Linkage mapping of a mouse gene, iv, that controls left-right asymmetry of the heart and viscera

DNAH11 compound heterozygous variants cause heterotaxy and congenital heart disease

Heterotaxy (HTX), a condition characterized by internal organs not being arranged as expected relative to each other and to the left-right axis, is often accompanied with congenital heart disease (CHD). The purpose was to detect the pathogenic variants in a Chinese family with HTX and CHD. A non-consanguineous Han Chinese family with HTX and CHD, and 200 unrelated healthy subjects were enlisted. Exome sequencing and Sanger sequencing were applied to identify the genetic basis of the HTX family. Compound heterozygous variants, c.3426-1G>A and c.4306C>T (p.(Arg1436Trp)), in the dynein axonemal heavy chain 11 gene (DNAH11) were identified in the proband via exome sequencing and further confirmed by Sanger sequencing. Neither c.3426-1G>A nor c.4306C>T variant in the DNAH11 gene was detected in 200 healthy controls. The DNAH11 c.3426-1G>A variant was predicted as altering the acceptor splice site and most likely affecting splicing. The DNAH11 c.4306C>T variant was predicted to be damaging, which may reduce the phenotype severity. The compound heterozygous variants, c.3426-1G>A and c.4306C>T, in the DNAH11 gene might be the pathogenic alterations resulting in HTX and CHD in this family. These findings broaden the variant spectrum of the DNAH11 gene and increase knowledge used in genetic counseling for the HTX family.

The genetics of situs inversus without primary ciliary dyskinesia

Situs inversus (SI), a left-right mirror reversal of the visceral organs, can occur with recessive Primary Ciliary Dyskinesia (PCD). However, most people with SI do not have PCD, and the etiology of their condition remains poorly studied. We sequenced the genomes of 15 people with SI, of which six had PCD, as well as 15 controls. Subjects with non-PCD SI in this sample had an elevated rate of left-handedness (five out of nine), which suggested possible developmental mechanisms linking brain and body laterality. The six SI subjects with PCD all had likely recessive mutations in genes already known to cause PCD. Two non-PCD SI cases also had recessive mutations in known PCD genes, suggesting reduced penetrance for PCD in some SI cases. One non-PCD SI case had recessive mutations in PKD1L1, and another in CFAP52 (also known as WDR16). Both of these genes have previously been linked to SI without PCD. However, five of the nine non-PCD SI cases, including three of the left-handers in this dataset, had no obvious monogenic basis for their condition. Environmental influences, or possible random effects in early development, must be considered.

Situs inversus and ciliary abnormalities: 20 years later, what is the connection?

Heterotaxy (also known as situs ambiguous) and situs inversus totalis describe disorders of laterality in which internal organs do not display their typical pattern of asymmetry. First described around 1600 by Girolamo Fabrizio, numerous case reports about laterality disorders in humans were published without any idea about the underlying cause. Then, in 1976, immotile cilia were described as the cause of a human syndrome that was previously clinically described, both in 1904 by AK Siewert and in 1933 by Manes Kartagener, as an association of situs inversus with chronic sinusitis and bronchiectasis, now commonly known as Kartagener’s syndrome. Despite intense research, the underlying defect of laterality disorders remained unclear. Nearly 20 years later in 1995, Björn Afzelius discussed five hypotheses to explain the connection between ciliary defects and loss of laterality control in a paper published in the International Journal of Developmental Biology asking: ‘Situs inversus and ciliary abnormalities: What is the connection?’. Here, nearly 20 research years later, we revisit some of the key findings that led to the current knowledge about the connection between situs inversus and ciliary abnormalities.

Hepatocellular carcinoma in situs ambiguus: CT findings of a rare disposition

Heterotaxic disorders or situs ambiguus are uncommon anatomical variations constituted by a partial mirror-image disposition of intra thoracic and/or abdominal solid organs. These variations are challenging because rarely met in a surgeon's career, and because of the coexistence of numerous other anatomical variants, like ones related to the asymmetrical organs, causing difficulties when a surgical management is required. We report the case of a 57-year-old patient presenting liver cirrhosis in which regular follow-up discovered a hepatocellular carcinoma of the right part of the liver associated to numerous anatomical variations in the setting of a situs ambiguus. This patient was successfully treated by a sub-segmentectomy via a right sub-costal laparotomy. There were neither peroperative nor postoperative complications. This case emphasizes the technical difficulties faced, successfully managed thanks to a good preoperative screening, and allows us to review literature of such a rare and challenging situation.

Rere controls retinoic acid signalling and somite bilateral symmetry

One of the most notable features of the vertebrate body plan organization is its bilateral symmetry, evident at the level of vertebrae and skeletal muscles. Here we show that a mutation in Rere (also known as atrophin2) leads to the formation of asymmetrical somites in mouse embryos, similar to embryos deprived of retinoic acid. Furthermore, we also demonstrate that Rere controls retinoic acid signalling, which is required to maintain somite symmetry by interacting with Fgf8 in the left-right signalling pathway. Rere forms a complex with Nr2f2, p300 (also known as Ep300) and a retinoic acid receptor, which is recruited to the retinoic acid regulatory element of retinoic acid targets, such as the Rarb promoter. Furthermore, the knockdown of Nr2f2 and/or Rere decreases retinoic acid signalling, suggesting that this complex is required to promote transcriptional activation of retinoic acid targets. The asymmetrical expression of Nr2f2 in the presomitic mesoderm overlaps with the asymmetry of the retinoic acid signalling response, supporting its implication in the control of somitic symmetry. Misregulation of this mechanism could be involved in symmetry defects of the human spine, such as those observed in patients with scoliosis.

Establishment of left-right asymmetry in vertebrates: genetically distinct steps are involved

Vertebrates exhibit a characteristic pattern of asymmetrical positioning of the visceral organs along the left-right axis. A remarkable developmental step establishes this pattern--primitive organs migrate from symmetrical midline positions of origin into lateral positions. The first organ to pursue such movement is the cardiac tube, which forms a rightward 'D' loop; other organs follow concordantly. The signals and mechanisms directing such organ migration can be studied by analysis of heritable defects of humans and mice. In general, these defects behave as loss-of-function mutations that lead to random determination of visceral situs: for an affected embryo there is an equal chance of correct situs or situs inversus. Distinct phenotypes and patterns of inheritance of these defects suggest that at least three genes are involved in left-right determination, apparently members of a developmental pathway. These genes should be amenable to molecular analysis. We are studying a recessive allele of the mouse called inversus viscerum (iv). Using linkage analysis with cloned restriction fragment length polymorphism markers, we have genetically mapped the iv gene to the distal portion of mouse chromosome 12. We are now pursuing isolation of the gene using methods of positional cloning. Analysis of the iv gene product and of its site and timing of expression may offer clues to how left-right lateralization occurs.

Development of handed body asymmetry in mammals

We have proposed a three step model for the specification of left-right in mammalian embryos. The fundamental assumption is that handedness is imparted by an asymmetrical molecule. Conversion of molecular asymmetry to the cellular level gives a property to one side of the embryo to bias an otherwise random generation of an asymmetrical gradient which can be interpreted by developing organs. Rat embryos, treated at discrete stages, show a window of sensitivity for disruption of handedness, which may reflect the time of conversion/biasing. Heat shock and several chemicals cause left-right inversion in up to 50% of embryos exposed during neural groove formation. Earlier stages are less sensitive; no treatment begun after foregut pocket formation influences asymmetry. Evidence for cellular interactions in left-right specification comes from the apparent rescue of iv/iv mutant embryos in chimeras. We are looking for molecular left-right disparity before morphological asymmetry but detect no differences in two-dimensional protein profiles. Using an indirect measure, we find a right-left gradient of tissue oxygen in embryos at the 20-30 somite stage. This may reflect asymmetrical vasculature, as we have suggested to explain drug-induced asymmetrical limb malformations.

Heterotaxy syndrome -- asplenia and polysplenia as indicators of visceral malposition and complex congenital heart disease

Heterotaxy results from failure of the developing embryo to establish normal left-right asymmetry. Typical manifestations include abnormal symmetry and malposition of the thoraco-abdominal organs and vessels, complex congenital heart disease and extracardiac defects involving midline-associated structures. The spleen is almost always affected, and there is syndromic clustering of the malformations corresponding to the type of splenic abnormality present. This review outlines the embryologic and genetic background of the heterotaxy syndrome as well as the characteristic anatomic features, clinical manifestations, and diagnostic clues of its two main presentations with asplenia or polysplenia.

Retinoic acid coordinates somitogenesis and left–right patterning in vertebrate embryos

A striking feature of the body plan of a majority of animals is bilateral symmetry. Almost nothing is known about the mechanisms controlling the symmetrical arrangement of the left and right body sides during development. Here we report that blocking the production of retinoic acid (RA) in chicken embryos leads to a desynchronization of somite formation between the two embryonic sides, demonstrated by a shortened left segmented region. This defect is linked to a loss of coordination of the segmentation clock oscillations. The lateralization of this defect led us to investigate the relation between somitogenesis and the left-right asymmetry machinery in RA-deficient embryos. Reversal of the situs in chick or mouse embryos lacking RA results in a reversal of the somitogenesis laterality defect. Our data indicate that RA is important in buffering the lateralizing influence of the left-right machinery, thus permitting synchronization of the development of the two embryonic sides.

Genes for left-handedness: how to search for the needle in the haystack?

Although several genes that determine left-right asymmetry for structural syndromes such as situs inversus have been characterised in recent years (Supp, Witte, Potter, & Brueckner, 1997), there has been little progress in determining which genes or loci predispose to left-right handedness in humans. Linkage analysis has been used widely for the localisation of genes followed by their positional cloning. The complex genetics of handedness is one of the greatest problems for standard linkage analysis. Several genetic models have been proposed for the inheritance of handedness in humans. On the basis of these models, left-handedness can be considered a common single gene trait with a high gene frequency and a non-mendelian inheritance pattern. We report here a possible strategy, using these genetic models, that can be applied for the identification for genes determining handedness in humans.

Primary ciliary dyskinesia (Siewert's/Kartagener's syndrome): respiratory symptoms and psycho-social impact

BACKGROUND

Although the pathophysiological defect in primary ciliary dyskinesia (PCD; Siewert's/Kartagener's syndrome) is now well characterised, there are few studies of the impact of the condition upon health function, particularly in later life. This study assesses the health impact of the condition in a large group of patients. In addition, it assesses the similarity in age of diagnosis, symptoms and problems of those with situs inversus (PCD-SI) and those with situs solitus (PCD-SS).

METHODS

Postal questionnaire sent to members of the UK Primary Ciliary Dyskinesia Family Support Group. The questionnaire contained the St. George's Respiratory Questionnaire (SGRQ) and the SF-36 questionnaire for assessing health status.

RESULTS

93 questionnaires were returned, representing a 66% response rate. Replies were received from similar numbers of PCD-SI and PCD-SS. Individuals with PCD-SI did not show a significant tendency to be diagnosed earlier, and neither did they show any difference in their symptoms, or the relationship of symptoms to age. Respiratory symptoms were fairly constant up until the age of about 25, after which there was a slow increase in symptoms, and a decline in health status, patients over the age of 40 being about one and a half standard deviations below the mean on the physical component score of the PCS. Patients diagnosed earlier in life, and hence who had received more treatment for their condition, had better scores on the SGRQ Impact and Activity scores.

CONCLUSIONS

PCD is a chronic condition which has a progressively greater impact on health in the second half of life, producing significant morbidity and restriction of life style. Early diagnosis, and hence earlier treatment, may improve symptoms and the impact of the condition.

Parametric and non-parametric linkage analysis of several candidate regions for genes for human handedness

The frequency of left-handedness in the general population is around 11%. Both environmental and genetic models have been proposed to explain the aetiology of human handedness. The majority of genetic models, such as those of Annett, McManus and Klar, propose a single gene determinant with a non-Mendelian inheritance pattern. As left-handedness is correlated with cerebral asymmetry and is a feature of left-right asymmetry, genes involved in the development of left-right asymmetry can be considered as candidate genes. Candidate gene analysis was performed using an informative extended pedigree, and also using nuclear families of right-handed parents with left-handed children. Segregation analysis in the extended pedigree identified allele sharing in the NODAL and DNAHC13 candidate regions on chromosome 10 and 1. Linkage analysis using the models of Klar and McManus, and non-parametric analysis on nuclear families, subsequently excluded all candidate regions tested. This demonstrates the power to identify the genes specifying handedness by the conduct of extended genetic studies on these and similar cohorts.

Is the handedness gene on the X chromosome? Comment on Jones and Martin (2000)

G. V. Jones and M. Martin (2000) argued, contrary to M. C. Corballis (1997), that a gene for handedness might plausibly be located in homologous, noncombining regions of the X and Y chromosomes. The specific model they proposed is unlikely to be correct, but a case can be made for an X-linked gene that has no homologue on the Y chromosome and that is subjected to X-inactivation in females. An X-linked gene predicts no overall sex difference in the incidence of left-handedness; the slight preponderance of left-handers among males might then be attributed to a higher incidence of pathologically induced left-handedness.

Differential expression of flectin in the extracellular matrix and left-right asymmetry in mouse embryonic heart during looping stages

A novel extracellular matrix protein flectin (250 kD M(r)) shows specific left-right asymmetric expression before and throughout the looping process during heart development in avian embryos [Tsuda et al., 1996]. Flectin is a candidate molecule to provide directionality to the looping process in the avian model. In this study on mouse embryonic heart development, flectin is shown to be developmentally regulated and to be expressed in a specific asymmetric fashion, but in a different pattern from that observed in avian hearts. The molecules involved in development tend to be the same, but timing of expression, modulation, and asymmetry are different. In the mouse embryo, flectin is expressed symmetrically when the cardiogenic plate is formed. As looping progresses, flectin expression becomes asymmetric. There is right side predominance at the outflow tract and left side predominance at the ventricular portion of the tubular heart. The left side predominance of flectin develops in an anteroposterior direction, while right side predominance of the outflow tract remains relatively unchanged. These differential expression patterns of flectin decrease once the looping process is completed. After looping, flectin becomes restricted to the epicardium and subepicardial extracellular regions. In inv/inv mice, a known mouse model for human situs inversus, in which the directionality of heart looping is inverted, flectin expression pattern is mirror image of that of normal mouse embryos during looping stages. Our study indicates that, in the mouse, flectin shows a specific asymmetric expression pattern after initiation of heart looping and that this asymmetric expression pattern is related to the directionality of looping. The remodeling of the extracellular matrix (ECM) including specific flectin expression begins with the looping process. This morphogenetic change of the ECM coincides with the differentiation of each region of the tubular heart.

Advances in the molecular genetics of congenital structural heart disease

Molecular genetic analyses have generated significant advances in our understanding of congenital heart disease. Techniques of genetic mapping with polymorphic microsatellites and fluorescence in situ hybridization (FISH) have provided informative tools for localization and identification of disease genes. Some cardiovascular diseases have proven to result from single gene defects. Others relate to more complex etiologies involving several genes and their interactions. Elucidation of the molecular genetic etiologies of congenital heart disease prompts consideration of DNA testing for cardiac disorders. Future integration of these diagnostic modalities with improved treatments may ultimately decrease morbidity and mortality from congenital heart diseases.

Cloning and chromosomal localization of human Cdc42-binding protein kinase beta

The p21 GTPases, Rho and Cdc42, regulate numerous cellular functions by binding to members of a serine/threonine protein kinase subfamily. These functions include the remodeling of the cell cytoskeleton that is a feature of cell growth and differentiation. Two of these p21 GTPase-regulated kinases, the myotonic dystrophy protein kinase-related Cdc42-binding kinases (MRCKalpha and beta), have been recently characterized in rat. Both of these proteins phosphorylate nonmuscle myosin light chain, a prerequisite for the activation of actin-myosin contractility. Here we report the cDNA cloning of the human homologue of MRCKbeta, CDC42BPB, which was found by Northern blot analysis to be expressed in a wide range of tissues. The human CDC42BPB gene maps to cytogenetic band 14q32.3 by FISH analysis.

Left-right asymmetry in animal development

Most animal species exhibit left-right asymmetry in their body plans and show a strong bias for one handedness over the other. The mechanism of handedness choice, recognized as an intriguing problem over a century ago, is still a mystery. However, from recent advances in understanding when and how asymmetry arises in both invertebrates and vertebrates, developmental pathways for establishment and maintenance of left-right differences are beginning to take shape, and speculations can be made on the initial choice mechanism.

Fish mapping of a translocation breakpoint at 6q21 (or q22) in a patient with heterotaxia

Heterotaxia is a congenital lateralization defect of visceral organs. As several single-genes that act on the formation of left-right asymmetry during embryogenesis have been identified in animals, a defect in the similar system may play a role in heterotaxia in man. We previously reported a Japanese girl with heterotaxia associated with a de novo balanced translocation (6;18)(q21 or q22;q21.3 or q22). In the present study, based on a hypothesis that one of the putative situs-determining genes is disrupted at a breakpoint of the translocation, we first isolated a yeast artificial chromosome (YAC) clone covering a breakpoint, 6q21 (or q22) of the translocation. Then, using STSs mapped on the YAC, we isolated bacterial artificial chromosome (BAC) clones spanning the breakpoint. FISH analysis using the BAC clones as probes revealed that the breakpoint is confined to a segment between two STS loci, WI-4066 and the CHLC.GATA6B06.192, within a genetic distance of 1.4 cM. The human connexin43 gene was not disrupted in our patient, although mutations of this gene have been reported in patients with complex heart disease and heterotaxia. The molecular localization of the translocation breakpoint in our patient may contribute to the positional cloning of a putative heterotaxia gene.

Mutation of an axonemal dynein affects left-right asymmetry in inversus viscerum mice

The development of characteristic visceral asymmetries along the left-right (LR) axis in an initially bilaterally symmetrical embryo is an essential feature of vertebrate patterning. The allelic mouse mutations inversus viscerum (iv) and legless (lgl) produce LR inversion, or situs inversus, in half of live-born homozygotes. This suggests that the iv gene product drives correct LR determination, and in its absence this process is randomized. These mutations provide tools for studying the development of LR-handed asymmetry and provide mouse models of human lateralization defects. At the molecular level, the normally LR asymmetric expression patterns of nodal and lefty are randomized in iv/iv embryos, suggesting that iv functions early in the genetic hierarchy of LR specification. Here we report the positional cloning of an axonemal dynein heavy-chain gene, left/right-dynein (lrd), that is mutated in both lgl and iv. lrd is expressed in the node of the embryo at embryonic day 7.5, consistent with its having a role in LR development. Our findings indicate that dynein, a microtubule-based motor, is involved in the determination of LR-handed asymmetry and provide insight into the early molecular mechanisms of this process.

Adrenergic neurotransmitters and calcium ionophore-induced situs inversus viscerum in Xenopus laevis embryos

Xenopus laevis embryos at the blastula-early tail bud stage were exposed to norepinephrine or octopamine dissolved in culture saline until they reached the larval stage. The left-right asymmetry of the heart and gut was then examined. We found that these adrenergic neurotransmitters induced situs inversus in the heart and/or gut in up to 35% of tested neurula embryos. Norepinephrine-induced situs inversus was blocked by the alpha-1 adrenergic antagonist prazosin. Furthermore, A23187, a calcium ionophore, also increased the incidence of situs inversus up to 54% when late-neurula embryos were exposed to the solution. A23187 treatment initiated before neural groove formation was less effective. The incidence of situs inversus induced by these reagents decreased towards the control level (2.2%, 25 untreated embryos out of 1127 embryos in total) in embryos past the stage of neural tube closure. In the present experiments we obtained 22 gut-only situs inversus embryos having an inverted gut and a normal heart. In contrast, such embryos were not observed among the 1127 untreated embryos. An adrenergic signal mediated by an increase in intracellular free calcium may be involved in the asymmetrical visceral morphogenesis of Xenopus embryos.

De novo balanced translocation (6;18)(q21;q21.3 or q22) [corrected] in a patient with heterotaxia

We report on a sporadic case of heterotaxia with a de novo chromosome structural abnormality. The patient had inversely located heart (dextrocardia), stomach, duodenum, and cecum. In addition, she had cerebral atrophy, hypertelorism with telecanthus, infraorbital skin furrows, ear-lobe grooves, prominent maxilla and teeth, large carp mouth, short fifth fingers with limited flexion, generalized hypotonicity, and severe psychomotor retardation. High-resolution chromosome banding analysis demonstrated an apparently balanced translocation: 46,XX,t(6;18)(q21;q21.3). It is hypothesized that both heterotaxia and the chromosomal abnormality in the patient are causally related and a putative situs determining gene has been disrupted by the chromosome break, i.e., a position effect or a cryptic deletion at around the breakpoints. The translocation in our patient may be a good source for positional cloning of the gene.

Influence of genetic and maternal diabetes in the pathogenesis of visceroatrial heterotaxy in mice

The NOD mouse is known as a spontaneous model of insulin-dependent diabetes mellitus. Fetuses in this strain present anomalies of the viscera, and the incidence increases in fetuses from dams with clinically manifested diabetes. To examine the role of maternal diabetes and the genetical influence in inducing heterotaxy, NOD dams were mated with males of the ICR strain (the original strain of the NOD) and with C57BL/6J sires (not genetically related to the NOD). The frequency of visceroatrial heterotaxy in fetuses from diabetic dams varied with the fetal genotype, being 65% (33/51) in NODxNOD (dam X sire, respectively), 24% (12/50) in NODxICR, and 7% (4/57) in NODxC57BL/6J. The cases with heterotaxy showed a tendency toward right isomerism of the viscera and had severe cardiac defects, such as endocardial cushion defect and double-outlet right ventricle or transposition of the great arteries. The fetal body weight from diabetic dams in each mating was lower than that from non-diabetic dams (P < 0.05), suggesting that maternal diabetes, rather than abnormal situs, is the main determinant for decreased fetal growth. These findings demonstrate that the liability to heterotaxy induced by maternal diabetes is influenced by the fetal genotype.

The degree of lateralization of paw usage (handedness) in the mouse is defined by three major phenotypes

Lateralization of paw usage in the laboratory mouse may be a useful model system in which to assess the genetic and developmental cause of asymmetry of hand usage. With a set number of paw reaches from a centrally placed food tube, individual mice from an inbred strain will exhibit a reliable number of left and right paw reaches. For a single inbred strain, there are approximately equal numbers of left-pawed and right-pawed mice, but strain differences have been reported in the degree of lateralization of paw preference. We reported a preliminary strain survey in which the strains appeared to fall into two groups of highly lateralized and weakly lateralized paw preference (Biddle et al., 1993). We review here our expanded survey of genetically different strains and stocks of the laboratory mouse, including different species and subspecies. The major genetic trait is the degree of lateralization of paw preference and the strain differences appear to fall into three major classes of highly lateralized, weakly lateralized, and ambilateral preference. The trait exhibits both additivity and dominance in preliminary reciprocal crosses, depending on which strain pairs are used. The wide difference between strains that have highly lateralized and ambilateral paw preference suggests specific genetic tools that could be used to begin a genetic dissection of the causes of this trait. Preliminary assessment of the size of the corpus callosum in three strains with significantly different degrees of lateralization suggests that genetically determined deficiencies and absence of this structure are not the direct cause of the strain differences in the trait of degree of lateralization. In the expanded survey, some strains appear to exhibit a directional deviation from equal numbers of mice with left and right paw usage. Therefore, direction of paw usage may not be a genetically neutral trait, but replicate assessments and genetic tests are needed to confirm this.

Defects in the determination of left-right asymmetry

Images

Left-right asymmetric expression of the TGF beta-family member lefty in mouse embryos

Examples of lateral asymmetry are often found in vertebrates, such as the heart being on the left side, but the molecular mechanism governing the establishment of this left-right (L-R) handedness is unknown. A diffusible morphogen may determine L-R polarity, but a likely molecule has not so far been identified. Here we report on the gene lefty, a member of the transforming growth factor-beta family, which may encode a morphogen for L-R determination. Lefty protein contains the cysteine-knot motif characteristic of this superfamily and is secreted as a processed form of relative molecular mass 25K-32K. Surprisingly, lefty is expressed in the left half of gastrulating mouse embryos. This asymmetric expression is very transient and occurs just before the first sign of lateral asymmetry appears. In the mouse mutants iv and inv, which cause situs inversus, the sites of lefty expression are inverted, indicating that lefty is downstream of iv and inv. These results suggest that lefty may be involved in setting up L-R asymmetry in the organ systems of mammals.

Molecular pathways controlling heart development

Heart formation requires complex interactions among cells from multiple embryonic origins. Recent studies have begun to reveal the genetic pathways that control cardiac morphogenesis. Many of the genes within these pathways are conserved across vast phylogenetic distances, which has allowed cardiac development to be dissected in organisms ranging from flies to mammals. Studies of cardiac development have also revealed the molecular defects underlying several congenital cardiac malformations in humans and may ultimately provide opportunities for genetic testing and intervention.

Asplenia syndrome in a child with a balanced reciprocal translocation of chromosomes 11 and 20 [46,XX,t(11;20)(q13.1;q13.13)]

We present a 6-year-old girl with a balanced 11;20 translocation [46,XX,t(11;20)(q13.1;q13.13)pat], asplenia, pulmonic stenosis, Hirschsprung disease, minor anomalies, and mental retardation. This case represents the second report of an individual with situs abnormalities and a balanced chromosome rearrangement involving a breakpoint at 11q13. Polymerase chain reaction (PCR) analysis of microsatellite markers excluded uniparental disomy for chromosomes 11 and 20. Segregation analysis of markers in the 11q13 region in the proposita and her phenotypically normal carrier sibs did not show a unique combination of maternal and paternal alleles in the patient. We discuss several possible explanations for the simultaneous occurrence of situs abnormalities and a balanced 11;20 translocation. These include (1) chance, (2) a further chromosome rearrangement in the patient, (3) gene disruption and random situs determination, and (4) gene disruption plus transmission of a recessive or imprinted allele from the mother.

Autosomal dominant transmission of familial laterality defects

Heterotaxy results from failure to establish normal left-right asymmetry during embryonic development. Most familial cases are thought to be autosomal recessive. We have identified a family in which 4 individuals from 3 generations manifest laterality defects. Twenty-five family members have been examined. Two have complete reversal of normal laterality (situs inversus) while 2 others have asplenia, midline liver, and complex cardiac malformations (situs ambiguus). Two additional obligate gene carriers are anatomically normal (situs solitus). Male-to-male transmission confirms autosomal inheritance. Identification of this family establishes an autosomal dominant form of laterality defect, suggesting that a portion of sporadic cases may be new-mutation dominant or unrecognized familial cases. The finding of all forms of laterality (solitus, ambiguus, and inversus) among obligate disease gene carriers within a single family may be relevant to genetic evaluation and counseling in apparently isolated patients with laterality disturbance.

Maternal effect of low temperature on handedness determination in C. elegans embryos

C. elegans embryos, larvae, and adults exhibit several left-right asymmetries with an invariant dextral handedness, which first becomes evident in the embryo at the 6-cell stage. Reversed (sinistral) handedness was not observed among > 10,000 N2 adults reared at 16 degrees C or 20 degrees C under standard conditions. However, among the progeny of adults reproducing at 10 degrees C, the frequency of animals with sinistral handedness was increased to approximately 0.5%. Cold pulse experiments indicated that the critical period for this increase was in early oogenesis, several hours before the first appearance of left-right asymmetry in the embryo. Hermaphrodites reared at 10 degrees C and mated with males reared at 20 degrees C produced sinistral outcross as well as sinistral self-progeny, indicating that the low temperature effect on oocytes was sufficient to cause reversals. Increased frequency of reversal was also observed among animals developed from embryos lacking the egg shell. Possible mechanisms for the control of embryonic handedness are discussed in the context of these results, including the hypothesis that handedness could be dictated by the chirality of a gametic component.

Developmental asymmetries in experimental animals

The early embryo orients to the antero-posterior axis and differentiates along this, and the dorso-ventral and lateral axes. From Drosophila melanogaster, detailed knowledge has accrued of how segmentation and dorso-ventral differentiation proceed, and of their genic control, mostly by selector and homeobox (Hox) genes. The study of the control of lateral differentiation, instead, has been largely neglected. Yet handed asymmetry (the "obvious" asymmetries of, for example, heart, lung, anatomical features of the nervous system, etc.) is basic and, possibly, universal. In the mouse, two genes control this: the iv gene which, when mutated, leads to random, in the place of biased, asymmetry and so to random situs inversus viscerum: and the inv mutation which, by contrast, results in 100% situs inversus. Both mutants act as autosomal recessives. Human situs inversus is heterogeneous and may be akin to that produced by the murine iv gene. In spite of situs inversus, there is no shift of hand preference; but there is no information on other lateralization, e.g. of language or of dermatoglyphic patterns. Handed asymmetry is known in Drosophila, but there is no information on its control. In the experimental nematode, Caenorhabditis elegans, asymmetry arises when differently programmed cells arrange themselves to the two body sides, and is present already at the six-cell stage; and even the major sensory neurons chains along the body axis are distributed unequally on the two sides of the worm. Experimentally, by embryonic micro-manipulation or the use of chemical mutagens, the normal and invariate direction of handed asymmetry can be reversed.

Case report on situs inversus totalis in two Sprague-Dawley rats

We macro- and microscopically examined two cases of congenital visceral transposition (situs inversus totalis) in SD rats. We also investigated the possibility of situs inversus in association with immotile-cilia syndrome. The rats had grown normally with no clinical signs of disease. Although all organs including the vascular system were located opposite to the normal position and displayed a mirror image on macroscopic observation, no abnormality was found in any of the organs on microscopic examination. Electron-microscopic observation revealed in neither animal any structural abnormalities of the cilia and flagella, which are one of the diagnostic characterizations of immotile-cilia syndrome. Congenital transposition of the viscera is rare and there are few reports examining complications with situs inversus in rats. This report will be helpful in accumulating information on this condition.

Mutations of the Connexin43 gap-junction gene in patients with heart malformations and defects of laterality

BACKGROUND

Gap junctions are thought to have a crucial role in the synchronized contraction of the heart and in embryonic development. Connexin43, the major protein of gap junctions in the heart, is targeted by several protein kinases that regulate myocardial cell-cell coupling. We hypothesized that mutations altering sites critical to this regulation would lead to functional or developmental abnormalities of the heart.

METHODS

Connexin43 DNA from 25 normal subjects and 30 children with a variety of congenital heart diseases was amplified by the polymerase chain reaction and sequenced. Mutant DNA was expressed in cell culture and examined for its effect on the regulation of cell-cell communication.

RESULTS

The 25 normal subjects and 23 of the 30 children with heart disease had no amino acid substitutions in connexin43. All six children with syndromes that included complex heart malformations had substitutions of one or more phosphorylatable serine or threonine residues. Four of these children had two independent mutations, suggesting an autosomal recessive disorder. Five of these children had substitutions of proline for serine at position 364. A seventh child, with a different heart condition, also had a point mutation in connexin43. Transfected cells expressing the Ser364Pro mutant connexin43 sequence showed abnormalities in the regulation of cell-cell communication, as compared with cells expressing normal connexin43.

CONCLUSIONS

Mutations in the connexin43 gap-junction gene, which lead to abnormally regulated cell-cell communication, are associated with visceroatrial heterotaxia.

Heterotaxia syndrome and autosomal dominant inheritance

Previous familial cases of recurrent heterotaxia have suggested an autosomal recessive or exceptionally X-linked or dominant inheritance. Here, we report six families including 18 affected members, consistent with autosomal dominant inheritance. Among these, four families have more than one case of heterotaxia. The other two families have one member with heterotaxia and at least one other affected member with an "isolated" heart malformation, which could be considered as a mild form of heterotaxia. In five families, the disorder is transmitted through two or three generations. In one family, the patients are of the same generation but are linked to each other by obligate carriers. We suggest a rule to classify these families with heart malformations, according to the etiologic factor involved (rule of precocity). This rule might be useful to other disruptions of morphogenetic processes.

Axial rotation in rat embryos: morphological analysis and microsurgical study on the role of the allantois

In mouse and rat embryos, the embryonic disc develops within a cup-shaped "egg cylinder" and consists of an inner layer of ectoderm and an outer layer of endoderm. Because of this configuration, the embryo first develops in a dorsally flexed position and then undergoes "axial rotation" to a ventrally flexed position. In the present study, we first analyzed the morphological process of axial rotation in rat embryos using novel reference axes set in the egg cylinder that remained invariant during the process. Our new perspective allowed us to demonstrate that the process consists of three movements which start at different stages of development: twisting of the upper body at stage 12/s7-8, twisting of the middle body at stage 13/s11-12, and twisting of the lower body (so called "tail") at stage 14/s15-16. Axial rotation is an interesting developmental event not only because it is such a dynamic process but also because it is one of the earliest morphological signs of body asymmetry. This asymmetry is strongly biased in that the tail almost always finishes up on the right side of the embryo for reasons that are still unknown. In the second part of the study, we performed microsurgical experiments to extend our previous finding that removal of the allantois results in random determination of tail sidedness. We demonstrated that an allantois transplanted from another embryo can prevent this abnormal sidedness in an embryos whose allantois had been removed and that transecting the allantois did not lead to abnormal tail sidedness. A possible explanation is that the allantois produces a chemical factor that controls tail sidedness.

Toward a molecular understanding of congenital heart disease

BACKGROUND

This review discusses the incidence and importance of congenital heart disease (CHD), the reasons that investigation of causative mechanisms for human CHD has been slow, and the limitations of the multifactorial theory for the etiology of CHD.

METHODS AND RESULTS

The molecular defects underlying three vasculopathies--Marfan's syndrome (fibrillin), supravalvar aortic stenosis, and Williams' syndrome (elastin)--and hereditary telangiectasia are presented to emphasize the role of microfibrils and extracellular matrix in the pathophysiology of these vascular defects. Animal models of CHD, including situs inversus, canine conotruncal malformations, and chick neural crest ablation, are examined to emphasize how such studies relate to human CHD, especially by pointing to single-gene defects for conotruncal malformations, candidate loci for situs inversus, and phenotypic variability caused by neural crest lesions. The crucial role of cardiac transcription factors in heart morphogenesis is emphasized by review of gene knockout studies of these factors, which cause fetal death secondary to heart maldevelopment. Several lines of evidence demonstrating genetic etiologies of human CHD are also presented, including the mapping of familial atrial septal defects, to prove that one anatomic type of CHD may be due to single-gene defects at different loci. Review of atrioventricular canal, both secondary to trisomy 21 and as an autosomal-dominant familial defect, reiterates this conclusion. The evidence that monosomy on chromosome 22 causes multiple types of CHD, including aortic arch and conotruncal defects as part of the CATCH-22 syndrome, is presented, with results supporting the idea that deletions at this site alone may cause 5% of surgically treated CHD.

CONCLUSIONS

We conclude that (1) human CHD is frequently due to single-gene defects and that even sporadic defects may arise from a single-gene abnormality; (2) a common genetic defect may cause several apparently different forms of CHD; (3) elucidation of the genetic basis of CHD provides clues to normal cardiovascular developmental biology; (4) the same cardiac malformation can be caused by mutant genes at different loci; and (5) interactions of clinical investigators (cardiologists and cardiothoracic surgeons) with basic scientists should allow more rapid progress in defining the genetic basis of CHD.

Asplenia syndrome and isolated total anomalous pulmonary venous connection in siblings

We report on a family with asplenia syndrome in one and total anomalous pulmonary venous connection (TAPVC) in the other sib. Both conditions are rare, may have a genetic cause and belong to a spectrum of laterality disorders. This suggests that both asplenia syndrome and TAPVC in this family are the clinical expression of a single genetic disorder.

Cardiovascular development. Prospects for a genetic approach

Genetics is a powerful tool, especially when used in combination with embryology, in the seeking of genes necessary for assembly of the cardiovasculature. The first questions must address the types of cellular decisions that are made during development. As for simpler systems in C elegans and D melanogaster, the lineage and cell-fate decisions of the cardiovascular progenitors need to be assessed. In addition it is likely that new paradigms will emerge for multicellular assembly. The study of cardiovascular mutations will define individual genetic steps that define organotypic decisions. A genetic approach is a natural extension of embryology, physiology, and anatomy, fields of great sophistication with regard to the cardiovasculature, because, like them, it focuses on integrative biology and on the intact organism. The zebrafish is particularly well suited to a combination genetic-embryologic study of the fashioning of the cardiovasculature.

The value of radionuclide splenic scanning in the evaluation of asplenia in patients with heterotaxy

Splenic anomalies frequently accompany conotruncal and atrioventricular septal malformations. Asplenia is a major factor in the mortality of newborns with the heterotaxy syndrome, requiring an early and accurate diagnosis. We evaluated the splenic status of five consecutive patients with heterotaxy syndrome by radionuclide splenic scanning with 99mTc-labelled and denatured red blood cells (RBCs) and by real-time abdominal ultrasonography. Examination and comparison of the findings using these diagnostic methods suggest that the former has some diagnostic pitfalls which arise from the symmetrical location of the liver in the abdomen. This leads to difficulty in the interpretation of overlapping signals from the blood pool of the liver and from the spleen.

Mapping a gene for familial situs abnormalities to human chromosome Xq24-q27.1

Ambiguous abdominal situs, asplenia/polysplenia and severe cardiac malformations characterize heterotaxy in humans. These anomalies result from the inability of the developing embryo to establish normal left-right asymmetry. We have studied an interesting family in which the heterotaxy phenotype segregates as an X-linked recessive trait. In order to map the heterotaxy locus (HTX), we have analysed 39 family members using highly-polymorphic microsatellite markers from the X chromosome. One of these markers, DXS994, shows no recombination with the disease locus in 20 informative meioses. Linkage analysis results in a maximum lod score of 6.37. Current genetic and physical mapping data assign the order of loci in Xq24-q27.1 as cen-DXS1001-(DXS994, HTX)-DXS984-tel. These results establish the first mapping assignment of situs abnormalities in humans.

Microsurgical study on the mechanisms determining sidedness of axial rotation in rat embryos

Sidedness of left/right asymmetric body structures is strongly biased in most animals by mechanisms that are not well understood. In rat embryos, axial rotation starts at the 9-10 somite stage and is almost completed at the 17-18 somite stage. As a result, the ventrally flexed tail (caudal part of the body) and chorioallantoic placenta on the yolk sac take up their position normally on the right side of the embryo. Because the tail and chorion become connected via the allantois around the time when axial rotation takes place, we hypothesized that the allantois and possibly its connection to the chorion is important in determining sidedness of the tail. In the present study, we tested this hypothesis by surgically removing either the allantois or chorion before axial rotation started. Embryos were explanted at 8 AM on Day 9 of gestation (presomite stage), and either the allantois or chorion was removed using microforceps. Embryos were then cultured in rotating bottles, and sidedness of the tail, chorioallantoic placenta, and bulboventricular loop (heart) was determined after 50 hours (approximately 25-26 somite stage). Removal of the allantois (n = 55) resulted in absence of the umbilical cord and a 49.1% incidence of inverted tail; a chorioallantoic placenta-like structure developed on the yolk sac in the normal position.(ABSTRACT TRUNCATED AT 250 WORDS)

Expression of the IV (reversed and/or heterotaxic) phenotype in SWV mice

Approximately 50% of iv/iv mice have situs inversus (mirror image reversal of viscera) and 40% have heterotaxia (anomalous arrangement of viscera). The occurrence of heterotaxia is independent of situs. Using the cross-intercross breeding system to put the iv gene on the SWV background, an occasional presumed iv/+ mouse was found that had an IV (situs inversus and/or heterotaxic) phenotype. Testcrosses of these reversed animals indicated an iv/+ genotype. Since iv is linked tightly to Igh-C on chromosome 12, we inferred the genotype with a polymorphism of Igh-C demonstrated using the polymerase chain reaction (PCR). This confirmed them to be iv/+. The expression of the IV phenotype in animals heterozygous for the iv gene may be due to an interaction of iv with an autosomal recessive gene found in SWV. We have not found the IV phenotype in heterozygous iv/+ mice following placement of the iv gene on six other inbred strains. Rarely, we also found that presumed SWV +/+ mice had the IV phenotype. Test matings of these phenodeviants, corroborated by PCR, have confirmed them to be +/+. Although the phenotypes of the affected SWV +/+ and iv/+ mice resembled those found in iv/iv mice, the occurrence of situs inversus and heterotaxia were not independent of each other, and most of the SWV mice with the IV phenotype had heterotaxia with situs solitus. This infrequent dominant expression of the iv gene has so far only been seen when iv is on the SWV background. These findings are consistent with the idea that this phenomenon is due to the interaction of the iv gene with another gene found so far only in the SWV strain.

Reversal of left-right asymmetry: a situs inversus mutation

A recessive mutation was identified in a family of transgenic mice that resulted in a reversal of left-right polarity (situs inversus) in 100 percent of the homozygous transgenic mice tested. Sequences that flanked the transgenic integration site were cloned and mapped to mouse chromosome 4, between the Tsha and Hxb loci. During early embryonic development, the direction of postimplantation turning, one of the earliest manifestations of left-right asymmetry, was reversed in homozygous transgenic embryos. This insertional mutation identifies a gene that controls embryonic turning and visceral left-right polarity.