全外显子测序结合先天性心脏病相关基因过滤在一家族性房间隔缺损家系中检测出新的致病突变TBX20（D176N）

A novel variant in TBX20 (p.D176N) identified by whole-exome sequencing in combination with a congenital heart disease related gene filter is associated with familial atrial septal defect # # 全外显子测序结合先天性心脏病相关基因过滤在一家族性房间隔缺损家系中检测出新的致病突变TBX20（D176N） 1 first-author 2 1 3 1 corresp ‡Corresponding Author ‡Corresponding Author †E-mail:yangyifengcsuxy@gmail.com †E-mail:yangyifengcsuxy@gmail.com yangyifengcsuxy@gmail.com Department of Cardiothoracic Surgery, the Second Xiangya Hospital, Central South University, Changsha 410011, China Department of Cardiothoracic Surgery, the Second Xiangya Hospital, Central South University, Changsha 410011, China Department of Cell Biology, School of Life Sciences, Central South University, Changsha 410013, China Department of Cell Biology, School of Life Sciences, Central South University, Changsha 410013, China Center of Clinical Gene Diagnosis and Therapy, the State Key Laboratory of Medical Genetics, the Second Xiangya Hospital, Central South University, Changsha 410011, China Center of Clinical Gene Diagnosis and Therapy, the State Key Laboratory of Medical Genetics, the Second Xiangya Hospital, Central South University, Changsha 410011, China Congenital heart disease (CHD) is the leading cause of birth defects, and its etiology is not completely understood. Atrial septal defect (ASD) is one of the most common defects of CHD. Previous studies have demonstrated that mutations in the transcription factor T-box 20 (TBX20) contribute to congenital ASD. Whole-exome sequencing in combination with a CHD-related gene filter was used to detect a family of three generations with ASD. A novel TBX20 mutation, c.526G > A (p.D176N), was identified and co-segregated in all affected members in this family. This mutation was predicted to be deleterious by bioinformatics programs (SIFT, Polyphen2, and MutationTaster). This mutation was also not presented in the current Single Nucleotide Polymorphism Database (dbSNP) or National Heart, Lung, and Blood Institute (NHLBI) Exome Sequencing Project (ESP). In conclusion, our finding expands the spectrum of TBX20 mutations and provides additional support that TBX20 plays important roles in cardiac development. Our study also provided a new and cost-effective analysis strategy for the genetic study in small CHD pedigree. 研究目的 2 寻求该房间隔缺损家系遗传致病原因。 创新要点 2 1．鉴定出一个全新的家族性房间隔缺损相关性 TBX20 突变；2．首次使用全外显子测序结合先天性心脏病相关基因过滤的方法来研究小家系遗传致病因素；3． TBX20 的T-boxDNA结合域的突变与先天性心脏病有关。 研究方法 2 对一个临床发现的房间隔缺损家系（图1a）的先证者进行全外显子测序，运用公共数据库过滤后，使用先天性心脏病相关基因再次过滤，得到了19个候选基因；然后，运用SIFT、Polyphen-2和MutationTaster等软件预测，排除了13个多态性位点（表2）；最后，运用共分离检测（聚合酶链式反应产物直接测序），找到该家系致病的遗传因素，即TBX20基因发生了错义突变（D176N）（图2），该突变位点在ESP和dbSNP数据库中也未曾发现，且该位点在多种生物中高度保守（图1c）。 重要结论 2 1．本研究发现的 TBX20 突变（D176N）是该房间隔缺损家系致病的原因，同时该突变位点为世界上首次报道；2．全外显子测序结合先天性心脏病相关基因过滤是一个分析小家系遗传致病因素的有效又经济的方法。 Congenital heart disease (CHD) Atrial septal defect (ASD) Whole-exome sequencing CHD-related gene filter TBX20 先天性心脏病 房间隔缺损 全外显子测序 先天性心脏病相关基因 TBX20 Introduction 1 Congenital heart disease (CHD) is the most common birth defect and the leading non-infectious cause of death in the newborn, affecting 19–75 per 1000 live births. Since CHD could cause prenatal lethality, the actual incidence may be much higher (Pierpont et al., 2007 2007 ; Bruneau, 2008 2008 ; Richards and Garg, 2010 2010 ). Atrial septal defect (ASD; OMIM 612794) is one of the most common forms of CHD and occurs in both isolation and other complex cardiac malformations. Genetically, CHD is a very heterogeneous disease. To date, the amount of genes related to CHD including ASD has been identified (Andersen et al., 2013 2013 ): (1) transcription factors and co-factors, e.g., GATA4 (OMIM 600576), NKX2-5 (OMIM 600584), TBX5 (OMIM 601620), and TBX20 (OMIM 606061); (2) ligands-receptors, e.g., CRELD1 (OMIM 607170); (3) structure protein of sarcomere, e.g., MYH6 (OMIM 160710), MYH7 (OMIM 160760), and ACTC1 (OMIM 102540) (Posch et al., 2010b 2010b ; Wessels and Willems, 2010 2010 ; Ware and Jefferies, 2012 2012 ; Andersen et al., 2013 2013 ; Fahed et al., 2013 2013 ). T-box 20 (TBX20) is a member of the T-box family that encodes the transcription factor TBX20. TBX20 carries strong transcriptional activation and repression domains, and physically or genetically interacts with several cardiac development transcription factors, including NKX2-5, GATA4, GATA5, and TBX5 regulating various aspects of embryonic heart development. In the developing mouse embryos, tbx20 is expressed in cardiac progenitor cells, as well as in the developing myocardium and endothelial cells associated with endocardial cushions, the precursor structures for the cardiac valves and the atrioventricular septum, which implies that tbx20 is essential for proper heart development. Loss function of tbx20 in the mouse has been found in connection with various forms of congenital heart defects, including defects in septation, valvulogenesis, cardiomyopathy, and arrhythmia (Stennard et al., 2003 2003 ; Stennard et al., 2005 2005 ; Kirk et al., 2007 2007 ; Liu et al., 2008 2008 ; Posch et al., 2010a 2010a ; Sotoodehnia et al., 2010 2010 ; Shen et al., 2011 2011 ; Zhang et al., 2011 2011 ; Qiao et al., 2012 2012 ). In our study, by using whole-exome sequencing in combination with a CHD-related gene filter, all non-coding and synonymous variants, as well as variants present in the Single Nucleotide Polymorphism Database (dbSNP), 1000 Genomes, HapMap, YH, and Exome Sequencing Project (ESP) databases and variants which are not in 455 CHD-related genes (Data S1 S1 ) were excluded initially. According to prediction by three bioinformatics programs (SIFT, Polyphen2, and MutationTaster) and co-segregation analysis, we identified a novel mutation (c.526G > A/p.D176N) in exon3 of TBX20 in all affected members in three generations of a family with ASD. To the best of our knowledge, this mutation has not been reported in previous studies. Materials and methods 1 Subjects 2 A family from Hunan Province in central-south China with seven members across three generations participated in this study. Three patients were diagnosed as having ASD (I1, II2, and III1) (Table 1 1 ; Fig. 1a 1a ). All patients were diagnosed by transthoracic echocardiograms in the Department of Cardiothoracic Surgery of the Second Xiangya Hospital, China. All family members were provided informed consent for collection, storage, and use of DNA for the purpose of research. A proband (III1 in Fig. 1a 1a ) consented specifically for whole-exome sequencing. This study protocol was approved by the Review Board of the Second Xiangya Hospital of the Central South University, China. CHD: congenital heart disease; RA: right atrium; RV: right ventricle; LVEF: left ventricular ejection fraction 2 Family 2 Age 2 CHD 4 Echocardiography 2 TBX20 ASD size (mm) RA (mm) RV (mm) LVEF (%) DNA Protein III1 (proband) 7 months ASD 15 29 26 69 526G>A D176N I1 59 years ASD 2 35 34 60 526G>A D176N I2 61 years No 33 30 62 II1 31 years No 32 30 65 II2 28 years ASD 12 43 41 63 526G>A D176N II3 25 years No 32 31 69 III2 3 years No 24 22 72 (a) Pedigree of the family affected with ASD. Family members are identified by generations and numbers. Squares: male members; circles: female members; black symbols: affected members; white symbols: unaffected members; arrow: proband. (b) Sequencing results of the TBX20 mutation. Sequence chromatogram indicates a G to A transition of nucleotide 526. (c) Alignment of multiple TBX20 protein sequences across species. The D176 affected amino acid locates in the highly conserved amino acid region in different mammals Methods 2 DNA extraction 3 Genomic DNA (gDNA) was extracted from peripheral blood lymphocytes of the participants. gDNA was prepared using a DNeasy Blood & Tissue Kit (Qiagen, Valencia, CA) on the QIAcube automated DNA extraction robot (Qiagen, Hilden, Germany) as previously described (Tan et al., 2012 2012 ). Targeted capture and massive parallel sequencing 3 Exome capture and high-throughput sequencing (HTS) were performed in the State Key Laboratory of Medical Genetics of China in collaboration with Beijing Genomic Institute (BGI Shenzhen, China) (Wang et al., 2010 2010 ). gDNA (5 μg) from the proband (III1) in this family was captured with the NimbleGen SeqCap EZ library exome capture reagent (Roche Inc., Madison, USA) and sequenced (Illumina HiSeq2000, 90 base paired-end reads; Illomina Inc., USA). Briefly, gDNA was randomly fragmented by a Covaris S2 instrument (Covaris Inc., USA). Then, the 250–300 bp fragments of DNA were subjected to three enzymatic steps: end repair, A-tailing, and adapter ligation. Once the DNA libraries were indexed, they were amplified by ligation-mediated polymerase chain reaction (PCR). Extracted DNA was purified and hybridized to the NimbleGen Seqcap EZ Library. Each captured library was then loaded onto the Illumina HiSeq2000 platform. Illumina base calling software V1.7 was employed to analyze the raw image files with default parameters. Read, mapping and variant detection 3 Single-nucleotide polymorphism (SNP) analysis was performed as previously described (Gao et al., 2013 2013 ): (1) reads were aligned to the NCBI human reference genome (gh19/NCBI 37.1) with SOAPaligner method V2.21; (2) for paired-end reads with duplicated start and end sites, only one copy with the highest quality was retained and the reads with adapters were removed; (3) SOAPsnp V1.05 was used to assemble the consensus sequence and call genotypes; (4) small insertions and deletions (INDELs) detection was used with the Unified Genotyper tool from GATK V1.0.4705. Filtering and annotation 3 Five major steps were taken to prioritize all the high-quality variants among CHD-related genes (Gao et al., 2013 2013 ): (1) variants within intergenic, intronic, and untranslated regions (UTRs) and synonymous mutations were excluded from later analysis; (2) variants in dbSNP132 ( http://www.ncbi.nih.gov/projects/SNP/ http://www.ncbi.nih.gov/projects/SNP/ ), the 1000 Genomes project (1000G, http://www.1000genomes.org http://www.1000genomes.org ), and HapMap project ( ftp://ftp.ncbi.nlm.nih.gov/hapmap ftp://ftp.ncbi.nlm.nih.gov/hapmap ) were excluded; (3) variants in YH database ( http://yh.Genomics.org.cn/ http://yh.Genomics.org.cn/ ) and National Heart, Lung, and Blood Institute (NHLBI) ESP database ( http://evs.gs.washington.edu/EVS/ http://evs.gs.washington.edu/EVS/ ) were further excluded; (4) variants not in 455 CHD-related genes (Data S1 S1 ) were excluded (Wilde and Behr, 2013 2013 ; Zaidi et al., 2013 2013 ); (5) SIFT ( http://sift.bii.astar.edu.sg/ http://sift.bii.astar.edu.sg/ ), Polyphen2 ( http://genetics.bwh.harvard.edu/pph2/ http://genetics.bwh.harvard.edu/pph2/ ), and MutationTaster ( http://www.mutationtaster.org http://www.mutationtaster.org ) were used to predict the possible impact of variants. Mutation validation and co-segregation analysis 3 Sanger sequencing was used to validate the candidate variants found in the whole-exome sequencing. Segregation analysis was performed in all family members. Primer pairs used to amplify fragments encompassing individual variants were designed by an online tool PrimerQuest (Integrated DNA Technologies, Inc.; http://www.idtdna.com/Primerquest/Home/Index http://www.idtdna.com/Primerquest/Home/Index ) and the sequences of PCR primers will be provided upon request. Results 1 Patient characteristics and phenotype information 2 A Chinese family with isolated secundum ASD was first identified after the proband (III1) was referred for evaluation of a murmur at 7 months old. The echocardiography described a dilated right atrium, dilated right ventricle, and a secundum ASD measuring 15 mm in dimension. Meanwhile, the family history revealed that there were an additional two related living individuals diagnosed as having ASD. Both the proband (III1) and II2 underwent successful surgical repairs. I1 without any treatment was diagnosed with secundum ASD by echocardiography (Fig. 1a 1a ; Table 1 1 ). No other malformations were observed in the three affected members, which indicated that this family CHD is an isolated or non-syndromic CHD with an autosomal dominant pattern. Exome sequencing and co-segregation analysis 2 To detect the causative genetic alteration in this family, whole-exome sequencing in combination with a CHD-related gene filter was performed on the proband (III1). The result demonstrated a set of 19 single nucleotide variants in 16 CHD candidate genes after filtering (Table 2 2 ). Co-segregation analysis of six causative variants ( OBSCN , USF1 , TBX20 , LDB3 , MYH6 , and IFT20 ) (Table 2 2 ), which were predicted by three programs (SIFT, MutationTaster, and Polyphen2) showed that only TBX20 gene mutation segregated in all affected family members (Figs. 1a and 1b 1a and 1b ; Table 1 1 ). Unaffected family members who were assessed did not carry the mutation. The missense mutation (c.526G > A) results in a substitution of aspartic acid by asparagine in the TBX20 protein (p.D176N). This newly identified c.526G > A mutation was not found in our 200 control cohorts (Tan et al., 2012 2012 ). This mutation was also not presented in the current dbSNP and NHLBI ESP. Chr: chromosome; RB: reference sequence base; AB: alternative base identified; PD: probably damaging; DC: disease causing. Variants were share by two family members (III1 and II1) after filtering. Each row represents a single variant. The five rows beginning with OBSCN , USF1 , LDB3 , MYH6 (first), and IFT20 represent the five variants that were validated independently and screened for in affected family members. Only TBX20 was segregated with disease in this family Gene Chr Base position RB AB Mutation Amino acid alteration Sorting intolerant from tolerant Polyphen2 MutationTaster NOTCH2NL chr1 145273345 T C Missense S>P rs10910779 NOTCH2 chr1 120539661 C T Missense R>Q rs146498360 OBSCN chr1 228562288 G A Missense G>R Damaging (0.004) PD (0.997) DC (125) USF1 chr1 161011931 T G Missense Y>C Tolerated (0.199) PD (0.560) DC (194) ZNF638 chr2 71576412 A G Missense I>V rs12612365 ZNF638 chr2 71650308 G A Missense A>T Damaging (0.024) Benign (0.094) Polymorphism (58) VEGFC chr4 177605086 C T Missense M>I Tolerated (0.103) Benign (0.000) Polymorphism (10) DST chr6 56472194 C T Missense C>Y rs185733722 TBX20 chr7 35288308 C T Missense D>N Damaging (0.004) PD (0.985) DC (23) LRRC6 chr8 133634908 G T Missense P>H rs76147813 LDB3 chr10 88469751 C T Missense A>V Tolerated (0.291) PD (0.745) DC (64) PTPN11 chr12 112892433 T G Nonsense Y>* rs76982592 PTPN11 chr12 112892407 T G Missense S>A rs79068130 MYH6 chr14 23855762 A T Missense I>N Damaging (0.000) Benign (0.248) DC (194) MYH6 chr14 23871682 C T Missense G>S rs148962966 IFT20 chr17 26658963 T G Missense N>H Damaging (0.015) DC (68) DSC2 chr18 28651796 G T Missense R>S Tolerated (0.382) Benign (0.095) Polymorphism (110) DOT1L chr19 2211146 T C Missense V>A Damaging (0.014) Benign (0.001) Polymorphism (64) EP300 chr22 41527628 A G Missense S>G rs146242251 Variant analysis 2 The aspartic acid residue at position 176 in TBX20 protein is highly evolutionarily conserved in diverse species including chimp, monkey, chicken, pufferfish, zebrafish, melanogaster, and frog (Fig. 1c 1c ). Three programs for analyzing protein functions, Polyphen2, SIFT, and MutationTaster, predicted that the p.D176N variants are probably damaging (0.985), damaging (0.004), and disease causing (23), respectively. Discussion 1 Due to the complexity of CHD attributed by both genetic and nongenetic effectors, the etiology of CHD is still not completely understood. To date, approximately 500 genes have been revealed to be related to cardiac development defects in mice when mutated, and 55 human genes have been identified associated with CHDs (Andersen et al., 2013 2013 ; Fahed et al., 2013 2013 ; Wilde and Behr, 2013 2013 ; Zaidi et al., 2013 2013 ). Complex or rare Mendelian disorders in small CHDs pedigree make the discovery of novel genes difficult or impossible using the traditional approach (Rabbani et al., 2012 2012 ). However, next-generation sequencing technologies such as the whole-exome sequencing approach are improving as rapid, high-throughput, and cost-effective approaches to fulfill medical sciences and research demands (Ng et al., 2009 2009 ; Metzker, 2010 2010 ; Ku et al., 2011 2011 ). In our study, the pedigree is really small and it is difficult to discover a new causative gene. Therefore, we initially hypothesized that the causative gene is in the list of related genes for CHD (Data S1 S1 ) after analysis of whole-exome sequencing data. According to prediction by three bioinformatics programs (SIFT, Polyphen 2, and MutationTaster), six candidate causative genes were highly suspicious ( OBSCN , USF1 , TBX20 , LDB3 , MYH6 , and IFT20 ; Table 2 2 ). Co-segregation analysis demonstrated that only TBX20 gene mutation (c.526G > A/p.D176N) was segregated in all affected family members. If the variant is not in the 455 CHD-related genes, much more work needs to be done, such as whole-exome sequencing on all other family members. If so, it is inevitable that the cost and workload will increase. Therefore, our research provided a new and cost-effective strategy for genetic study in small CHD pedigree (Fig. 2 2 ). TBX20 plays a critical role in embryonic development and organogenesis, including cell type specification, tissue patterning, and morphogenesis (Smith, 1999 1999 ; Packham and Brook, 2003 2003 ; Showell et al., 2004 2004 ). Inherited TBX20 mutations (I152M, Q195*) in patients with ASD were first identified using the first generation sequencing technology (Kirk et al., 2007 2007 ). The author reported missense (I152M) and nonsense (Q195*) mutations in two families with isolated ASD or/and other cardiac structure anomaly. Subsequently, other studies identified other TBX20 mutations via the first generation sequencing technology. Liu et al. ( 2008 2008 ) found a number of variants among Chinese patients with ASD with or without other congenital heart defects, including tetralogy of Fallot (TOF), total anomalous pulmonary venous connection (TAPVC). Qian et al. ( 2009 2009 ) reported that two different variants of TBX20 were found in four children with ASD with or without other CHD. Posch et al. ( 2010a 2010a ) identified a TBX20 missense variant in a patient with ASD with additional TOF and cardiac valve defect (Table 3 3 ). AA: amino acid; ASD: atrial septal defect; CoA: coarctation of aorta; DCM: dilated cardiomyopathy; MR: mitral regurgitation; MVP: mitral valve prolapse; PFO: patent oval foramen; TAPVC: total anomalous pulmonary venous connection; TOF: tetralogy of Fallot; VSD: ventricular septal defect Reference Nucleotide change AA change Cardiac defect 2 Kirk et al. ( 2007 2007 ) 456C>G I152M ASD,VSD, PFO 583C>T Q195* ASD, CoA, MVP, MR, DCM 2 Liu et al. ( 2008 2008 ) 187G>A A63T ASD 361A>T I121F TAPVC, ASD 2 Qian et al. ( 2009 2009 ) 597C>G H186D ASD, MR, TOF, cleft mitral valve 601T>C L197P ASD, TOF Posch et al. ( 2010 2010 ) 374C>G I121M ASD, TOF, cardiac valve defect In this study, the whole-exome sequencing in combination with a CHD-related gene filter was performed to investigate a family with ASD. A novel mutation c.526G > A in TBX20 causing a missense change (p.D176N) that affected a highly conserved residue in an evolutionarily conserved protein was identified. The p.D176N was not found in the public databases and our 200 control cohorts. Meanwhile, Polyphen2, SIFT, and MutationTaster predicted that p.D176N will be deleterious in its effect. Co-segregated analysis showed that p.D176N segregates with disease in this family. These findings demonstrated that this variant should not be excluded from further study. This identified missense change (p.D176N) is in the T-box DNA binding domain of TBX20 (109–288 AA). TBX20 associated directly with other cardiac transcription factors, namely, the homeodomain factor NKX2-5 and zinc finger factor GATA4 and GATA5 (Stennard et al., 2003 2003 ). Modification of amino acid from aspartic acid to asparagine may not prevent binding to its target DNA site, but there are other possibilities, such as an influenced rate of scanning of DNA or co-factors for interaction, or abnormal structure stability when bound to co-factors (Posch et al., 2010a 2010a ). Previous studies have demonstrated that identified ASD-related TBX20 mutations are all in the T-box DNA binding domain (109–288 AA) except p.A63T (Fig. 3 3 ; Table 3 3 ) (Kirk et al., 2007 2007 ; Liu et al., 2008 2008 ; Qian et al., 2009 2009 ; Posch et al., 2010a 2010a ). Therefore, although in vitro assays were not performed in our study, we still believed that the mutation (p.D176N) in this study plays a critical role in CHDs. In our further analysis, the functional test will be performed. All mutations related to ASD are represented on the top. Mutations found in patients with CHD other than ASD are shown below the structural domain. # indicate the novel mutation in our study In summary, we reported a novel TBX20 mutation (p.D176N) in a three-generation family with three ASD patients. The present identification of a novel mutation not only further supports the important role of cardiac transcription factor TBX20 in congenital ASD, but also expands the spectrum of TBX20 mutations and will contribute to the genetic diagnosis and counseling of families with CHD. Meanwhile, our study provided a new and cost-effective analysis strategy for the genetic study in small CHD pedigree. References TA Andersen , KD Troelsen , LA Larsen . Of mice and men: molecular genetics of congenital heart disease . Cell Mol Life Sci , 2013 . 71 ( 8 ): 1327 - 1352 . DOI: 10.1007/s00018-013-1430-1 http://doi.org/10.1007/s00018-013-1430-1 . Of mice and men: molecular genetics of congenital heart disease BG Bruneau . The developmental genetics of congenital heart disease . Nature , 2008 . 451 ( 7181 ): 943 - 948 . 3936964 DOI: 10.1038/nature06801 http://doi.org/10.1038/nature06801 . The developmental genetics of congenital heart disease AC Fahed , BD Gelb , JG Seidman , 等 . Genetics of congenital heart disease: the glass half empty . Circ Res , 2013 . 112 ( 4 ): 707 - 720 . 3762637 DOI: 10.1161/CIRCRESAHA.112.300853 http://doi.org/10.1161/CIRCRESAHA.112.300853 . Genetics of congenital heart disease: the glass half empty X Gao , Y Su , LP Guan , 等 . Novel compound heterozygous TMC1 mutations associated with autosomal recessive hearing loss in a Chinese family . PLoS ONE , 2013 . 8 ( 5 ): e63026 8439649 DOI: 10.1371/journal.pone.0063026 http://doi.org/10.1371/journal.pone.0063026 . Novel compound heterozygous TMC1 mutations associated with autosomal recessive hearing loss in a Chinese family EP Kirk , M Sunde , MW Costa , 等 . Mutations in cardiac T-box factor gene TBX20 are associated with diverse cardiac pathologies, including defects of septation and valvulogenesis and cardiomyopathy . Am J Hum Genet , 2007 . 81 ( 2 ): 280 - 291 . 2117353 DOI: 10.1086/519530 http://doi.org/10.1086/519530 . Mutations in cardiac T-box factor gene TBX20 are associated with diverse cardiac pathologies, including defects of septation and valvulogenesis and cardiomyopathy CS Ku , N Naidoo , Y Pawitan . Revisiting mendelian disorders through exome sequencing . Hum Genet , 2011 . 129 ( 4 ): 351 - 370 . 11692465 DOI: 10.1007/s00439-011-0964-2 http://doi.org/10.1007/s00439-011-0964-2 . Revisiting mendelian disorders through exome sequencing C Liu , A Shen , X Li , 等 . T-box transcription factor TBX20 mutations in Chinese patients with congenital heart disease . Eur J Med Genet , 2008 . 51 ( 6 ): 580 - 587 . 18021748 DOI: 10.1016/j.ejmg.2008.09.001 http://doi.org/10.1016/j.ejmg.2008.09.001 . T-box transcription factor TBX20 mutations in Chinese patients with congenital heart disease ML Metzker . Sequencing technologies—the next generation . Nat Rev Genet , 2010 . 11 ( 1 ): 31 - 46 . 4021309 DOI: 10.1038/nrg2626 http://doi.org/10.1038/nrg2626 . Sequencing technologies—the next generation SB Ng , EH Turner , PD Robertson , 等 . Targeted capture and massively parallel sequencing of 12 human exomes . Nature , 2009 . 461 ( 7261 ): 272 - 276 . 17943234 DOI: 10.1038/nature08250 http://doi.org/10.1038/nature08250 . Targeted capture and massively parallel sequencing of 12 human exomes EA Packham , JD Brook . T-box genes in human disorders . Hum Mol Genet , 2003 . 12 ( S1 ): R37 - R44 . 17486088 DOI: 10.1093/hmg/ddg077 http://doi.org/10.1093/hmg/ddg077 . T-box genes in human disorders ME Pierpont , CT Basson , DW Benson , 等 . Genetic basis for congenital heart defects: current knowledge. A scientific statement from the American Heart Association Congenital Cardiac Defects Committee, Council on Cardiovascular Disease in the Young: endorsed by the American Academy of Pediatrics . Circulation , 2007 . 115 ( 23 ): 3015 - 3038 . 7076216 DOI: 10.1161/CIRCULATIONAHA.106.183056 http://doi.org/10.1161/CIRCULATIONAHA.106.183056 . Genetic basis for congenital heart defects: current knowledge. A scientific statement from the American Heart Association Congenital Cardiac Defects Committee, Council on Cardiovascular Disease in the Young: endorsed by the American Academy of Pediatrics MG Posch , M Gramlich , M Sunde , 等 . A gain-of-function TBX20 mutation causes congenital atrial septal defects, patent foramen ovale and cardiac valve defects . J Med Genet , 2010 . 47 ( 4 ): 230 - 235 . 12928051 DOI: 10.1136/jmg.2009.069997 http://doi.org/10.1136/jmg.2009.069997 . A gain-of-function TBX20 mutation causes congenital atrial septal defects, patent foramen ovale and cardiac valve defects MG Posch , A Perrot , F Berger , 等 . Molecular genetics of congenital atrial septal defects . Clin Res Cardiol , 2010 . 99 ( 3 ): 137 - 147 . 3698553 DOI: 10.1007/s00392-009-0095-0 http://doi.org/10.1007/s00392-009-0095-0 . Molecular genetics of congenital atrial septal defects L Qian , B Mohapatra , T Akasaka , 等 . Transcription factor neuromancer/TBX20 is required for cardiac function in Drosophila with implications for human heart disease . PNAS , 2009 . 105 ( 50 ): 19833 - 19838 . 3989190 DOI: 10.1073/pnas.0808705105 http://doi.org/10.1073/pnas.0808705105 . Transcription factor neuromancer/TBX20 is required for cardiac function in Drosophila with implications for human heart disease YL Qiao , HX Wanyan , QN Xing , 等 . Genetic analysis of the TBX20 gene promoter region in patients with ventricular septal defects . Gene , 2012 . 500 ( 1 ): 28 - 31 . 10703668 DOI: 10.1016/j.gene.2012.03.055 http://doi.org/10.1016/j.gene.2012.03.055 . Genetic analysis of the TBX20 gene promoter region in patients with ventricular septal defects B Rabbani , N Mahdieh , K Hosomichi , 等 . Next-generation sequencing: impact of exome sequencing in characterizing mendelian disorders . J Hum Genet , 2012 . 57 ( 10 ): 621 - 632 . 12753300 DOI: 10.1038/jhg.2012.91 http://doi.org/10.1038/jhg.2012.91 . Next-generation sequencing: impact of exome sequencing in characterizing mendelian disorders AA Richards , V Garg . Genetics of congenital heart disease . Curr Cardiol Rev , 2010 . 6 ( 2 ): 91 - 97 . 14717921 DOI: 10.2174/157340310791162703 http://doi.org/10.2174/157340310791162703 . Genetics of congenital heart disease T Shen , I Aneas , N Sakabe , 等 . TBX20 regulates a genetic program essential to adult mouse cardiomyocyte function . J Clin Invest , 2011 . 121 ( 12 ): 4640 - 4654 . 15888044 DOI: 10.1172/JCI59472 http://doi.org/10.1172/JCI59472 . TBX20 regulates a genetic program essential to adult mouse cardiomyocyte function C Showell , O Binder , FL Conlon . T-box genes in early embryogenesis . Dev Dyn , 2004 . 229 ( 1 ): 201 - 218 . 11719807 DOI: 10.1002/dvdy.10480 http://doi.org/10.1002/dvdy.10480 . T-box genes in early embryogenesis J Smith . T-box genes—what they do and how they do it . Trends Genet , 1999 . 15 ( 4 ): 154 - 158 . 8012981 DOI: 10.1016/S0168-9525(99)01693-5 http://doi.org/10.1016/S0168-9525(99)01693-5 . T-box genes—what they do and how they do it N Sotoodehnia , A Isaacs , PI de Bakker , 等 . Common variants in 22 loci are associated with QRS duration and cardiac ventricular conduction . Nat Genet , 2010 . 42 ( 12 ): 1068 - 1076 . 17450126 DOI: 10.1038/ng.716 http://doi.org/10.1038/ng.716 . Common variants in 22 loci are associated with QRS duration and cardiac ventricular conduction FA Stennard , MW Costa , DA Elliott , 等 . Cardiac T-box factor TBX20 directly interacts with Nkx2-5, GATA4, and GATA5 in regulation of gene expression in the developing heart . Dev Biol , 2003 . 262 ( 2 ): 206 - 224 . 16312260 DOI: 10.1016/S0012-1606(03)00385-3 http://doi.org/10.1016/S0012-1606(03)00385-3 . Cardiac T-box factor TBX20 directly interacts with Nkx2-5, GATA4, and GATA5 in regulation of gene expression in the developing heart FA Stennard , MW Costa , D Lai , 等 . Murine T-box transcription factor TBX20 acts as a repressor during heart development, and is essential for adult heart integrity, function and adaptation . Development , 2005 . 132 ( 10 ): 2451 - 2462 . 11830355 DOI: 10.1242/dev.01799 http://doi.org/10.1242/dev.01799 . Murine T-box transcription factor TBX20 acts as a repressor during heart development, and is essential for adult heart integrity, function and adaptation ZP Tan , C Huang , ZB Xu , 等 . Novel ZFPM2/FOG2 variants in patients with double outlet right ventricle . Clin Genet , 2012 . 82 ( 5 ): 466 - 471 . 15528948 DOI: 10.1111/j.1399-0004.2011.01787.x http://doi.org/10.1111/j.1399-0004.2011.01787.x . Novel ZFPM2/FOG2 variants in patients with double outlet right ventricle JL Wang , X Yang , K Xia , 等 . TGM6 identified as a novel causative gene of spinocerebellar ataxias using exome sequencing . Brain , 2010 . 133 ( 12 ): 3510 - 3518 . 17118425 DOI: 10.1093/brain/awq323 http://doi.org/10.1093/brain/awq323 . TGM6 identified as a novel causative gene of spinocerebellar ataxias using exome sequencing SM Ware , JL Jefferies . New genetic insights into congenital heart disease . J Clin Exp Cardiol , 2012 . S8:003 11917048 DOI: 10.4172/2155-9880.S8-003 http://doi.org/10.4172/2155-9880.S8-003 . New genetic insights into congenital heart disease MW Wessels , PJ Willems . Genetic factors in non-syndromic congenital heart malformations . Clin Genet , 2010 . 78 ( 2 ): 103 - 123 . 12087054 DOI: 10.1111/j.1399-0004.2010.01435.x http://doi.org/10.1111/j.1399-0004.2010.01435.x . Genetic factors in non-syndromic congenital heart malformations AAM Wilde , ER Behr . Genetic testing for inherited cardiac disease . Nat Rev Cardiol , 2013 . 10 ( 10 ): 571 - 583 . 7463948 DOI: 10.1038/nrcardio.2013.108 http://doi.org/10.1038/nrcardio.2013.108 . Genetic testing for inherited cardiac disease S Zaidi , M Choi , H Wakimoto , 等 . De novo mutations in histone-modifying genes in congenital heart disease . Nature , 2013 . 498 ( 7453 ): 220 - 223 . 18614996 DOI: 10.1038/nature12141 http://doi.org/10.1038/nature12141 . De novo mutations in histone-modifying genes in congenital heart disease WJ Zhang , HY Chen , Y Wang , 等 . Tbx20 transcription factor is a downstream mediator for bone morphogenetic protein-10 in regulating cardiac ventricular wall development and function . J Biol Chem , 2011 . 286 ( 42 ): 36820 - 36829 . DOI: 10.1074/jbc.M111.279679 http://doi.org/10.1074/jbc.M111.279679 . Tbx20 transcription factor is a downstream mediator for bone morphogenetic protein-10 in regulating cardiac ventricular wall development and function We thank the patient and their families for participating in this study. We are grateful to Mrs. Jian WANG for her assistance in collecting blood samples from the Center of Clinical Gene Diagnosis and Therapy, the State Key Laboratory of Medical Genetics, the Second Xiangya Hospital, Central South University, China. Compliance with ethics guidelines Ji-jia LIU, Liang-liang FAN, Jin-lan CHEN, Zhi-ping TAN, and Yi-feng YANG declare that they have no conflict of interest. All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5). Informed consent was obtained from all patients for being included in the study. Additional informed consent was obtained from all patients for which identifying information is included in this article. 10.1631/jzus.B1400062 Project supported by the National Natural Science Foundation of China (Nos. 81370204, 81300072, and 81101475) 2014-03-02 2014-08-30 2014-05-12 2022-01-05 Copyright © Zhejiang University and Springer-Verlag Berlin Heidelberg 2014 2014 Journal of Zhejiang University-SCIENCE B (Biomedicine and Biotechnology) 09 15