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Loss of function in ROBO1 is associated with tetralogy of Fallot and septal defects
  1. Paul Kruszka1,
  2. Pranoot Tanpaiboon2,
  3. Katherine Neas3,
  4. Kathleen Crosby2,
  5. Seth I Berger1,
  6. Ariel F Martinez1,
  7. Yonit A Addissie1,
  8. Yupada Pongprot4,
  9. Rekwan Sittiwangkul4,
  10. Suchaya Silvilairat4,
  11. Krit Makonkawkeyoon4,
  12. Lan Yu5,
  13. Julia Wynn5,
  14. James T Bennett6,7,8,
  15. Heather C Mefford7,
  16. William T Reynolds9,
  17. Xiaoqin Liu9,
  18. Mathilda T M Mommersteeg10,
  19. Wendy K Chung5,11,
  20. Cecilia W Lo9,
  21. Maximilian Muenke1
  1. 1 Medical Genetics Branch, National Human Genome Research Institute, The National Institutes of Health, Bethesda, Maryland, USA
  2. 2 Division of Genetics and Metabolism, Children’s National Health System, Washington, DC, USA
  3. 3 Genetic Health Service New Zealand (Central Hub), Wellington, New Zealand
  4. 4 Division of Pediatric Cardiology, Department of Pediatrics, Chiangmai University, Chiang Mai, Thailand
  5. 5 Department of Pediatrics, Columbia University Medical Center, New York, New York, USA
  6. 6 Center for Integrative Brain Research, Seattle Children’s Research Institute, Seattle, Washington, USA
  7. 7 Division of Genetic Medicine, Department of Pediatrics, University of Washington, Seattle, Washington, USA
  8. 8 Division of Genetic Medicine, Seattle Children’s Hospital, Seattle, Washington, USA
  9. 9 Department of Developmental Biology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
  10. 10 Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK
  11. 11 Department of Medicine, Columbia University Medical Center, New York, New York, USA
  1. Correspondence to Dr Paul Kruszka, Medical Genetics Branch, National Human Genome Research Institute, The National Institutes of Health, 35 Convent Drive, MSC 3717, Building 35, Room 1B-203, Bethesda, MD 20892, USA; paul.kruszka{at}


Background Congenital heart disease (CHD) is a common birth defect affecting approximately 1% of newborns. Great progress has been made in elucidating the genetic aetiology of CHD with advances in genomic technology, which we leveraged in recovering a new pathway affecting heart development in humans previously known to affect heart development in an animal model.

Methods Four hundred and sixteen individuals from Thailand and the USA diagnosed with CHD and/or congenital diaphragmatic hernia were evaluated with chromosomal microarray and whole exome sequencing. The DECIPHER Consortium and medical literature were searched for additional patients. Murine hearts from ENU-induced mouse mutants and transgenic mice were evaluated using both episcopic confocal histopathology and troponin I stained sections.

Results Loss of function ROBO1 variants were identified in three families; each proband had a ventricular septal defect, and one proband had tetralogy of Fallot. Additionally, a microdeletion in an individual with CHD was found in the medical literature. Mouse models showed perturbation of the Slit-Robo signalling pathway, causing septation and outflow tract defects and craniofacial anomalies. Two probands had variable facial features consistent with the mouse model.

Conclusion Our findings identify Slit-Robo as a significant pathway in human heart development and CHD.

  • Congenital Heart Disease
  • ROBO1
  • tetralogy of Fallot

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  • Acknowledgements We are grateful to the families for consenting to participate in this publication.

  • Contributors PK, PT and WKC designed the study. PT, KN, KC, YP, RW, SS, KM and JW collected data. SIB, YAA, LY, HCM, JTB, PK and WKC performed next-generation sequencing. AFM and LY performed Sanger sequencing. MTMM, WTR and CWL conducted animal studies. PK, PT, WKC and MM drafted the manuscript. All authors revised the manuscript.

  • Funding This work was supported by the intramural programme of the National Human Genome Research Institute, National Institutes of Health, the Wellcome Trust and the British Heart Foundation (PG/15/50/31594), the Burroughs Wellcome Fund Career Award for Medical Scientists (JTB), the National Institute of Health grant (HD057036) and by Columbia University’s Clinical and Translational Science Award (CTSA), grant (UL1 RR024156) from National Center for Advancing Translational Sciences/National Institutes of Health (NCATS-NCRR/NIH), a grant from CHERUBS, a grant from the National Greek Orthodox Ladies Philoptochos Society, Inc. and generous donations from The Wheeler Foundation, Vanech Family Foundation, Larsen family, Wilke family and many other families. Funding was also provided to CWL by the National Institutes of Health (HL098180 and HL132024). This study makes use of data generated by the DECIPHER community. A full list of centres who contributed to the generation of the data is available from and via email from

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval National Human Genome Research Institute IRB.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement We deposit phenotypic and genomic data including medically significant findings in public databases, ClinVar or dbGAP, consistent with NHGRI datasharing policy. Consent forms for this protocol inform participants of the data sharing plan.