Novel genetic mechanisms of congenital Annual US cost is $158 - - PowerPoint PPT Presentation

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Novel genetic mechanisms of congenital diaphragmatic hernia

Wendy Chung, MD PhD Kennedy Family Professor of Pediatrics and Medicine Columbia University

Congenital diaphragmatic hernia

• 1 in 3000 births
• 8% of all birth defects
• Annual US cost is $158 million
• 20%-40% mortality
• 40% -50% Non-isolated
• Up to 25% with CHD
• Developmental delay/ID common

Chongqing Three Gorges Central Hospital

DHREAMS protocol

• Birth cohort
• Neonates affected with diaphragm defects
• Samples from affected case and both biological parents (Trio collection)
• Developmental assessments at 2 and 5 years
• Retrospective cohort
• Children and adults with a personal history of a diaphragm defect
• Samples from affected case and both biological parents (Trio collection)
• Genetic analysis
• Natural history studies

L CDH

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Study protocol

• Eligible subjects
• Children and fetuses
• Protocol
• Collection of blood from proband and biological parents
• Over 100 data points on prenatal history, NICU stay, surgical report, and family history
• Prospective cohort
• Collection of skin and diaphragm at time of surgery
• Pulmonary Hypertension assessment at 1 and 3 months
• 2 year developmental assessment
• Vineland Adaptive Behavior Scale II
• Bayley Scales of Infant Development III
• 5 year developmental assessment
• Vineland Adaptive Behavior Scale II
• Child Behavior Check List, Parent and Teacher
• Wechsler Preschool and Primary Scale of Intelligence IV

Genetic Evidence for CDH

• Familial aggregation
• Higher rate of concordance in monozygotic v.s. dizygotic twins
• Mouse studies elucidated the role of several genes in

diaphragm development

• Coup-TFII, Slit3, Gata4, Fog2, Wt1
• Chromosome anomalies (10-30%)
• T21, T18, T13, tetrasomy12p, 15q26, 8p23.1, 1q41-q42
• Single gene disorder (15-??%)
• Donnai-Barrow syndrome (LRP2 2q31), Mathew-Wood syndrome

(STRA6 15q24), Denys-Drash (WT1, 11q13)

• GATA6, GATA4, ZFPM2 and others

Published Current Study Duplication Deletion Translocation/ inversion

7 4 2 2 7 3 4 4 4 4 3 3 3 9 4 5 2 3

q25-q31.2 q41-q42 q22 q31 p15 pks q22-q23 p23.1 p21 pter-p22 p13 pter-q11 p12=-3.3 P22.3 p23.1 p13.11-p12.3 q12 p12.3 q11.1-11.21 Chr2 Chr1 q37 Chr3 Chr4 Chr5 Chr6 Chr7 Chr8 Chr9 Chr10 Chr11 q23.3-q25 q23.3-qter q35.2 trisomy q25.3-qter Chr12 Chr13 Chr14 Chr15 Chr16 Chr17 Chr18 trisomy Chr19 Chr20 Chr21 Chr22 q33.3-q34 q32-qter

26

q26 p11-13 trisomy

8p23.1 8p21.2

6M 12M 18M 3M 9M 15M 21M

07-0010 01-0162

Wat et al., 2009 [51] Slavotinek et al., 2005 [53] Shimokawa et al., 2005 [16] Faivre et al., 1998 [54]

192,262 15,227,167 8,043,620 11,883,409 7,256,229 12,077,383 6,504,084 12,752,448 6,365,021 12,611,673 17,870,612

SGK223 CLDN23 MFHAS1 ERI1 PPP1R3B TNKS MSRA PRSS55 RP1L1 C8orf74

SOX7

PINX1 XKR6 MTMR9 SLC35G5 FAM167A BLK

GATA4

NEIL2 FDFT1 CTSB DEFB136 DEFB135

Deletions of 8p23.1 associated with CDH

a

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Whole exome sequencing in familial CDH

Exon 1 Exon2 Exon3 Exon4 Exon5 Exon6 Exon7 Exon1

1 615 616 783 784 909 910 997 998 1146 1147 1329 1 442 206 261

NZnF GATA CZnF GATA

211 265 315

p.R252W c.754C>T

p.R252P c.755G>C

p.R252W

p.F208L p.F211L p.F214S p.E216D p.G221R p.M223T p.R229S p.G234S p.N239D p.N239S p.Y244S p.M247T p.I255T p.R260Q p.L261P p.N248S

p.R283H c.848G>A

p.A6V p.G16C p.G21V p.H28D p.H28Y p.S52F p.G64E p.G69D p.S70T p.P87S p.S90R p.G93A p.D95A p.S160T p.P163R p.P163S p.R266X p.V267M p.C271R p.N273S p.T277I p.T280M p.N285K p.C292R p.A294V p.G296R p.G296S p.G296C p.H302R p.M310V p.Q316E p.R320W p.K329N p.A346V p.T354A p.E359K p.V380M p.L403M p.P407Q p.A411V p.D425N p.S429T p.H436Y p.A442V c.139_141delTCC c.341_342insA c.366_368dupCGC c.69_374dupTGCCGC c.677delC c.1074delC c.1075delG

Human A C G L Y H K MN G I N R P L I K P Q R R L S A S R R V G L S C A N C Q T T T T T L WR R N A E G E P V C N A C Chimpanzee A C G L Y H K MN G I N R P L I K P Q R R L S A S R R V G L S C A N C Q T T T T T L WR R N A E G E P V C N A C Rhesus A C G L Y H K MN G I N R P L I K P Q R R L S A S R R V G L S C A N C Q T T T T T L WR R N A E G E P V C N A C Mouse A C G L Y H K MN G I N R P L I K P Q R R L S A S R R V G L S C A N C Q T T T T T L WR R N A E G E P V C N A C Rat A C G L Y H K MN G I N R P L I K P Q R R L S A S R R V G L S C A N C Q T T T T T L WR R N A E G E P V C N A C Rabbit A C G L Y H K MN G I N R P L I K P Q R R L S A S R R V G L S C A N C Q T T T T T L WR R N A E G E P V C N A C Dolphin A C G L Y H K MN G I N R P L I K P Q R R L S A S R R V G L S C A N C Q T T T T T L WR R N A E G E P V C N A C Elephant A C G L Y H K MN G I N R P L I K P Q R R L S A S R R V G L S C A N C Q T T T T T L WR R N A E G E P V C N A C Opossum A C G L Y H K MN G I N R P L I K P Q R R L S A S R R V G L S C A N C Q T T T T T L WR R N A E G E P V C N A C Chicken A C G L Y H K MN G I N R P L F K P Q R R L S A S R R V G L S C A N C H T T T T T L WR R N A E G E P V C N A C X.tropicalis A C G L Y H K MN G I N R P L I K P Q R R L S A S R R V G L S C A N C H T T T T T L WR R N A E G E P V C N A C Zebrafish A C G L Y H K MN G I N R P L V K P Q R R L S A S R R V G L S C T N C Q T T T T T L WR R N A E G E P V C N A C

p.R283H

240 295

GATA4 information

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• A zinc finger transcription factor that controls gene

expression and differentiation in a variety of cell types.

• Located at 8p23.1-p22 where there is a recurrent

microdeletion associated with both congenital heart disease and CDH (Wat et al. 2009).

• GATA4 is an important component of the retinoic signaling

pathway.

• ~14% of mice with heterozygous Gata4+/Δex2 had diaphragm

defects and ~36% had cardiac defect. (Jay et al. 2007).

• The N-terminal zinc finger of GATA4 interacts with FOG2

during cardiac morphogenesis (Crispino et al. 2001). FOG2 is an important gene in diaphragm development (Ackerman et al. 2005).

GATA4

I II III IV 1 2 +/+ 1 +/+ 2 +/+ 3 +/- 4 +/+ 1 2 +/+ 3 4 +/- 5 +/+ 1 +/- 2 +/+

GATA4 c.754 C>T p.R252W genotype

A

A B C D

III.4 Father III.4 Father II.3 Grandfather II.3 Grandfather Not all Genetic Conditions Run in Families De novo mutations are common in autism, schizophrenia, intellectual disabilities, seizures, birth defects, syndromes

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Number Percent

Gender Male 212 58.6% Female 150 41.4% CDH classification Isolated 208 57.5% Complex 149 41.2% Unknown 5 1.4% DHREAMS cohort (n=283): Time of recruitment Neonatal 229 80.9% Fetal 9 3.2% Child 45 15.9% Discharge vital status (n=283) Survived 241 85.2% Deceased 42 14.8% Development assessment¶ (n=283) At 2 years follow-up 152 53.7% At 5 years follow-up 70 24.7% No assessment at either 2 or 5 years 128 45.2% Additional anomalies in complex cases (n=149) Cardiovascular 66 44.3% Neurodevelopmental§ 37 24.8% Skeletal 26 17.4% Genitourinary 14 9.4% Gastrointestinal 13 8.7%

Characteristics

• f CDH

patients (n=362)

Types of Genetic Variants

C A G C A G C A G C A G C A G C A G C A G

Gln Gln Gln Gln DNA Bases ->

Original DNA code

Amino acids -> Gln Gln Gln

C A G C A G C G G C A G C A G C A G C A G

Gln Gln Arg Gln Gln Gln Gln

Deleterious missense (D-mis) C A G C A G U A G

Gln Gln STOP

Likely Gene Disrupting (LGD)

Burden of coding LGD and damaging de novo variants in CDH patients

Gene Sets Variant class Number of variants Baseline expectation Fold enrichment P-value All Genes Synonymous 110 109.1 1.01 0.48 Missense 295 250.6 1.18 3.42E-03 D-mis 138 93.7 1.47 1.08E-05 LGD 57 32.9 1.73 8.60E-05 Constrained Genes Synonymous 34 38.8 0.88 0.80 Missense 112 88.1 1.27 7.91E-03 D-mis 59 38.0 1.55 9.39E-04 LGD 30 12.0 2.50 9.05E-06 Other Genes Synonymous 76 70.3 1.08 0.26 Missense 184 162.6 1.13 0.053 D-mis 80 55.7 1.44 1.28E-03 LGD 27 20.9 1.29 0.11

Higher enrichment of damaging variants in complex cases and female cases

Case group Variant class Number of variants Baseline expectation Fold enrichment P-value Complex Silent 44 44.9 0.98 0.57 (n=149) Missense 124 103.1 1.2 0.025 D-mis 62 38.5 1.61 3.08E-04 LGD 23 13.5 1.7 0.012 Isolated Silent 63 62.7 1.01 0.5 (n=208) Missense 165 144 1.15 0.046 D-mis 74 53.8 1.38 5.22E-03 LGD 31 18.9 1.64 6.52E-03 Female Silent 44 45.9 0.96 0.63 (n=150) Missense 118 105.6 1.12 0.12 D-mis 64 39.3 1.63 1.85E-04 LGD 29 13.9 2.09 2.51E-04 Male Silent 66 63.2 1.04 0.38 (n=212) Missense 177 145.1 1.22 5.63E-03 D-mis 74 54.3 1.36 6.45E-03 LGD 28 19 1.47 0.032

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Genes with recurrent de novo LGD or missense variants

MYRF is a new syndromic CDH gene associated with pulmonary hypertension and pulmonary hypoplasia

Study Sample ID Genetic Sex# De novo variant (NM_001127392.2) Diaphragm defect Cardiovascular defect Urogenital defect Other malformations Current study 01-1008 XY c.235dupG: p.G81Wfs*45 L-CDH ASD,VSD,ToF Bilateral undescended testes No 01-0429 XX c.1303G>A:p.G435 R L-CDH VSD No internal genital organs, blind- ending vagina Accessory spleen 04-0042 XY c.2036T>C:p.V679A L-CDH ASD,VSD Unknown Unknown (Deceased) 05-0050 XY c.2084G>A:p.R695 H CDH HLHS Ambiguous genitalia, undescended testes Intellectual disability and motor delay at 2 years old 01-0033 XX c.1904-1G>A R-CDH Scimitar syndrome Unknown Unknown (Deceased) 01-0591* XX Unknown HLHS Unknown Unknown (Deceased) CHU-11 XY c.1786C>T:p.Q596* Pulmonary hypoplasia Dextrocardia Swyer syndrome with female genitalia Right pulmonary hypoplasia PCGC[29] 1-02264 XY c.1160T>C:p.F387S Pulmonary hypoplasia AAH, CoA, HLHS Ambiguous genitalia, hypospadias, undescended testis No 1-03160 XY c.1209G>C:p.Q403 H Right hemi- diaphragm eventration Scimitar syndrome, AAH, ASD, BAV, HLHS, MS, VSD Undescended testis Lung hypoplasia 1-07403 XY c.1435C>G:p.L479V Pulmonary hypoplasia BAV, CoA Swyer syndrome with female genitalia Short stature Pinz et al.[30] Case 1 XY c.2336+1G>A Pulmonary hypoplasia Scimitar syndrome, cor triatriatum Penoscrotal hypospadias, micropenis, unilateral cryptorchidism Mild speech delay, pulmonary hypoplasia, tracheal anomalies Case 2 XY c.2518C>T:p.R840* R-CDH Scimitar syndrome Persistent urachus, Undescended testis Cleft spleen, thymic involution, thyroid fibrosis Chitayat et

• al. [31]

Fetus case XY c.1254_1255dupGA: p.T419RfsX14 Pulmonary hypoplasia HLHS Ambiguous external genitalia, right hepato-testicular fusion and left spleno-testicular fusion Mild pulmonary hypoplasia, intestinal malrotation

MYRF is a membrane-associated transcription factor that plays a role in

• ligodendrocyte differentiation and myelination

Genetic Overlap with Other Disorders

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Biological processes involved in CDH

Functional groups of genes associated with CDH

clinical diagnosis (N) de novo SNV (N) de novo CNV (N) rare inherited CNV (N) Group1 (N=93): damaging de novo variants Genetic diagnosis (30) LGD in known or (constrained and HDE) genes (25) pLI>0.5 (5) hot spot regions (4) D-mis in known or (constrained and HDE) genes (13) PD-mis in known genes (16) Group2 (N=181): likely damaging de novo variants LGD in any other genes (32) pLI<0.5 (12) pLI>0.5 (29) D-mis in other genes (5) PD-mis in any other genes (125) non-frameshift deletion/insertion (13) Group3 (n=181): without damaging de novo variants B-mis/sys (73) no de novo SNV (108)

Genetic groups based on the type of de novo/rare inherited variants

Damaging de novo variants are associated with higher mortality and severe pulmonary hypertension in 647 CDH patients

All CDH Isolated Complex Dead (%) Alive p-value Dead (%) Alive p-value Dead (%) Alive p-value Mortality prior to initial discharge Group1 27 (29.7%) 64 0.015 10 (23.3%) 33 0.023 17 (35.4%) 31 0.51 Group2 27 (15.2%) 151 9 (7.5%) 111 18 (31.0%) 40 Group3 32 (18.1%) 145 18 (14.9%) 103 14 (25%) 42 Severe (%) Mild p-value Severe (%) Mild p-value Severe (%) Mild p-value Pulmonary hypertension at 1 month Group1 44 (71.0%) 18 0.0033 21 (77.8%) 6 0.0014 23 (65.7%) 12 0.83 Group2 72 (51.8%) 67 46 (47.4%) 51 26 (61.9%) 16 Group3 59 (45.0%) 72 33 (37.9%) 54 26 (59.1%) 18 Severe (%) Mild p-value Severe (%) Mild p-value Severe (%) Mild p-value Pulmonary hypertension at 3 months Group1 13 (28.2%) 33 0.16 5 (23.8%) 16 0.57 8 (32%) 17 0.37 Group2 19 (17.0%) 93 11 (14.5%) 65 8 (22.2%) 28 Group3 17 (15.6%) 92 11 (15.1%) 62 6 (16.7%) 30

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Damaging de novo variants are associated with neurodevelopmental delay at 2 and 5 yo in CDH patients

A B

All CDH Isolated CDH Complex CDH N Mean (S.D.) p-value N Mean (S.D.) p-value N Mean (S.D.) p-value Weight at 2yr Group1 38

• 1.06 (1.4)

0.1 18

• 0.82 (1.6)

0.1 20

• 1.28 (1.2)

0.1 Group2 97

• 0.75 (1.3)

68

• 0.85 (1.2)

29

• 0.51 (1.6)

Group3 78

• 0.61 (1.1)

53

• 0.54 (1.2)

25

• 0.78 (1.0)

Height at 2yr Group1 37

• 0.56 (1.6)

0.2 17

• 0.47 (1.9)

0.4 20

• 0.64 (1.5)

0.3 Group2 94

• 0.15 (1.2)

66

• 0.14 (1.2)

28

• 0.19 (1.2)

Group3 76

• 0.12 (1.7)

51

• 0.14 (2.0)

25

• 0.06 (1.0)

Head size at 2yr Group1 31

• 0.35 (1.5)

0.3 14

• 0.04 (1.4)

0.5 17

• 0.60 (1.6)

0.02 Group2 82 0.26 (1.3) 55 0.06 (1.2) 27 0.69 (1.5) Group3 61 0.40 (4.3) 38 0.65 (5.4) 23

• 0.01 (1.3)

Weight/height at 2yr Group1 34

• 0.64 (0.9)

0.7 16

• 0.37 (1.0)

0.3 18

• 0.88 (0.9)

0.2 Group2 92

• 0.67 (1.4)

65

• 0.88 (1.2)

27

• 0.19 (1.7)

Group3 73

• 0.73 (1.4)

48

• 0.71 (1.4)

25

• 0.78 (1.3)

Weight at 5yr Group1 17

• 0.78 (1.7)

0.05 6

• 1.04 (1.2)

0.03 11

• 0.63 (2.0)

0.5 Group2 41

• 0.74 (1.5)

25

• 0.75 (1.1)

16

• 0.72 (2.0)

Group3 31 0.06 (1.4) 22 0.01 (1.1) 9 0.19 (1.9) Height at 5yr Group1 18

• 1.02 (1.2)

0.003 6

• 0.93 (1.0)

0.005 12

• 1.06 (1.3)

0.4 Group2 41

• 0.33 (1.2)

24

• 0.29 (0.9)

17

• 0.39 (1.4)

Group3 28 0.24 (1.2) 20 0.48 (1.1) 8

• 0.38 (1.4)

Weight/height at 5yr Group1 14

• 0.13 (1.6)

0.03 4

• 0.18 (1.2)

0.3 10

• 0.11 (1.8)

0.07 Group2 33

• 0.83 (1.3)

20

• 0.67 (1.3)

13

• 1.07 (1.4)

Group3 24 0.15 (1.3) 17

• 0.08 (1.2)

7 0.70 (1.6)

Damaging de novo variants are associated with short stature and lower weight at 5 yo in CDH patients Damaging de novo variants are associated with neurodevelopmental delay at 2 yo in CDH patients

All CDH Isolated CDH Complex CDH Assessment Domains N Mean (S.D.) p-value N Mean (S.D.) p-value N Mean (S.D.) p-value Bayley Scales of Infant Development III at 2 years of age Language Group1 32 84.6 (20) 0.0006 14 85.1 (22) 0.003 18 84.1 (19) 0.2 Group2 91 96.5 (15) 63 98.4 (13) 28 92.4 (20) Group3 68 97.4 (15) 45 99.4 (14) 23 93.6 (16) Cognitive Group1 32 84.8 (17) 0.0003 14 90.4 (19) 0.05 18 80.6 (15) 0.01 Group2 89 95.2 (13) 63 97.4 (10) 26 89.8 (18) Group3 68 96.7 (14) 45 97.3 (14) 23 95.4 (13) Motor Group1 32 83.5 (19) 0.00002 14 86.4 (20) 0.003 18 81.2 (18) 0.02 Group2 91 94.4 (14) 63 97.0 (11) 28 88.4 (17) Group3 68 98.7 (15) 45 100.1 (15) 23 96.1 (14) Vineland Adaptive Behavior Scale II at 2 years of age Communication Group1 40 90.4 (17) 0.0009 18 92.3 (18) 0.004 22 88.8 (16) 0.2 Group2 111 98.4 (12) 79 100.8 (9) 32 92.4 (17) Group3 88 99.2 (11) 60 100.2 (11) 28 97.0 (12) Daily living skill Group1 40 89.0 (17) 0.007 18 93.4 (19) 0.3 22 85.3 (16) 0.09 Group2 111 97.3 (14) 79 99.2 (10) 32 92.7 (19) Group3 88 98.1 (14) 60 99.1 (13) 28 96.0 (15) Social Group1 40 87.9 (13) 0.01 18 91.8 (14) 0.5 22 84.6 (12) 0.06 Group2 111 94.5 (11) 79 95.8 (9) 32 91.4 (16) Group3 88 94.6 (10) 60 95.5 (11) 28 92.8 (8) Motor Group1 40 90.0 (14) 0.006 18 93.9 (15) 0.1 22 86.7 (13) 0.08 Group2 110 96.9 (11) 79 98.5 (10) 31 92.8 (13) Group3 88 95.9 (12) 60 96.7 (12) 28 94.0 (10) Adaptive behavior Group1 40 87.7 (16) 0.002 18 91.8 (17) 0.08 22 84.3 (14) 0.07 Group2 111 95.9 (12) 79 98.0 (9) 32 90.6 (17) Group3 88 96.2 (11) 60 97.2 (12) 28 93.9 (11)

Damaging de novo variants are associated with neurodevelopmental delay 5 yo in CDH patients

All CDH Isolated CDH Complex CDH Assessment Domains N Mean(S.D.) p-value N Mean (S.D.) p-value N Mean (S.D.) p-value Wechsler Preschool and Primary Scale of Intelligence IV at 5 years of age IQ Group1 12 90.6(15) 0.08 5 89.2(17) 0.5 7 91.6(16) 0.1 Group2 33 99.3(15) 21 97.4(15) 12 102.6(15) Group3 25 91.6(14) 17 93.0(15) 8 88.5(13) Vineland Adaptive Behavior Scale II at 5 years of age Communication Group1 15 92.5(16) 0.02 6 82.7(20) 0.005 9 99.1(7) 0.4 Group2 39 102.6(12) 24 100.7(10) 15 105.8(14) Group3 35 102.5(12) 22 102.3(13) 13 102.8(12) Daily living skill Group1 15 91.9(17) 0.05 6 85.3(21) 0.01 9 96.3(14) 0.7 Group2 39 100.8(10) 24 100.7(9) 15 100.9(11) Group3 35 99.3(12) 22 98.9(9) 13 99.8(15) Social Group1 15 91.5(14) 0.04 6 81.7(18) 0.006 9 98.0(7) 0.2 Group2 39 98.1(8) 24 96.0(7) 15 101.5(8) Group3 35 93.9(8) 22 92.7(8) 13 95.88(9) Motor Group1 15 87.3(17) 0.05 6 79.3(18) 0.003 9 92.6(16) 0.8 Group2 39 94.2(11) 24 94.3(10) 15 94.0(13) Group3 34 96.4(10) 22 96.1(8) 12 96.8(13) Adaptive behavior Group1 15 89.3(16) 0.02 6 80.2(20) 0.002 9 95.4(10) 0.6 Group2 39 98.5(10) 24 97.3(9) 15 100.4(12) Group3 34 97.2(9) 22 96.7(8) 12 98.1(11)

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Acknowledgments

Surgeons Vincent Duron Gudrun Aspelund Mark Arkovitz (p) Ken Azarow Brian Bucher Dai Chung (p) Michael Cotton Tim Crombleholme Robert Cusick Melissa Denko Mahmoud ElFiky Kimberly Fischer Mamatha Gowda Anthony Hesketh (p) David Kays Przemyslaw Kosinski Foong Yen Lim David McCulley Caroline Maloney George Mychaliska Xavier Pompar Doug Potoka (p) John Pietsch (p) David Schindel Samuel Soffer Charles Stolar (p) Amy Wagner Brad Warner Chen Qiang Xie Yi-Min Developmental Specialists Christiana Farkouh Annette Zygmunt Anketil Abreu Jennifer Butcher Kate Brennan (p) Kerry Miller Mary Michaeleen Cradock Bob Drongowski Teresa Gratton Barbra Jackson Jolene Johnson Arielle Wilson (p) Leah Miller (p) Howard Needleman Tasnim Najaf Molecular and Statistical Lab Patricia Lanzano Jiancheng Guo Lan Yu Liyong Deng Charles LeDuc Jimmy Duoung Yuan Zhang Yufeng Shen Hongjian Qi Linshan Shang (p) MGH Team Patricia Donahoe Francis High Caroline Coletti Mauro Longoni Research Coordinators Becca Hernan Julia Wynn Jennifer Kraszewski Lorrie S Burkhalter Trish Burns Mary Dabrowiak (p) Brandy Gonzalez Sheila Horak Jeannie Kreutzman Michelle Knezevich Cheryl Kornberg Karen Lukas Julia McKee Joy Perkins Tracy Perry Min Shi (p) Jayne Sicard –Su (p) Gentry Wools Jeannie Zuk Connie Keung (p) Julie Moteagudo (p) Christine Schad (p) Jessica Schultz (p) Ruth Swedler (p) Okochi Shunpel Aqsa Schakoor Cardiologists/Pulmonologists Usha Krishnan Eric Austin (p) Jeff Delaney Scott Fletcher Rob Gajarski Mark Grady Eunice Hahn (p) Shelby Kutty Eric Michelfelder Donald Moore (p) Erika Rosenzweig Shannon Nees MGH Patricia Donohoe Mauro Longoni Frances High Maria Loscertales Joy Maliackal Poulo Jessica Kim Caroline Collette Betty Gilman Functional Studies Gabrielle Kardon Kate Ackerman Xin Sun Funding (>$500) 1X01 HL132366-01 1P01HD068250-01 1P01HD068250-06A1 R01 HD057036-01A1 CHERUBS ACDHO Global CDH Breath of Hope Help4CD National Greek Orthodox Ladies Philoptochos Society, Inc. Fore Hadley Foundation The Wheeler Foundation The Vanech Foundation Larsen Family Brountzas/Kostaridis Family Wilke Family Henley Family Guzman and Padolina Family Orowitz Family Schwartz Family >100 donations from families of <$500

PI: Wendy Chung

Thank You to the 1200 + DHREAMS Families

Questions?

PI: Wendy Chung, wkc15@columbia.edu