncertain significance | ||
c.1315T>A | Uncertain significance | ||
c.1187G>A | Uncertain significance | ||
c.166T>C | Uncertain significance | ||
c.6401A>G | Uncertain significance | ||
c.3752T>C | Uncertain significance | ||
c.175G>A | Uncertain significance | ||
c.4348G>A | Uncertain significance | ||
c.757G>A | Uncertain significance | ||
10 | c.407G>C | Uncertain significance | |
c.2417A>C | Uncertain significance | ||
c.1766C>A | Uncertain significance | ||
c.1306G>A | Uncertain significance | ||
c.4793A>T | Likely benign | ||
11 | c.1630C>T | Pathogenic | |
c.409G>A | Uncertain significance | ||
c.3175A>C | Uncertain significance |