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Mathavan A, Mathavan A, Reddy R, Jones K, Eagan C, Alnuaimat H, Ataya A. Pulmonary hypertension in hereditary hemorrhagic telangiectasia: A clinical review. Pulm Circ 2023; 13:e12301. [PMID: 37868718 PMCID: PMC10585978 DOI: 10.1002/pul2.12301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 10/24/2023] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal dominant hereditary disorder characterized by recurrent spontaneous epistaxis, mucocutaneous telangiectasias, and solid organ arteriovenous malformations (AVMs). Pulmonary hypertension (PH) is an increasingly recognized complication in patients with HHT, most often precipitated by high-output heart failure in the presence of hepatic AVMs as well as pulmonary arterial hypertension in the form of a proliferative vasculopathy. The presence of PH in patients with HHT is associated with significant elevations in rates of morbidity and mortality. Additionally, there is growing recognition of a thromboembolic propensity in this population that increases the risk of chronic thromboembolic PH, posing unique clinical considerations regarding the use of anticoagulation. Patients with HHT are also at risk of PH due to disorders commonly seen in the general population, including left-sided heart and lung disease. The etiology of PH in HHT is multifaceted and complex; the diagnostic approach and treatment strategies must consider the underlying pathophysiology of HHT. This comprehensive review summarizes current knowledge of PH in HHT, detailing the pathogenesis of known etiologies, diagnostic evaluation, and suggested treatment modalities as well as emerging therapies that may be of future interest.
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Affiliation(s)
- Akash Mathavan
- Department of Internal MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Akshay Mathavan
- Department of Internal MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Renuka Reddy
- Division of Pulmonary, Critical Care, and Sleep MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Kirk Jones
- Department of Internal MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Christina Eagan
- Division of Pulmonary, Critical Care, and Sleep MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Hassan Alnuaimat
- Respiratory Institute Pulmonary, Critical Care, and Sleep MedicineCleveland Clinic Abu DhabiAbu DhabiUnited Arab Emirates
| | - Ali Ataya
- Division of Pulmonary, Critical Care, and Sleep MedicineUniversity of FloridaGainesvilleFloridaUSA
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Abston E, Hon S, Rodriguez-Lopez J, Moll M, Lanuti M, Farber HW, Wilson KC. Treatment of pulmonary hypertension in patients with Hereditary Hemorrhagic Telangiectasia - A case series and systematic review. Pulm Pharmacol Ther 2021; 68:102033. [PMID: 33895318 DOI: 10.1016/j.pupt.2021.102033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/22/2021] [Accepted: 04/12/2021] [Indexed: 11/19/2022]
Abstract
RATIONALE Pulmonary Arterial Hypertension (PAH), a rare complication of HHT is associated with poor outcome. There are no trials to date that have investigated whether pulmonary vasodilator therapy improves hemodynamics or survival in this disease. OBJECTIVE To determine whether pulmonary vasodilator therapy improves survival, exercise capacity, or hemodynamics in HHT patients with pre-capillary PH. METHODS We performed a before-and-after observational study on a multicenter cohort of subjects with HHT-PAH who received intravenous prostanoid therapy. We then conducted a systematic review, searching Medline and EMBASE through December 2019. Studies that enrolled HHT-PAH subjects and reported treatment outcomes were selected. PROSPERO #158179. RESULTS Twenty-one articles were selected. Studies were before-and-after observational studies, case reports, and case series. Among all subjects with HHT-PAH, both mPAP (65 ± 19 pre-treatment vs 51 ± 16 mmHg post-treatment p = 0.04) and PVR (12 ± 6 pre-treatment vs 8 ± 4 WU post-treatment p = 0.01) improved with treatment. The mPAP improved with either oral (57 ± 17 pre-treatment versus 44 ± 13 mmHg post-treatment, p = 0.03) or intravenous (80 ± 15 pre-treatment versus 64 ± 16 mmHg post-treatment, p = 0.017) therapy. PVR also improved with either oral (10 ± 4 pre-treatment versus 6 ± 3 WU post-treatment, p = 0.004) or intravenous (17 ± 5 pre-treatment versus 10 ± 4 WU post-treatment, p = 0.04) therapy. Survival among HHT-PAH patients who received oral or intravenous therapy was not different (p = 0.2). Unadjusted survival among HHT-PAH patients was longer than that of IPAH patients (p = 0.008). There was no difference in side effects among HHT-PAH patient who received oral or intravenous therapy (p = 0.1). CONCLUSION Pulmonary vasodilator therapy is effective in improving hemodynamics of subjects with HHT-PAH and was not associated with increased risk of side effects.
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Affiliation(s)
- Eric Abston
- Division of Allergy, Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA; Center for Thoracic Cancers, Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.
| | - Stephanie Hon
- Division of Allergy, Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA; Division of Pulmonary, Critical Care, And Sleep Medicine, Department of Medicine, Tufts Medical Center, Boston, MA, USA
| | - Josanna Rodriguez-Lopez
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Matt Moll
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Michael Lanuti
- Center for Thoracic Cancers, Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Harrison W Farber
- Division of Pulmonary, Critical Care, And Sleep Medicine, Department of Medicine, Tufts Medical Center, Boston, MA, USA
| | - Kevin C Wilson
- Division of Allergy, Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
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Yonker LM, Hawley MH, Moschovis PP, Lu M, Kinane TB. Recognizing genetic disease: A key aspect of pediatric pulmonary care. Pediatr Pulmonol 2020; 55:1794-1809. [PMID: 32533909 PMCID: PMC7384240 DOI: 10.1002/ppul.24706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 02/12/2020] [Indexed: 12/19/2022]
Abstract
Advancement in technology has improved recognition of genetic etiologies of disease, which has impacted diagnosis and management of rare disease patients in the pediatric pulmonary clinic. This review provides an overview of genetic conditions that are likely to present with pulmonary features and require extensive care by the pediatric pulmonologist. Increased familiarity with these conditions allows for improved care of these patients by reducing time to diagnosis, tailoring management, and prompting further investigation into these disorders.
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Affiliation(s)
- Lael M Yonker
- Pulmonary Division, Massachusetts General Hospital for Children, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Megan H Hawley
- Pulmonary Division, Massachusetts General Hospital for Children, Boston, Massachusetts.,Laboratory for Molecular Medicine, Partners HealthCare Personalized Medicine, Cambridge, Massachusetts
| | - Peter P Moschovis
- Pulmonary Division, Massachusetts General Hospital for Children, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Mengdi Lu
- Pulmonary Division, Massachusetts General Hospital for Children, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - T Bernard Kinane
- Pulmonary Division, Massachusetts General Hospital for Children, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Maddineni U, Worrall EF, Baker EA, Earasi M, Mathieu F, Guruli G. Urologic Surgery with Multisystem Comorbidities: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2018; 19:1047-1052. [PMID: 30171179 PMCID: PMC6135146 DOI: 10.12659/ajcr.909554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 06/20/2018] [Indexed: 11/09/2022]
Abstract
BACKGROUND Originally implemented for colorectal surgery, enhanced perioperative protocols have been incorporated into many surgical fields in an effort to improve outcomes. The cornerstone of many strategies includes patient education, liberalized oral intake on the day of surgery, no routine bowel prep, targeted multimodal analgesia, cautious use of IV hydration, early extubation, avoidance of NG tubes and/or surgical drains, and encouraging early postoperative ambulation. CASE REPORT We report on the successful outcome of a single patient with a rare autosomal dominant disorder (hereditary hemorrhagic telangiectasia) with multisystem involvement including pulmonary, cardiac, hematologic, gastrointestinal, renal, oncologic, and hepatic comorbidities, scheduled for open nephrectomy. CONCLUSIONS Prospective and retrospective studies are needed to specifically elucidate the role of similar management in higher-risk surgical candidates.
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Affiliation(s)
- Upendra Maddineni
- Department of Anesthesiology, McGuire Veterans Administration Medical Center, Richmond, VA, U.S.A
| | - Eric F. Worrall
- Department of Anesthesiology, Virginia Commonwealth University, Richmond, VA, U.S.A
| | - Erik A. Baker
- Department of Anesthesiology, McGuire Veterans Administration Medical Center, Richmond, VA, U.S.A
| | - Madhavi Earasi
- Department of Anesthesiology, McGuire Veterans Administration Medical Center, Richmond, VA, U.S.A
| | - Francis Mathieu
- Department of Anesthesiology, McGuire Veterans Administration Medical Center, Richmond, VA, U.S.A
| | - Georgi Guruli
- Department of Urology, McGuire Veterans Administration Medical Center, Richmond, VA, U.S.A
- Department of Urology, Virginia Commonwealth University, Richmond, VA, U.S.A
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Plumitallo S, Ruiz-Llorente L, Langa C, Morini J, Babini G, Cappelletti D, Scelsi L, Greco A, Danesino C, Bernabeu C, Olivieri C. Functional analysis of a novel ENG variant in a patient with hereditary hemorrhagic telangiectasia (HHT) identifies a new Sp1 binding-site. Gene 2018; 647:85-92. [PMID: 29305977 DOI: 10.1016/j.gene.2018.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 12/01/2017] [Accepted: 01/02/2018] [Indexed: 10/18/2022]
Abstract
Hereditary Hemorrhagic Telangiectasia (HHT) is a rare disease, with an autosomal dominant inheritance and a worldwide incidence of about 1: 5000 individuals. In >80% of patients, HHT is caused by mutations in either ENG or ACVRL1, which code for ENDOGLIN and Activin A Receptor Type II-Like Kinase 1 (ALK1), belonging to the TGF-β/BMP signalling pathway. Typical HHT clinical features are mucocutaneous telangiectases, arteriovenous malformations, spontaneous and recurrent epistaxis, as well as gastrointestinal bleedings. An additional, but less frequent, clinical manifestation in some HHT patients is the presence of Pulmonary Arterial Hypertension (PAH). The aim of this work is to describe the functional role of a novel ENG intronic variant found in a patient affected by both HHT and PAH, in order to assess whether it has a pathogenic role. We proved that the variant lies in a novel binding-site for the transcription factor Sp1, known to be involved in the regulation of ENG and ACVRL1 transcription. We confirmed a pathogenic role for this intronic variant, as it significantly reduces ENG transcription by affecting this novel Sp1 binding-site.
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Affiliation(s)
- Sara Plumitallo
- Molecular Medicine Department, General Biology and Medical Genetics Unit, University of Pavia, Via Forlanini 14, 27100 Pavia, Italy.
| | - Lidia Ruiz-Llorente
- Centro de Investigaciones Biológicas - Consejo Superior de Investigaciones Científicas and Centro de Investigación Biomédica en Red de Enfermedades Raras, Calle Ramiro de Maeztu 9, 28040 Madrid, Spain.
| | - Carmen Langa
- Centro de Investigaciones Biológicas - Consejo Superior de Investigaciones Científicas and Centro de Investigación Biomédica en Red de Enfermedades Raras, Calle Ramiro de Maeztu 9, 28040 Madrid, Spain.
| | - Jacopo Morini
- Physics Department, Radiation Biophysics and Radiobiology Lab, University of Pavia, Via Bassi 6, 27100 Pavia, Italy.
| | - Gabriele Babini
- Physics Department, Radiation Biophysics and Radiobiology Lab, University of Pavia, Via Bassi 6, 27100 Pavia, Italy.
| | - Donata Cappelletti
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Laura Scelsi
- Cardiothoracic-Vascular Department, Cardiology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Alessandra Greco
- Cardiothoracic-Vascular Department, Cardiology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Cesare Danesino
- Molecular Medicine Department, General Biology and Medical Genetics Unit, University of Pavia, Via Forlanini 14, 27100 Pavia, Italy; Genetic Counselling Service, IRCCS Fondazione Policlinico San Matteo, Piazzale Golgi 2, 27100 Pavia, Italy.
| | - Carmelo Bernabeu
- Centro de Investigaciones Biológicas - Consejo Superior de Investigaciones Científicas and Centro de Investigación Biomédica en Red de Enfermedades Raras, Calle Ramiro de Maeztu 9, 28040 Madrid, Spain.
| | - Carla Olivieri
- Molecular Medicine Department, General Biology and Medical Genetics Unit, University of Pavia, Via Forlanini 14, 27100 Pavia, Italy.
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Identification of multiple ACVRL1 mutations in patients with pulmonary arterial hypertension by targeted exome capture. Clin Sci (Lond) 2016; 130:1559-69. [PMID: 27316748 DOI: 10.1042/cs20160247] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 06/17/2016] [Indexed: 11/17/2022]
Abstract
Pulmonary artery hypertension (PAH) is characterized as sustained elevation of pressure in the pulmonary vascular system that is attributable to a variety of causes. More than a dozen genes have previously been proposed as being associated with PAH. To examine potential mutations of these genes in patients with PAH, we developed a targeted exome kit containing 22 PAH-associated genes for genetic screens of 80 unrelated patients with PAH. As a result, we identified 16 different mutations in the BMPR2 gene and four different mutations in ACVRL1, the gene for activin receptor-like kinase-1 (ACVRL1). However, no deleterious mutations were found in the remaining 20 genes. In the present study, we provided detailed characterization of the ACVRL1 mutations in four pedigrees, including two novel missense mutations (c.676G>A, p.V226M; c.955G>C, p.G319R) and two recurrent mutations (c.1231C>T, p.R411W; c.1450C>T, p.R484W). Furthermore, we showed that markedly reduced Smad1/5 phosphorylation levels and reduced activities of luciferase reporters in each of the four ACVRL1 mutant-transfected NIH-3T3 cells. Therefore, our findings demonstrated that missense mutations of ACVRL1 identified in the present study significantly affected the bone morphogenetic protein 9 (BMP-9) pathway, implicating PAH pathogenesis. Detailed genotype–phenotype correlation analysis revealed initial symptoms of hereditary haemorrhagic telangiectasia (HHT) in some of the patients, suggesting the importance of sequencing molecular markers for early identification and intervention of individuals at risk for PAH and potential HHT. We developed a customized exome sequencing system to identify mutations in these PAH-associated genes, and found two novel missense mutations and two recurrent mutations in the ACVRL1 gene in four unrelated Chinese families; we also determined hypomorphic alleles using functional studies.
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Miyake R, Fujino T, Abe K, Hosokawa K, Ohtani K, Morisaki H, Yamada O, Higo T, Ide T. Pulmonary arterial hypertension associated with hereditary hemorrhagic telangiectasia successfully treated with sildenafil. Int J Cardiol 2016; 214:275-6. [DOI: 10.1016/j.ijcard.2016.03.211] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 03/27/2016] [Indexed: 12/14/2022]
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8
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Machado RD, Southgate L, Eichstaedt CA, Aldred MA, Austin ED, Best DH, Chung WK, Benjamin N, Elliott CG, Eyries M, Fischer C, Gräf S, Hinderhofer K, Humbert M, Keiles SB, Loyd JE, Morrell NW, Newman JH, Soubrier F, Trembath RC, Viales RR, Grünig E. Pulmonary Arterial Hypertension: A Current Perspective on Established and Emerging Molecular Genetic Defects. Hum Mutat 2015; 36:1113-27. [PMID: 26387786 DOI: 10.1002/humu.22904] [Citation(s) in RCA: 157] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 09/04/2015] [Indexed: 12/20/2022]
Abstract
Pulmonary arterial hypertension (PAH) is an often fatal disorder resulting from several causes including heterogeneous genetic defects. While mutations in the bone morphogenetic protein receptor type II (BMPR2) gene are the single most common causal factor for hereditary cases, pathogenic mutations have been observed in approximately 25% of idiopathic PAH patients without a prior family history of disease. Additional defects of the transforming growth factor beta pathway have been implicated in disease pathogenesis. Specifically, studies have confirmed activin A receptor type II-like 1 (ACVRL1), endoglin (ENG), and members of the SMAD family as contributing to PAH both with and without associated clinical phenotypes. Most recently, next-generation sequencing has identified novel, rare genetic variation implicated in the PAH disease spectrum. Of importance, several identified genetic factors converge on related pathways and provide significant insight into the development, maintenance, and pathogenetic transformation of the pulmonary vascular bed. Together, these analyses represent the largest comprehensive compilation of BMPR2 and associated genetic risk factors for PAH, comprising known and novel variation. Additionally, with the inclusion of an allelic series of locus-specific variation in BMPR2, these data provide a key resource in data interpretation and development of contemporary therapeutic and diagnostic tools.
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Affiliation(s)
- Rajiv D Machado
- School of Life Sciences, University of Lincoln, Lincoln, United Kingdom
| | - Laura Southgate
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom.,Division of Genetics & Molecular Medicine, King's College London, London, United Kingdom
| | - Christina A Eichstaedt
- Centre for Pulmonary Hypertension, Thoraxclinic at the University Hospital Heidelberg, Heidelberg, Germany.,Institute of Human Genetics, Heidelberg University, Heidelberg, Germany
| | | | - Eric D Austin
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - D Hunter Best
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, Utah.,ARUP Institute for Clinical and Experimental Pathology, ARUP Laboratories, Salt Lake City, Utah
| | - Wendy K Chung
- Departments of Pediatrics and Medicine, Columbia University Medical Center, New York, New York
| | - Nicola Benjamin
- Centre for Pulmonary Hypertension, Thoraxclinic at the University Hospital Heidelberg, Heidelberg, Germany
| | - C Gregory Elliott
- Departments of Medicine, Intermountain Medical Center and the University of Utah School of Medicine, Salt Lake City, Utah
| | - Mélanie Eyries
- Unité Mixte de Recherche en Santé (UMR_S 1166), Université Pierre and Marie Curie Université Paris 06 (UPMC) and Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France.,Genetics Department, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,Institute for Cardiometabolism and Nutrition (ICAN), Paris, France
| | - Christine Fischer
- Institute of Human Genetics, Heidelberg University, Heidelberg, Germany
| | - Stefan Gräf
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom.,Department of Haematology, University of Cambridge, Cambridge, United Kingdom
| | | | - Marc Humbert
- Université Paris-Sud, Faculté de Médecine, Paris, France.,Département Hospitalo-Universitaire (DHU) Thorax Innovation (TORINO), Service de Pneumologie, Hôpital Bicêtre, AP-HP, Paris, France.,INSERM UMR_S 999, Laboratoire d'Excellence en Recherche sur le Médicament et l'Innovation Thérapeutique (LERMIT), Centre Chirurgical Marie Lannelongue, Paris, France
| | - Steven B Keiles
- Quest Diagnostics, Action from Insight, San Juan Capistrano, California
| | - James E Loyd
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Nicholas W Morrell
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom.,Addenbrooke's & Papworth Hospitals, Cambridge, United Kingdom
| | - John H Newman
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Florent Soubrier
- Unité Mixte de Recherche en Santé (UMR_S 1166), Université Pierre and Marie Curie Université Paris 06 (UPMC) and Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France.,Genetics Department, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,Institute for Cardiometabolism and Nutrition (ICAN), Paris, France
| | - Richard C Trembath
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Rebecca Rodríguez Viales
- Centre for Pulmonary Hypertension, Thoraxclinic at the University Hospital Heidelberg, Heidelberg, Germany.,Institute of Human Genetics, Heidelberg University, Heidelberg, Germany
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxclinic at the University Hospital Heidelberg, Heidelberg, Germany
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