Welcome to the Clinical Center Grand Rounds, a weekly series of educational lectures for physicians and health care professionals broadcast from the Clinical Center at the National Institutes of Health in Bethesda, MD. The NIH Clinical Center is the world's largest hospital totally dedicated to investigational research and leads the global effort in training today's investigators and discovering tomorrow's cures. Learn more by visiting us online at http://clinicalcenter.nih.gov THROUGH JULY GRAND ROUNDS WILL BE DESIGNED FOR GRADUATE MEDICAL EDUCATION, FOR THE FELLOWS AND THE STUDENTS, OF COURSE YOU ARE ALL WELCOME TO COME. IN AUGUST WE WILL TAKE A SUMMER BREAK AND START BACK IN SEPTEMBER WITH OUR REGULAR SERIES. SO UNFORTUNATELY TODAY, OUR FIRST SPEAKER DR. NURIA CARRILLO HAD A MEDICAL EMERGENCY AND IS UNABLE TO COME. SO WE ASK THERE PAUL KRUSZKA, OUR SECOND SPEAKER TO FILL IN WITH SOME EXTRA TIME SO ALL OF YOU WILL GET YOUR FULL CME CREDIT FOR ATTENDING THIS SESSION. AND DR. KRUSZKA WHO IS A MEMBER OF THE NATIONAL HUMAN GENOME RESEARCH INSTITUTE, IS AN INVESTIGATOR THERE AND HE IS GOING TO PRESENT HIS RESEARCH AND CLINICAL UPDATES ON INHERITED CONGENITAL HEART DISEASE. WHICH HE HAS BEEN STUDYING IN HIS INSTITUTE. HE IS A STAFF CLINICIAN IN THE MEDICAL GENETICS BRANCH OF THE NHGRI AND CAPTAIN IN THE COMMISSION CORPS. HE EARNED HIS MEDICAL DEGREE AT UNIVERSITY OF MICHIGAN IN 1998 AND COMPLETED HIS RESIDENCY IN FAMILY MEDICINE AT UNIVERSITY OF VIRGINIA. AFTER EARNING A MASTER AT UNIVERSITY OF MASSACHUSETTS AT AMHURST, MASSACHUSETTS HE THEN COMPLETED A CLINICAL GENETIC FELLOWSHIP HERE AT THE N.I.H. HIS RESEARCH INTERESTS INCLUDES GENOMIC STUDIES AND CONGENITAL HEART MALFORMATIONS AND INTERNATIONAL GENOMIC STUDIES. A LEAD INVESTIGATOR IN THE BASIS OF CONGENITAL HEART DISEASE STUDY AND LEAD CLINICIAN OF THE RECENTLY CREATED ATLAS OF HUMAN MALFORMATION SYNDROMES IN DIVERSE POPULATIONS. AND HIS RESEARCH TEAM HAS IDENTIFIED MULTIPLE NEW GENETIC ASSOCIATIONS WITH CONGENITAL HEART DISEASE. IN 2013 HE WAS NAMED PHYSICIAN RESEARCHER OF THE YEAR FOR THE U.S. PUBLIC HEALTH SERVICE. AND TODAY HE IS GOING TO PRESENT HIS TALK TITLED SUB SAHARAN AFRICA AND THE GENETIC BASIS OF CONGENITAL HEART DISEASE. PLEASE WELCOME DR. PAUL KRUSZKA. >> ALL RIGHT, WELCOME. IT'S A PLEASURE TO BE HERE. I SEE A LOT OF SUMMER STUDENTS OUT THERE. I KNEW YOU WOULD BE HERE, SO HOPEFULLY YOU WILL LEARN SOMETHING FROM THIS LECTURE. I HAVE NO FORMAL DISCLOSURES. ONLY INFORMAL DISCLOSURES. I'M A CLINICAL GENETICKIST AND NOT A CARDIOLOGIST SO THIS WILL BE GENOMIC BASED AS OPPOSED TO CARDIOLOGY BASED. HERE ARE MY MAIN OBJECTIVE. TO KEEP EVERYONE AWAKE. SO WE WILL SEE IF I'M SUCCESSFUL WITH THAT. I WANT TO PUT MY TALK INTO THE CONTEXT OF A CASE PRESENTATION, WHICH I WILL DO IN THE MIDDLE OF THE TALK. I FIND THAT'S ALWAYS AN EASIER WAY TO DEMONSTRATE SOME OF THE PRINCIPLES OF OUR RESEARCH. SO I ALWAYS LIKE TO START OFF WITH THIS SLIDE. A LOT OF WHAT WE DO IN OUR GROUP IS BECAUSE OF THE PLUMMETING COSTS OF GENOMIC SEQUENCING. AND I KNOW MANY OF YOU HAVE SEEN THIS CHART HERE. IT'S IN A LOT OF LECTURES WE GIVE IN OUR INSTITUTE TO NATIONAL HUMAN GENOME INSTITUTE. IT JUST SHOWS YOU HOW MUCH SEQUENCING IS DROPPING. AND THIS IS REALLY NEXT GENERATION SEQUENCING. AND THAT'S REALLY MADE MY TALK POSSIBLE TODAY. THIS WHITE LINE HERE IS MOORES LAW. THIS IS BASICALLY THE PRICE OF COMPUTERS, HOW MANY TRANSCYSTORS -- TRANSISTORS YOU CAN PUT ON A COMPUTER BOARD. AND SEQUENCING COSTS FOLLOWED THAT FOR A WHILE. HERE IN 2007 NEXT GENERATION SEQUENCING CAME ON BOARD AND CAUSED THIS DROP. EVEN PRESIDENT OBAMA IS HAPPY ABOUT ALL THIS. IN FRONT OF A DOUBLE HELIX HERE AND HE IS ANNOUNCING HIS PRECISION MEDICINE INITIATIVE. I BELIEVE A LOT OF THIS IS POSSIBLE BECAUSE OF THE TECHNOLOGY. LET'S START OUT WITH BASIC CONCEPTS IN CONGENITAL HEART DISEASE. IT COMPRISES STRUCTURAL MALFORMATIONS IN THE HEART THAT START IN EMBRYO GENESIS. SO THIS COLUMN IS THE EMBRYO, EARLY EMBRYO AND IT HAS THREE LAYERS, THE ACTIVE DERM, ECTO, DERM AND MESODERM. IT PROGRESSES INTO A HEART TUBE. IT SEPTATES INTO THE MATURE HEART WE SEE HERE, THE FOUR VENTRICLES. ANY PROBATION IN THIS PROCESS WILL CAUSE A CONGENITAL HEART MALFORMATION, WHETHER THAT'S ENVIRONMENTAL EFFECT OR CONGENITAL EFFECT. THIS IS A VERY OVER SIMPLIFIED DIAGRAM OF SOME PATHWAYS INVOLVED IN CONTROLLING HEART DEVELOPMENT. A LOT OF THESE ARE TRANSCRIPTION FACTORS. AND THERE'S BEEN A WEALTH OF KNOWLEDGE OVER THE LAST TWO DECADES IN THE PATHWAYS FORMING THE HEART, LARGELY DUE TO ANIMAL STUDIES. AND THERE IS STILL, AS I WILL SHOW YOU IN THE NEXT SLIDE, THERE'S STILL A LOT WE DON'T KNOW. THIS PIE GRAPH SHOWS YOU WHAT WE KNOW AND DON'T KNOW ABOUT ISOLATED CONGENITAL HEART DISEASE. SO WE THREW OUT DOWN SYNDROME, THAT WOULD BE A SYNDROMIC HEART DISEASE. THIS PIE GRAPH IS ISOLATED SO THE INDIVIDUAL DOESN'T HAVE ANY OTHER MALFORMATIONS. AND YOU CAN SEE THAT 10% ARE COPY NUMBER VARIATIONS. THEY ARE DUPLICATIONS OR DELETIONS IN LARGE SECTIONS OF DNA. SOMETIMES MILLIONS OF BASE PAIRS LONG THAN SINGLE GENES. THESE ARE MUTATIONS, ENVIRONMENTAL CAN BE A LOT OF DIFFERENT THINGS SUCH AS DIOXIN EXPOSURE, ALCOHOL IN UTERO EXPOSURE OR EVEN INFECTION LIKE RUBELLA. AS YOU CAN SEE THERE'S A LOT WE DON'T KNOW. THAT'S GREAT FOR ME, BECAUSE THAT KEEPS ME EMPLOYED. THIS ALSO SHOWS THAT CONGENITAL HEART DISEASE IS COMPLEX. IT'S A COMPLEX TRAIT. IT'S CAUSED BY, WE THINK MULTIPLE GENES INTERACTING WITH EACH OTHER AND ENVIRONMENT. SHIFT GEARS HERE, WE WILL TALK A LITTLE ABOUT EPIDEMIOLOGY. CONGENITAL HEART DISEASE IS THE MOST COMMON CONGENITAL MALFORMATION. IT MAKES UP ABOUT ONE THIRD OF ALL MAJOR BIRTH DEFECTS. 1.35 MILLION CHILDREN ARE BORN EVERY YEAR WITH A CONGENITAL HEART DEFECT. THIS FIGURE HERE IN THE BOLD, THESE ARE ALL VARIOUS CONGENITAL HEART DEFECTS. THE ABBREVIATIONS ARE HERE. AND THEY AFFECT ALMOST EVERY PORTION OF THE HEART AND OUTFLOW TRACT. IN PARENTHESES IS PREVALENCE PER MILLION. MOST COMMON IS VSD. IT'S A WHOLE IN VENTRICLE SEMINAL DEFECT. A HOLE BETWEEN THE LEFT AND RIGHT VENTRICLE. MOST OCCURS IN THE DEVELOPING WORLD. THIS WAS A GRAPH THAT LORENZO CAME UP WITH WORLD HEALTH ORGANIZATION DATA. HE MADE THE AREA, THE CIRCLES PROPORTIONAL TO THE AMOUNT OF BABIES THAT ARE BORN EACH YEAR WITH CONGENITAL HEART DISEASE. THEN ON THE Y AXIS IS GROSS DOMESTIC PRODUCT PER CAPITA. THESE CIRCLES ARE OBVIOUSLY GOING TO BE PROPORTIONAL TO POPULATION. INDIA AND CHINA ARE THE TWO LARGEST POPULATIONS IN THE WORLD. SO THEY ARE GOING TO HAVE A LOT OF CHILDREN BORN WITH CONGENITAL HEART DISEASE. BUT THEN YOU ALSO HAVE COUNTRIES LIKE NIGERIA WHO HAD 50% MORE CONGENITAL HEART DISEASE CASES THAN THE UNITED STATES. THAT'S BECAUSE THEIR FERTILITY RATE IS HIGHER. IN SOME COUNTRIES IN AFRICA THE FERTILITY RATE IS 14% IN WOMEN. YOU CAN IMAGINE MORE CHILDREN BEING BORN YOU ARE GOING TO HAVE A HIGHER QUANTITY OF CONGENITAL BIRTH DEFECTS. SO PROBABLY A LOT OF YOU ARE ASKING HOW DOES A CLINICAL GENETICIST OR GROUP AT THE NATIONAL INSTITUTES OF HEALTH GET INTERESTED IN RESEARCHING CONGENITAL HEART DISEASE IN AFRICA. IT REALLY STARTED WITH THIS MAN. THIS IS CRAIG SABLE. A PEDIATRIC CARDIOLOGIST HERE IN WASHINGTON DC. AND HE HAS BEEN GOING TO AFRICA, OR UGANDA WHICH IS A COUNTRY IN EAST SUB SAHARAN AFRICA FOR ABOUT TWO DECADES. AND TO HIS CREDIT THEY ARE NOW DOING OPEN HEART SURGERIES IN KUMPALA. HE STARTED THERE WITH JUST A HEART MACHINE DOING DIAGNOSIS. I WENT WITH HIM AS 2013, JUST AS A CLINICIAN, RESEARCHER. HERE ARE PHOTOS FROM THE HEART INSTITUTE. THIS IS AT MUAGO HOSPITAL. MADE FAMOUS FROM THE KING, MADE FAMOUS BY THE MOVIE WITH FOREST WHITAKER. THIS IS THE WAITING ROOM AND THESE ARE THE WARDS, YOU CAN SEE THE PARENTS ARE DRAWING OUT THE LINEN. YOU HAVE TO BRING YOUR OWN FOOD AND WATER, SO IT MAKES YOU APPRECIATE WHAT WE HAVE HERE IN OUR HOSPITALS IN THE UNITED STATES. I WENT TO UGANDA IN 2013 FOR A FEW WEEKS. I WENT WITH ANOTHER GENETICKIST BRENDAN LAMPIER. HE WAS A CLINICAL GENETICIST. ABOUT 119 PATIENTS IN TEN DAYS. YOU CAN SEE THAT 23-24% OF THE PATIENTS WE SAW WERE OBVIOUS LY SYNDROMIC TO US. THEY HAD FEATURES THAT SET THEM APART FROM ISOLATED CONGENITAL HEART DISEASE. THEY HAD DOWN SYNDROME, OTHER SYNDROMES. THAT IS PRECISELY THE REASON CRAIG SABLE INVITED US ON HIS TEAM. BECAUSE HE HAD NOTICED THERE WAS SUCH A LARGE POPULATION OF SYNDROMIC PATIENTS. AND HE WANTED TO HELP US IN MAKING THE DIAGNOSIS. ONE GREAT EXAMPLE IS NOONAN SYNDROME. IT RESPONDS DIFFERENTLY TO DIFFERENT TYPES OF THERAPY. IN NOONAN SYNDROME THE PULMONARY VALVE IS DISPLASTIC. IT'S NOT AMENABLE TO CARDIAC, THEY ARE BETTER TO GO IN SURGERY. THESE ARE A NUMBER OF REASONS THAT WE CAME AND ALSO YOU WOULD BE SURPRISED HOW MANY DOWN SYNDROME PATIENTS A LOT OF THE CARDIOLOGISTS WOULD MISS. IT'S NATURAL. IT'S NOT ALWAYS AN EASY DIAGNOSIS TO MAKE. A LOT OF WHAT WE DID THERE DURING WHAT I CALL AN OUTREACH CLINIC, OR SUPPORTING CRAIG WAS WE DID A LOT OF GENETIC COUNSELING FOR THESE. EVEN FOR DOWN SYNDROME, JUST EXPLAINING WHY THE CHILD HAD DOWN SYNDROME. IT WAS BECAUSE OF AN EXTRA CHROMOSOME AND NOT BECAUSE OF THE BIRTH CONTROL PILLS THAT THE WOMAN HAD BEEN TAKEN AS SHE WAS TOLD BY SOME OF THE VILLAGE ELDERS. THIS WAS ANOTHER REALLY PRODUCTIVE ENDEAVOUR OR US. YOU CAN SEE HERE THAT THE MOST COMMON MALFORMATION WE SAW WAS VENTRICULAR SEMINAL DEFECT. IT'S A MUCH MORE COMPLICATED HEART MALFORMATION. IT COMPRISES A LARGE VENTRICULAR SEMINAL DETECT. EFFECT. ONE THING YOU WILL NEVER SEE IN THE UNITED STATES IS A PATIENT LIKE THIS. THIS YOUNG MAN HAS TRITOLOGY, YOU CAN SEE HOW BLUE HIS LIPS, THE CLUBBING OF HIS FEET. ANYBODY KNOW WHY HE IS SQUATING LIKE THAT? HE ISN'T REPAIRED. INCREASING HIS VENOUS RETURN. I HAVE NEVER SEEN A PATIENT LIKE THAT BEFORE AND THEY WERE ALL OVER THE UGANDA, THEY ARE UNREPAIRED. I THINK A LOT OF THIS NUMBER IS ASCERTAINMENT BIAS. THAT THESE KIDS WITH TRITOLOGY FLOW ARE SICK ENOUGH TO GET TO THE HOSPITAL. NOT SICK ENOUGH TO PASS AWAY AS AN INFANT SUCH AS MAYBE HYPOPLASTIC LEFT HEART OR MAYBE NOT MINOR ENOUGH LIKE VENTRICULAR SEMINAL DEFECT. THERE HAVE NOT BEEN A GOOD EPIDEMIOLOGICAL STUDY. THAT'S JUST MY OBSERVATION AND I'VE OBSERVED IN OTHER PARTS OF THE WORLD ALSO. GENOMIC RESEARCH IS NOT NEW. IT'S NOT A NEW IDEA TO N.I.H. THIS IS REALLY A NEAT PROGRAM, IT WAS FUNDED BY THE N.I.H. IN THE WELCOME TRUST IN THE U.K. IT'S A PROGRAM TO PROMOTE AFRICAN SCIENTISTS CLINICIANS AND RESEARCHERS TO DO GENOMIC RESEARCH IN AFRICA AND IT'S A GRANT-BASED SYSTEM. I TOOK THIS RIGHT OFF THE WEBSITE. MOST AFRICAN COUNTRIES ARE BEING LEFT BEHIND IN THIS GENOMIC REVOLUTION, IF THIS ISN'T ADDRESSED IT WILL ATTRIBUTE TO WINDING GLOBAL AND ETHNIC INEQUALITIES IN HEALTH AND WELL-BEING. N.I.H. SET UP CENTERS FOR MEN DILON GENOMICKS. THEY HAVE COLLECTED ALMOST 20,000 SAMPLES. 261 INSTITUTIONS IN 36 COUNTRIES. IT'S AMAZING THE CONTINENT OF AFRICA IS BLANK. THAT'S KIND OF TELLING OF THE RESEARCH. IT'S CHANGING WITH H3 AFRICA. THERE'S A LOT MORE RESEARCH GOING ON IN AFRICA. BUT IT'S DEFINITELY A CONTINENT THAT HAS BEEN OVER LOOKED. WHEN I FIRST CONTEMPLATED DOING RESEARCH WITH CRAIG, I JUST DID A PUBMED SEARCH FOR CONGENITAL HEART MALFORMATIONS AND ALSO NOTICED IN AFRICA THERE'S MUCH LESS THAN YOU WILL SEE IN OTHER PARTS OF THE WORLD. I'M A STAFF CLINICIAN, THE PRINCIPLE INVESTIGATOR IN OUR GROUP. MAX HAS BEEN DOING RESEARCH MAINLY FOCUSING ON THE BRAIN BUT ALSO MADE SOME NEAT FINDINGS IN CONGENITAL HEART DISEASE AND RECENTLY WITH CRAIG EDITED A BOOK IN CONGENITAL HEART DISEASE. THE ANSWER TO THE QUESTION ABOUT FIVE SLIDES AGO HOW DO WE GET INTO THIS, IT WAS COMPLETELY A NO-BRAINER FOR US. WE WERE EAGER TO TEAM UP WITH CRAIG IN THE UGANDA HEART INSTITUTE. A LOT HAS CHANGED SINCE 2013, 2014 WE ESTABLISHED A COLLABORATION WITH TEACHING HOSPITAL. DR. McCURRY IS THE CARDIOLOGIST. THIS IS A PICTURE OF ONE OF THE WALKWAYS. AND IT'S BEEN A VERY PRODUCTIVE COLLABORATION. WE HAVE RECEIVED ALMOST 500 SAMPLES. IN THE NORTHERN PORTION OF THAILAND IN CHILL WONG KERN UNIVERSITY. IN INDIA HERE IS MY BOSS, MAX, AND MYSELF. WE GAVE SOME TALKS THERE AND DOING A COLLABORATION WE HOPE AND ALSO IN BANGALOR. IT'S AN INTERESTING POPULATION THERE'S A LOT OF UNIONS AND WE WONDER ABOUT RECESSIVE DISEASE AND CONGENITAL HEART DISEASE. THE PROBLEM WITH INDIA, IT'S VERY DIFFICULT TO DO RESEARCH. THEY ONLY ALLOW EXPORTING OF 10% OF SAMPLES WHEN YOU DO RESEARCH THERE. WE MADE A PROPOSAL TO INDIA TO TRY TO DO MORE THERE. RIGHT NOW IT'S AT THE LEVEL OF THE INDIAN MEDICAL RESEARCH COUNCIL. SO HOPEFULLY THAT WILL GO THROUGH BECAUSE IT WOULD BE REALLY PRODUCTIVE PLACE TO DO RESEARCH. SO WE CHANGED THE NAME OF OUR PROTOCOL IN AFRICA AND IN ASIA AND NOW WE CALL IT THE INTERNATIONAL BECAUSE WE ARE FORMING COLLABORATIONS THROUGHOUT THE WORLD. WE WILL TALK ABOUT A WORKUP, CONGENITAL HEART DISEASE WORKUP. A CASE REPORT. THIS IS A TABLE, OR A FIGURE OUT OF OUR BOOK FOR A WORKUP. IT'S A BASIC CLINICAL GENETICS WORKUP. HISTORY, PHYSICAL EXAMINATIONS FOR DYSMORPHIC FEATURES. EVERY PATIENT HAS TO HAVE AN ECHOCARDIOGRAM TO DEFINE THE ANATOMY OF THE HEART. WE TRY TO GET PARENTS. SO NOT ONLY DO WE WANT TO DO A GENOTYPE AND PHENOTYPE ON THE PATIENTS, BUT THE PARENTS. IF YOU HAVE THE PARENTS AS MANY OF YOU KNOW WHO DO GENOMIC RESOURCE, YOUR CHANCE OF FINDING SOMETHING INTERESTING ARE MUCH HIGHER. LIKE MANY LABS AT THE NATIONAL INSTITUTES OF HEALTH WE HAVE A LOT OF DIFFERENT TOOLS IN OUR TOOL BOX. CHROMOSOMAL MICRO ARRAY. LARGE DELETIONS OR DUPLICATIONS IN THE DNA. NEXT GENERATION SEQUENCING, THAT'S WHERE YOU MASSIVELY PARALLEL SEQUENCE THE GENOME, XOME MEANS ONLY THE CODING. ALL KINDS OF COMPUTER STUFF FOR BIO INFORMATICS AND FUNCTIONAL STUDIES IN OUR LAB WE STUDY BOTH THE ZEBRA FISH AND MOUSE. THIS IS ONE THING I'M PROUD OF THAT WE HAVE DEVELOPED OVER THE LAST YEAR. EXOME ANALYSIS PIPELINE AND A LARGE PART OF IT IS DUE TO FELLOWS IN OUR INSTITUTE THAT ARE VERY GIFTED WITH COMPUTERS, STATISTICS, AND GENOMICKS. THIS IS SETH BERGER WHO DID A LOT OF THE PEARL SCRIPTING TO MAKE UP OUR OWN HOMEMADE PIPELINE THAT WORKS BEAUTIFULLY. IT'S JUST REALLY A NEAT PIPELINE AND WE DRAG A LOT OF INFORMATION THROUGH ANNOVAR, THE DATABASE, 60,000 EXOMES READILY AVAILABLE, WE DRAG THAT THROUGH OUR VARSIFTER, OTHER ANALYSIS. THE OTHER THING WE DO TO BACK UP THAT IS WORKING VERY WELL, WE FOUND IT TO BE VERY SENSITIVE IS GETTING COPY NUMBER VARIATIONS OFF OF EXOMES AND HOPEFULLY IN THE NEXT FEW MONTHS I WILL HAVE A BETTER STATISTIC THAN JUST SAYING IT'S VERY SENSITIVE. I DIDN'T HAVE A PICTURE OF DAVID MURDOCK BUT HE IS A VERY TALENTED FELLOW IN OUR RESIDENCY PROGRAM. AND HE WAS KIND ENOUGH TO DEVELOP THIS FOR US. I TRIED TO DO IT ONE WEEK AND ALMOST THREW MY COMPUTER OUT THE WINDOW. BUT HE WAS ABLE TO DO IT QUICKLY AND USES THE BIO WULF WHICH IS THE CLUSTER IN OUR INSTITUTE. LET'S JUMP INTO THE CASE PRESENTATION. TIME TO WAKE UP. THIS IS THE MOST INTERESTING PART, AT LEAST FOR A LOT OF THE CLINICIANS LIKE MYSELF OUT THERE. THIS IS KIND OF AN EXAMPLE OF HOW WE GO THROUGH THE PROCESS OF EVALUATING PATIENTS AND WE DO THIS ON A LOT OF PEOPLE. THIS IS A 4-YEAR-OLD BOY WITH AN ATRIAL SEPTAL DEFECT. HOLE IN THE WALL DIVIDING THE ATRIA. THESE HEART ANOMALIES ARE LARGELY OVER SHADOWED AS YOU WILL SEE BY OTHER ANOMALIES THIS IS A PEDIGREE OF FAMILY. HERE IS THE PROBIN. IT HAS THREE HEALTHY SISTERS. SO CIRCLES ARE FEMALE. SQUARES ARE MALE. AND THEN THE MOST NOTABLE FINDING ON THIS YOUNG MAN HE HAS A VENTRAL WALL DEFECT. YOU CAN SEE HERE THAT'S HIS HEART BEATING OUT BECAUSE THERE'S A DEFECT IN HIS VENTRAL WALL. A YOUNG MAN FROM RWANDA, A COUNTRY THAT BORDERS UGANDA. THIS IS ACTUALLY THE FIRST PATIENT WE RAN THROUGH OUR PIPELINE. BECAUSE THIS CHILD HAS MULTIPLE CONGENITAL ANOMALIES WE THOUGHT OUR SUCCESS RATE MIGHT BE HIGHER. SO HERE IS SOME OF THE OTHER FEATURES THIS YOUNG MAN HAS. HE HAS A CLEFT LIP. HIS EYES ARE WIDELY SPACED, DEPRESSED NASAL BRIDGE. HE HAS SKIN PENECAL COMING OFF HIS SCALP. A NUMBER OF LIMB ABNORMALITIES. CUTANEOUS, THIRD AND LEFT DIGIT OF HIS LEFT HAND, THIS IS SPLIT FOOT HE IS MISSING METATARSALS IN HIS LEFT FOOT. THERE'S A CONSTRICTION BAN. CLEFT FOOT. THERE'S HIS ELBOW RIGHT THERE. THESE ARE X-RAYS. AND THE X-RAYS CONFIRM WHAT YOU SAW CLINICALLY THE TERMINATION DEFECTS. AND WE CAN SEE HERE CUTANEOUS INDAKTICALLY CLEFT FOOT, THESE ARE THE LONG BONES IN THE FOOT. WE TOOK DNA FROM THIS YOUNG MAN'S BLOOD. SO WE ISOLATED DNA STANDARD WAY FROM THE BLOOD. IN MOST CLINICAL GENETICISTS WILL DO A MICRO ARRAY WITH MULTIPLE CONGENITAL ANOMALIES. WE DID THAT, THERE WAS NOTHING INTERESTING IN THE MICRO ARRAY. WE DID GENOME SEQUENCING. WE DID BOTH PARENTS. WE DIDN'T DO SIBLINGS. WE FOUND DENOVO IQCK. THERE'S NOT MUCH MANY THE MEDICAL LITERATURE ABOUT THIS GENE. IT WAS GLUTAMINE TO GLUE TANIC ACID. IQ MOTIF. WE DID SANGER SEQUENCING JUST TO VALIDATE OUR FINDINGS. THIS WAS ALL INTERESTING. THIS WAS A DENOVO FINDING. ABOUT 80% OF US HAVE DENOVO FINDINGS. IF I DO GENOMES ON YOU AND YOUR PARENTS ABOUT 80% WILL HAVE A DENOVO IN A PRECODING POSITION. IT'S INTERESTING BUT NOT REALLY MUCH MORE THAN THAT UNTIL YOU DO SOME TYPE OF FUNCTIONAL STUDY OR MATCH IT UP WITH ANOTHER CASE. THERE'S NOT A LOT OF CASES LIKE THIS IN THE WORLD. I TRIED TO MATCH IT UP. I FOUND A GROUP OF PATIENTS WITH VENTRAL WALL DEFECTS BUT THEY DIDN'T HAVE THE LIMB ANOMALIES AND DIDN'T FIND ANY OTHER ANOMALIES IN IQCK. WE DECIDED TO DO SOME ANIMAL STUDIES. IN THE ZEBRA FISH. SHOW OF HANDS HERE, A LOT OF SUMMER STUDENTS DOES ANYONE KNOW WHAT A MORPHOLINO KNOCK DOWN IS? HOPEFULLY SOMEBODY DOESN'T KNOW. I WILL EXPLAIN IT BRIEFLY. THIS IS A MYO, INJECTION INTO A ONE CELL EMBRYO OF A ZEBRA FISH. WE HAVE A TALENTED SCIENTIST IN OUR LAB. SUN KUK KONG WHO DOES THESE EXPERIMENTS. A MORPHOLINO ABOUT A 25 BASE OLIGOMER THAT ATTACHES TO RNA IN BLOCKS. TRANSLATION OF THE RNA TO A PROTEIN, SO HERE IS THE MRNA AND THE MORPHOLINO. IT KNOCKS DOWN THE GENE EXPRESSION. THAT'S WHERE THIS TERM COMES FROM. WE INJECTED A MORPHOLINO IN IC QK. THEY ARE A GREAT MODEL BECAUSE THEY ARE TRANSPARENT. THIS IS THE CONTROL. WE ALSO DID A CONTROL MORPHOLINO. THIS IS WHERE THE HEART IS. NORMAL LOOKING 48 HOUR FISH. ALL THIS RIGHT HERE IS CARDIAC EDEMA, SO SOMETHING IS GOING ON WITH THE HEART. THE TAIL DOESN'T FORM. WE THINK THE GENE MIGHT BE IMPORTANT. THE NEXT THING WE DO, HOLD ON A SECOND. OK, I SKIPPED A SLIDE. WE TRIED TO RESCUE THE MORPHOLINO WITH HUMAN MRNA WITH THIS GENE. NOT ZEBRA FISH, BUT HUMAN MRNA. THAT'S AN INTERESTING CONCEPT PUTTING HUMAN GENES INTO THE TRANSLATED FISH. IF WE PUT THE MORPHOLINO IN AND KNOCK DOWN THE ZEBRA FISH MRNA AND PUT WILD TYPE HUMAN MRNA FOR THIS GENE IT RESCUES THE PHENOTYPE. ANYONE KNOW WHY THE MORPHOLINO DOESN'T KNOCK DOWN THE HUMAN MRNA. THE HUMAN RNA, WE REMOVE THE BINDING SITE AND FIVE PRIME UTR. THIS IS FREE TO TRANSLATE INTO THE PROTEIN AND RESCUE THIS. THIS IS JUST THE CONTROL. THEN TO TAKE THE EXPERIMENT ONE STEP FURTHER. THE HUMAN MORPHOLINO WE INJECTED THE ONE CELL PHASE. TO TAKE THE EXPERIMENT ONE STEP FURTHER WE INJECT THE MORPHOLINO TO KNOCK DOWN THE ZEBRA FISH MRNA AND THEN PUT IN THE MUTATION OR VARIANT THAT THE LITTLE BOY HAS. SO HERE IT IS. YOU CAN SEE THE ZEBRA FISH IS SICK. TAIL MALFORMATIONS AND CARDIAC EDEMA. WHAT'S INTERESTING ABOUT THIS, THAT'S WHY I THINK WE ARE UNLIKELY TO FIND A LOT OF OTHER CASES LIKE THIS, IS THAT IF YOU GO ONE AMINO ACID PROXIMAL OR FIVE PRIME TO POSITION 222 AND YOU SUBSTITUTE AN ISOLEUCIN WITH A SERENE IT RNA WILL RESCUE THE FISH. IT'S ONLY THIS ONE PARTICULAR SPOT THAT SEEMS TO BE IMPORTANT. THAT'S AN EXAMPLE OF ONE CASE. WE HAVE A LOT OF CASES THAT WE ARE DOING THIS WITH. AND RIGHT NOW MOST OF OUR SAMPLES ARE FROM NIGERIA AND THAILAND. AND THESE ARE THE CARDIAC PHENOTYPES OF ALL OF OUR PROBINS WE HAVE COLLECTED SAMPLES SO FAR. WE HAVE ABOUT 300 PROBANS PLUS THEIR PARENTS. WE HAVE A LOT MORE SAMPLES THAN THAT. WE DON'T ALWAYS GET A TRIO, FOR SOME REASON IT SEEMS A LOT OF FATHERS DON'T WANT TO DONATE BLOOD. I FIND THAT IN THE UNITED STATES AND ABROAD, SOMETHING ABOUT MEN DON'T LIKE GIVING BLOOD. SOMETIMES WE ONLY HAVE DUOS. INTERESTING IN BOTH NIGERIA AND THAILAND WE HAVE MORE TRITOLOGY OF FLOW THAN SEPTAL DETECT. I THINK THIS IS ASCERTAINMENT BIAS. ALSO WE HAVE A LOT OF TRUNCUS ARTERIOSUS. THIS IS WHERE THE PULMONARY ARTERY DOESN'T DIVIDE. WE HAVE DONE MOLECULAR TESTING ON 78 PROBANDS AND 204 FAMILY MEMBERS. AND WE HAVE SOME PRELIMINARY RESULTS. REALLY INTERESTING FINDINGS. AS EXPECTED WE WOULD FIND A LOT OF COPY VARIATIONS. ABOUT 23% OF OUR COHORT HAS A SIGNIFICANT COPY NUMBER VARIATION. THE MOST COMMON ONE WE FIND IS 21Q WHICH IS TRITOLOGY OF FLOW AND I WILL SHOW YOU A SLIDE OF 22 Q11. THIS 11% IS THE MOST INTERESTING PART. ABOUT 11% OF OUR COHORT HAS SINGLE NUCLEOTIDE MUTATION, IN GENES SHOWN TO CAUSE, THESE ARE NOVEL FINDINGS. I WILL TALK ABOUT THESE IN A SECOND. OVER HERE WE HAVE DENOVO VARIANTS OF UNKNOWN SIGNIFICANCE. THESE ARE INTERESTING FINDINGS IN THAT THEY ARE DE NOVO IN CONSERVED LOCATIONS BUT THERE'S REALLY NO ANIMAL MODEL OR HUMAN CASES TO BACK IT UP. WE DON'T KNOW WHAT TO DO WITH IT, WELL WE DO BUT IT WILL TAKE A LONG TIME TO TEASE ALL THIS OUT. WE ARE COLLABORATING WITH OTHER CONGENITAL HEART DISEASE GROUPS. OTHER GROUPS LIKE STANFORD AND NHLBI IN HOPES TO PUT OUR DATA TOGETHER TO FIND SECOND AND THIRD AND FOURTH HITS FOR PEOPLE WHO HAVE VARIANTS IN THESE. AND ABOUT 36% REALLY EVERYTHING AS FAR AS WE CAN SEE LOOKS NORMAL. THAT DOESN'T MEAN THERE ISN'T SOMETHING WRONG. EXOME CAPTURE KITS DON'T CAPTURE ALL EXOMES OR ALL PORTIONS OF THE GENE, WE KNOW THAT FOR A FACT. AS A MATTER OF FACT I WORK FOR MAX MUNCA, MUNCA SYNDROME, 23 54R. THEY DON'T CAPTURE THAT MUTATION. THIS IS THE MOST COMMON COPY NUMBER VARIATION WE FIND. THIS IS A YOUNG MAN FROM NIGERIA WITH 22Q11, BY THE WAY ALL PATIENTS I HAVE HAVE CONSENTED FOR ME TO PUT THEIR PICTURE HERE. THIS IS THE ESTIMATED DELETION FREQUENCY IN CONGENITAL HEART DISEASE, INTERRUPTED AORTIC, 50-89% OF INDIVIDUALS WITH THIS MALFORMATION HAVE 22Q11 DELETION SYNDROME. 8-35. THAT'S WHAT WE ARE SEEING MOST IN OUR PATIENTS. WE AREN'T NEW TO THIS TYPE OF RESEARCH. THIS IS PROBABLY ONE OF THE MOST COMPLETE EXOME SEQUENCING STUDIES THAT CONCENTRATE ON DE NOVO, ARTICLE ON NATURE BY ZIADIE ET. AL A FEW WEEKS AGO. THEY HAD ABOUT 365 TRIOS. IN SOME OF OUR NEW FINDINGS IN THEIR SUPPLEMENTARY TABLES WE FOUND SOME OF OUR GENES IN THERE SO IT WILL BE INTERESTING TO COMBINE FORCES. THIS GETS BACK TO THE BEGINNING OF OUR TALK WITH DECREASING COST OF EXOME SEQUENCING AND NEXT GENERATION SEQUENCING, IF THIS WAS CARRIED OUT TO 2016 IT WOULD KEEP GOING UP. DISEASE DISCOVERING GENES, USING WHOLE EXOME SEQUENCING. SO THIS IS A REALLY EXCITING TIME TO BE IN GENOMIC RESEARCH. MY LAST SLIDE A NICE SPIN OFF THIS WHOLE PROJECT, WE RECENTLY LAUNCHED A WEBSITE FORMAL FORMATION SYNDROMES IN DIVERSE POPULATIONS. AND THIS REALLY GREW OUT OF THIS CONGENITAL HEART DISEASE PROJECT. IT WAS KIND OF A NICE SIDE EFFECT. THIS IS, I WILL SAY, IT'S ON THE EMBRYONIC STAGE RIGHT NOW. WE HOPE TO GROW A LOT THIS SUMMER. FORTUNATELY WE HAVE FOUR MOTIVATED SUMMER INTERNS THIS SUMMER AND HOPEFULLY THAT WILL HELP OUR MANPOWER AND GET MORE OF OUR PHOTOS LOADED UP ONTO THIS WEBSITE. THAT'S ALL I HAVE FOR YOU. I STRETCHED IT OUT AN EXTRA 15 MINUTES. I HOPE THAT'S OK. A LOT OF PEOPLE TO THANK. FOLKS IN OUR LAB. CHILDREN'S NATIONAL MEDICAL CENTER, LAGOS UNIVERSITY, MULAGO HOSPITAL, CHIANG MAI. AND HOSPITAL WORKERS IN RWANDA. THAT'S ALL I HAVE, IF YOU WANT TO OPEN IT UP FOR QUESTIONS. [APPLAUSE] >> WELL, THANK YOU VERY MUCH. IF YOU HAVE QUESTIONS, PLEASE USE THE MICROPHONES. WE HAVE A QUESTION OVER HERE ON THE RIGHT. >> FIRST, A QUESTION. AND A COMMENT. FIRST I WILL DO THE COMMENT. THERE'S ANOTHER ATLAS WE USED. I WAS A FELLOW IN PEDIATRIC IN NEW YORK A LONG TIME AGO, EITHER SMITH OR JONES. I GET IT MIXED UP. >> IT'S SMITH. IT'S ACTUALLY ONE OF THE BEST-SELLING BOOKS, MEDICAL BOOKS THAT THE EDITOR IS KEN JONES. >> THAT'S RIGHT. >> HE TOLD ME HE PUT HIS KIDS THROUGH COLLEGE WITH THAT BOOK. IT'S A VERY WIDE-SELLING BOOK. BUT I INVITE YOU TO FLIP THROUGH IT AT THE LIBRARY, ALMOST ALL THE PATIENTS ARE CAUCASIAN. WHEN I WAS IN, SOME OF THESE COUNTRIES, NIGERIA, UGANDA, THERE WAS ALWAYS A LONG LINE AFTER OUR TALKS WITH PEOPLE WITH PICTURES OF CHILDREN WITH MALFORMATION SYNDROMES. AND THAT'S HOW THIS WHOLE IDEA CAME UP. MAYBE WE SHOULD START PUTTING THESE PICTURES ON THE WEB AND TRY TO IDENTIFY THEM FIRST MOW MOLECULARLY. YOU ARE RIGHT ABOUT SMITH. >> AND THE OTHER THING I REMEMBER DOING QUITE A NUMBER OF MISCARRIAGES AND ABORTIONS, ETC.. WE WERE NEVER ABLE TO COME TO ANY CONCLUSIONS BECAUSE THERE WERE NO FACILITY TO DO ANY TYPE OF GENETIC SCREENING ETC. WE WOULD FIND ALL KINDS OF BORDERLINE STRANGE THINGS BUT UNFORTUNATELY ALL WE DID WAS THE ANATOMIC PATHOLOGY. DISSECTING HEARTS WAS ALWAYS A PAIN AND LEARNING HOW TO PROBE THE TRUNCUS ARTERIOSUS IS AN ART ITSELF. YOU CAN'T TELL UNLESS YOU HAVE SOMETHING REALLY GROSS IN YOUR HAND. I THINK THAT WOULD BE SOMETHING TO LOOK FOR SCREENING A GIGANTIC POPULATION OF MISCARRIAGES AND ABORTIONS. THEY COME TO MOST HOSPITALS, I HAD TO DO AUTOPSIES ON THEM AND PEOPLE CAN'T REALLY COME TO CONCLUSIONS. THAT WOULD BE A BETTER SOURCE, BECAUSE YOU CAN SEE THE ONES THAT DIDN'T MAKE IT IN CONTRAST TO THE ONE'S THAT DID. >> THANK YOU. ABSOLUTELY. >> I WANT TO THANK YOU FOR THIS TALK. MY QUESTION IS THINKING ABOUT THE PATIENTS WHO ARE AFFLICTED WITH THESE PROBLEMS. PARTICULARLY THE ONE YOU SHOWED, DO YOU HAVE ANY FANTASIES FOR 50 YEARS FROM NOW, OR 20 YEARS FROM NOW FOR WHAT MIGHT BE DONE ABOUT CHILDREN BORN WITH THIS DISEASE? OR WOULD YOU SAY IT'S GOT TO START BEFORE THAT? >> YEAH. I THINK A LOT OF US HAVE FANTASIES ABOUT THAT, FOR 50 YEARS. THERE IS A LOT OF CONGENITAL HEART MALFORMATIONS, STRUCTURAL MALFORMATIONS AND THEN THERE'S ALSO A LOT OF ARRHYTHMIAS. RIGHT VENTRICULAR DYSPLASIA WHERE YOU DEVELOP HEART FAILURE AND THERE'S NOTHING YOU CAN REALLY FIX WITH IT. IN MY FANTASY AND I THINK A LOT OF PEOPLE, INCLUDING PATIENTS SOME DAY WITH THE IPS TECHNOLOGY, WE TAKE A PIECE OF SKIN OR WHATEVER AND START GROWING NEW HEARTS WITHOUT THE VARIANT. I THINK THAT'S, WE ARE NOWHERE NEAR THAT, BUT I THINK THAT'S A LOT OF OUR FANTASY. >> HI. YES, SORT OF A NITTY-GRITTY DETAIL KIND OF QUESTION, BUT I NOTICED IN THE CASE STUDY IN THE PEDIGREE THAT THE PROBAND HAD AN AFFECTED UNCLE. I WAS WONDERING IF YOU HAD GOTTEN BLOOD FROM THEM? >> NO, WE DID NOT. I DIDN'T TALK MUCH ABOUT THAT BECAUSE I DON'T KNOW MUCH ABOUT THAT UNCLE. BUT YOU ARE ABSOLUTELY RIGHT. DID PICK UP. IT WAS AN ANSIFALLOT CASE. >> THANK YOU FOR STEPPING IN TODAY, SOLO HOME RUN. >> THANK YOU. >> I WISH EVERYBODY A SAFE SUMMER. [APPLAUSE]