Genomic Effects on Right Ventricular Function, Clinical Features and Outcomes in CHD

摘要 外科修复和心脏干预的巨大进步提高了即使是最严重的心脏病患者的生存率。 复杂形式的先天性心脏病（CHD）。随着这一显著的成功， 围手术期慢性心脏病发病率和加速死亡率。右心室（RV）功能障碍是一种 在患有多种形式CHD的儿童和成人中，这是长期结果的重要决定因素。结局 由于RV功能障碍和相关的合并症目前主要被认为是血流动力学或 生理因素。然而，常规的临床和影像学变量只能解释一小部分 冠心病患者右心室功能和临床结局的变异性，表明迄今为止， 不被承认的贡献者我们假设多种遗传因素导致了无法解释的 RV性能和患者结局的变化。探讨基因组因素与 临床结果，我们将研究两个例子的冠心病，右心室（RV）功能障碍 特别是影响预后的因素：法洛四联症（TOF）和左心发育不良综合征（HLHS）。 我们拟议的研究人群将利用PCGC开发的独特的临床和遗传数据库， 以及各个PCGC中心和其他联盟内的队列。在目标1中，我们将研究 在TOF和HLHS患者中发现的罕见损害性变体对RV功能、临床结局 和影响结果的解剖亚型。我们的主要结果将是RV射血分数， 心脏MRI（CMR）。次要结局将包括收缩和舒张功能的其他CMR指标， 以及临床结局，如无移植存活率、持续性室性和房性心动过速， 心力衰竭定义为纽约心脏协会III级或IV级。在目标2中，我们将研究 在TOF和HLHS患者中发现的常见变异对RV功能、临床结局和 影响结果的解剖亚型。主要和次要结局将与 目标1。目标3将评估与结局相关的罕见和常见变异对 心肌细胞功能、代谢、基因表达和染色质可及性， 诱导多能干细胞分化成心肌细胞（iPSC-CM）和CHD组织。我们将 使用生物信息学和功能测定来定义与结果相关的常见变体，并推导出iPSC-CM CHD变异，单独或除了罕见和常见的结果相关变异。我们将评估 收缩松弛、能量参数和iPSC-CM中的转录活性。我们将补充 这些研究使用CHD组织的单细胞核测序（NucSeq）和ATACseq分析来探索 结果相关变异如何影响体内心肌细胞生物学。通过识别影响 结果，我们的建议将推进机制的见解，改善风险分层，并提供 为CHD患者的整个生命周期提供更精确的个性化治疗。

ABSTRACT Dramatic advances in surgical repair and cardiac intervention have improved survival in even the most complex forms of congenital heart disease (CHD). With this notable success, there has been a shift from perioperative to chronic cardiac morbidity and accelerated mortality. Right ventricular (RV) dysfunction is an important determinant of long-term outcomes in children and adults with many forms of CHD. Outcomes such as RV dysfunction and associated comorbidities are currently thought of primarily in terms of hemodynamic or physiological factors. However, routine clinical and imaging variables have explained only a small percentage of the variability in RV function and clinical outcomes in CHD patients, suggesting an important role for as-yet- unrecognized contributors. We hypothesize that multiple genetic factors contribute to the unexplained variation in RV performance and patient outcomes. To investigate the relationship of genomic factors and clinical outcomes, we will study two exemplars of CHD for which right ventricular (RV) dysfunction especially impacts outcomes: tetralogy of Fallot (TOF) and hypoplastic left heart syndrome (HLHS). Our proposed study population will leverage a unique clinical and genetic database developed by the PCGC, as well cohorts within individual PCGC centers and other consortia. In Aim 1, we will study the effects of rare damaging variants identified in patients with TOF and HLHS on RV function, clinical outcomes, and anatomical subtypes influencing outcomes. Our primary outcome will be RV ejection fraction by cardiac MRI (CMR). Secondary outcomes will include other CMR measures of systolic and diastolic function, as well as clinical outcomes such as transplant-free survival, sustained ventricular and atrial tachycardias, and heart failure defined as New York Heart Association Class III or IV. In Aim 2, we will study the effects of common variants identified in patients with TOF and HLHS on RV function, clinical outcomes, and anatomical subtypes influencing outcomes. Primary and secondary outcomes will be identical to those in Aim 1. Aim 3 will assess the effects of rare and common variants associated with outcomes on cardiomyocyte function, metabolism, gene expression, and chromatin accessibility in isogenic induced pluripotent stem cells differentiated into cardiomyocytes (iPSC-CMs) and CHD tissues. We will define outcome-associated common variants using bioinformatic and functional assays, and derive iPSC-CMs with CHD variants, alone or in addition to rare and common outcome-associated variants. We will assess contraction relaxation, energetic parameters, and transcriptional activities in iPSC-CMs. We will complement these studies with single cell nuclear sequencing (NucSeq) and ATACseq analyses of CHD tissues to explore how outcome-associated variants influence in vivo cardiomyocyte biology. By identifying genes affecting outcomes, our proposal will advance mechanistic insights, improve risk-stratification and provide resources for more precise personalized therapies for CHD patients across the lifespan.