Genetics of Patent Ductus

Arteriosus Susceptibility and Treatment

Hanine Hajj, MD, and John M. Dagle, MD, PhD
The ductus arteriosus is a vital fetal structure designed to close shortly after birth. Although
many physiologic and pharmacologic investigations have characterized the closure of this
structure, genetic studies of persistent patency of the ductus arteriosus (patent ductus
arteriosus, PDA) are relatively recent. Progress in the identication of specic genes
associated with PDA is well behind that of many adult-onset diseases because of several
reasons ranging from the lack of large biorepositories for this unique population to the
belief that any genetic contribution to PDA is minimal. Viewing the PDA as a complex,
developmentally inuenced disease with both genetic and environmental risk factors has
resulted in initial successes in some genetic studies. We will introduce several genetic
approaches, which have been or are currently being applied to the study of PDA, that have
been successful in identifying polymorphisms associated with adult diseases. Genetic
investigations of PDA will be discussed with respect to heritability, in general, and to
specic risk genes. Several animal models that have been used to study PDA-related genes
will also be presented. Further advances in discovering genetic variation causing PDA will
drive the more rational use of current therapies, and may help identify currently unknown
targets for future therapeutic manipulation.
Semin Perinatol 36:98-104 2012 Elsevier Inc. All rights reserved.
KEYWORDS genetics, neonate, patent ductus arteriosus, PDA
T
he ductus arteriosus (DA) is a vital in utero vascular
connection between the aorta and pulmonary artery that
allows right ventricular output to bypass the nonventilated
fetal lungs. This structure is absolutely necessary for normal
cardiovascular and pulmonary vascular development of the
fetus. Patency of the DA (patent ductus arteriosus, PDA),
both in utero and after birth, is regulated by a ne balance of
constricting and dilating forces.
1
Postnatal closure of the DA
is an important step in normal cardiopulmonary transition
and occurs in 2 phases. Initially, increasing partial pressure of
O
2
(arterial) and decreasing amount of circulating prosta-
glandins allow the smooth muscles of the DA to contract,
functionally limiting luminal blood ow. After this physio-
logic occlusion has occurred, hypoxia and nutrition depriva-
tion of the medial layer of the DA results in the elaboration of
inammatory mediators and growth factors.
2
These com-
pounds subsequently induce brosis, resulting in permanent
anatomic closure of the DA, which is responsible for creating
the ligamentum arteriosum. This complex, developmentally
regulated process is dependent on both environmental and
genetic factors.
Overview of
Genetic Approaches
to PDA Gene Discovery
Identication of specic disease-associated genes can be car-
ried out by (1) linkage methods using large extended fami-
lies, smaller inbred families, or affected relative pairs; (2)
association studies using case/parent trios or casecontrol
samples; or (3) direct sequencing of either exons or entire
genes. All 3 approaches can be performed at either a candi-
date gene or a genomewide level, and each of these strategies
have advantages and disadvantages that are dependent on the
mode of disease inheritance as well as on economic and tech-
nologic factors.
3
Gene discovery is often most successful us-
ing complementary approaches, each designed to be infor-
mative under different circumstances. PDA and its response
to attempted pharmacologic closure are likely complex traits
Department of Pediatrics, Carver College of Medicine, University of Iowa,
Iowa City, IA.
Address reprint requests to John M. Dagle, MD, PhD, Department of Pedi-
atrics, Carver College of Medicine, University of Iowa, Iowa City, IA
52242. E-mail: john-dagle@uiowa.edu
98 0146-0005/12/$-see front matter 2012 Elsevier Inc. All rights reserved.
doi:10.1053/j.semperi.2011.09.019
inuenced by several genes (and alleles in each gene) work-
ing via both known and as yet undetermined genetic mech-
anisms in the context of many specic environmental factors.
Candidate gene association studies are hypothesis-based
investigations into genes thought to be important in biologic
pathways responsible for the condition of interest. The selec-
tion of candidate genes can be based on several factors, in-
cluding clinical information, results of animal or cell culture
studies, or even best guesses. Studies of PDA, for example,
would likely include candidate genes in prostaglandin path-
ways, given the well-documented importance of these com-
pounds in maintaining ductal patency. Advantages of this
approach over a genomewide strategy include lower cost,
more thorough coverage of any individual gene under inves-
tigation, and use of a lower threshold for statistical signi-
cance, as fewer polymorphisms (observations) are tested. Al-
though model-free hypotheses (discussed later in the text)
are needed to nd genes in new and unexpected pathways,
conrming likely candidates allows a direct focus on func-
tional and therapeutic targets.
In contrast to candidate gene studies, genomewide associ-
ation (GWA) studies are evaluations of most (if not all)
known genes. These studies are quite thorough from a ge-
nome standpoint, but may not completely cover specic in-
dividual candidate genes of high interest. Because of the com-
prehensive nature of these studies, however, previously
unknown pathways may be discovered that are very impor-
tant in the etiology of the disease of interest. In the past
several years, GWA studies have led to gene identications
for a wide range of complex human traits, including type 2
diabetes,
4
multiple sclerosis,
5
asthma,
6
colorectal cancer,
7
breast cancer,
8
Kawasaki syndrome,
9
and glaucoma.
10
The
utility of GWA studies was highlighted in a review by Mano-
lio et al
11
in 2008 reporting the identication of nearly 100
loci for 40 common diseases and traits. GWA studies have
taken advantage of recent developments in both genotyping
technology and statistical analysis. Increasingly larger biore-
positories and extensive scientic collaborations have pro-
vided sample sizes with enough power to not only detect
signicant signals but also to perform independent replica-
tion studies. A haplotype map of the human genome is now
available for identication of an appropriate number of tag-
ging single nucleotide polymorphisms (SNPs) to capture
most of the known variation present.
12,13
Although the cost of
this technology has dropped signicantly over the past sev-
eral years, GWA studies remain expensive compared with
approaches focusing on individual candidate genes.
For a GWA approach to succeed, the disorder of interest
must have one (or a few) relatively common polymor-
phism(s) that contributes (or contribute) to a substantial por-
tion of the disease burden.
14
In other words, GWA studies do
not identify rare or family-specic polymorphisms contrib-
uting to disease, even if the contributions are substantial. The
actual effects identied by most GWA studies have had mod-
est odds ratios (ORs of 1.2-1.5 in many cases). However, the
cumulative effect of combinations of variants may be more
predictive of a disease than any one isolated polymorphism.
Two studies have reported the combined effects of multiple
SNPs.
15,16
In studies of prostate cancer and cardiovascular
risk, individual SNPs had modest ORs, but when specic risk
SNPs were combined into a panel, a subset of individuals
with high risks (OR: 10) was disclosed. Incorporation of
the effects of multiple gene/SNP combinations should allow
for the practical application of genetic risks at the individual
level. Genetic and pharmacogenomic studies have already led
to modications in drug choice and/or dosages for medica-
tions such as coumadin,
17
abacavir,
18
and statins.
19
Thus, in
addition to uncovering new biological pathways of disease,
the discovery of a new disease locus for PDA may lead to
immediate improvements in patient care.
PDA Overview
Persistent PDA may best be thought of as at least 2 distinct
diseases. PDA can be rst divided into a relatively rare con-
dition seen in term infants and an extremely common condi-
tion present in very preterm infants. In addition to age, PDA
can also be segregated by whether the condition exists as part
of a constellation of other physical anomalies (syndromic
PDA) or as an isolated nding (nonsyndromic PDA). The vast
majority of PDA cases seen in preterm infants are nonsyn-
dromic, as the PDA would likely not be present if the infant
had been born at term. In contrast, PDA cases seen in term
infants can be either syndromic or nonsyndromic. Finally,
PDA associated with major congenital heart disease (CHD)
(in either term or preterm infants) is often considered in a
separate category, as the etiological mechanisms associated
with altered cardiac blood owand pressure are likely related
to structural perturbations. It is important to appropriately
classify (ie, carefully phenotype) PDA by the different sub-
types for genetic analyses, as each is likely to have different
contributions of environmental and genetic factors.
PDA in Term Infants
The prevalence of PDA in term infants is approximately 2-8
per 10,000 live births,
20-24
constituting 5%-7% of all cases of
CHD in term infants. Higher rates of PDA have been re-
ported, but it is unclear whether preterm infants and infants
with other congenital heart anomalies were included in these
analyses. Some cases of racial differences in the prevalence of
PDA in term infants have been reported
22
; however, race has
not been consistently identied as a risk factor for PDA.
25
Reports of a gender bias in term infants with PDA have been
inconsistent. More than 35 years ago, Cascos and Segrado
studied 119 cases of PDA diagnosed in 900 consecutive cases
of CHD. The vast majority of PDA cases (104 of 119) were
described as isolated or nonsyndromic. PDA was found to be
3 times more likely in females, but the incidence of CHD in
siblings was 3 times more likely in male PDA cases than in
females. Based on these ndings, the authors concluded that
PDA had a multifactorial causative mechanism with poly-
genetic inheritance.
26
Thus, PDA was recognized several de-
cades ago as what we now call a complex human disease.
Familial clustering of PDA has also been reported and re-
viewed by Sletten and Pierpont.
27
Genetics of PDA susceptibility and treatment 99
Online Mendelian Inheritance in Man (http://www.
ncbi.nlm.nih.gov/omim) lists more than 100 disorders in
which PDA is found, supporting the idea that single genes
(loci) can contribute to syndromic PDA (examples shown in
Table 1). Several genetic studies have focused on PDA asso-
ciated with syndromes in small cohorts of subjects, often
excluding preterm infants and individuals with major CHD.
Several investigators have identied a syndrome including
both thoracic aortic aneurysm and PDA,
28,29
which was sub-
sequently linked to the chromosome region 16p12.2-
13.13.
30
Zhu et al reported an analysis of PDA in 2 kindreds
that also presented with thoracic aortic aneurysm. Mutations
in MYH11, a gene encoding smooth muscle myosin heavy
chain 11 and located at 16p13.11, were identied as the
cause for this syndrome.
31
Guo et al subsequently identied
missense mutations in the smooth muscle -actin gene
(ACTA2) that also resulted in a syndrome involving thoracic
aortic aneurysms and PDA.
32
Given the need for interactions
between actin and myosin to generate contraction in vascular
smooth muscle cells, associations between abnormal con-
tractile proteins and altered closure of the PDA are not sur-
prising. Additionally, a genomewide linkage study reported
by Mani et al examining consanguineous PDA cases in an
Iranian kindred identied an associated region on chromo-
some 12q24 that was designated PDA1.
20
The specic gene
and etiologic molecular lesions present at this locus have not
been identied. Finally, mutations in the gene transcription
factor AP-2 beta (TFAP2B) have been found to result in Char
syndrome, a rare disorder characterized by facial dysmor-
phism, hand anomalies, and PDA.
20,33
TFAP2B mutations
have also been reported in familial nonsyndromic cases of
PDA, which may reect the signicant phenotypic variability
in Char syndrome.
34,35
TFAP2B encodes the transcription fac-
tor AP-2, a regulatory protein found in neural crest-derived
cells. A biological link between neural crest cells and PDA
was discovered using an animal model system to study de-
velopmental origins of the DA. Research in avian model sys-
tems have elegantly demonstrated the contribution of neural
crest cells to the sixth aortic arch from which the DA origi-
nates.
36
In addition, transcription factor AP-2 has been re-
ported to regulate the expression of both EPAS1 (endothelial
PAS domain protein 1, which is also known as hypoxia-
inducible factor 2) (involved in oxygen sensing) and endo-
thelin-1 (ET-1; a potent vasoconstrictor) in ductal smooth
muscles in a fetal mouse model.
37
TFAP2B and EPAS1 will
also be discussed later with respect to preterm PDA.
PDA in Preterm Infants
PDA commonly occurs in preterm infants and has been re-
ported to be a signicant risk factor for the subsequent de-
velopment of several long-term morbidities associated with
pretermbirth, including cerebral palsy
38
and bronchopulmo-
nary dysplasia.
39
Notably, not all preterm infants develop a
PDA. Data from the Vermont Oxford Network (an interna-
tional collaboration of more than 800 neonatal intensive care
units
40
) show the overall incidence of PDA in infants weigh-
ing 1500 g to be approximately 37%. The incidence of PDA
in preterm infants increases almost linearly with decreasing
gestational age, as shown in Figure 1. For each additional
week of gestational age completed, the risk of PDA decreases
by approximately 9%, emphasizing not only the signicant
environmental and developmental component of this condi-
tion but also the benet to the infant of extending gestation.
Additionally, it is intriguing to speculate on the various ge-
netic and environmental factors that determine whether a
preterm infant born at 27 weeks gestation will fall into the
50% of individuals who have a PDA or the 50% who will be
spared.
Two recent retrospective twin studies have strongly sug-
gested a familial component for PDA in preterminfants. Both
studies investigated the concordance rates of PDA in mo-
nozygotic compared with dizygotic preterm twins, but used
different statistical strategies. The report by Lavoie et al in-
vestigated 318 neonates (70 monozygotic twin pairs and 89
dizygotic twin pairs) and determined heritability using struc-
tural equation models to estimate additive genetic, shared
environmental, and nonshared environmental inuences.
41
They reported a 93% heritability for PDA requiring indo-
methacin therapy and 48% heritability for PDA requiring
surgical ligation (ie, failing indomethacin therapy). In addi-
tion, relatively high heritability estimates were also found for
bronchopulmonary dysplasia, as determined by either need
for supplemental oxygen at 36 weeks corrected age (82%) or
by the more recent physiologic denition
42
(79%). A larger
Table 1 Genetic Syndromes Associated With Patent Ductus
Arteriosus
Syndrome Gene Location
MowatWilson SMADIP1 2q22
LoeysDietz TGFBR2 3p22
Char TFAP2B 6p21-p12
LoeysDietz TGFBR1 9q22
Noonan PTPN11 12q24
HoltOram TBX5 12q24.1
RubinsteinTaybi CREBBP 16p13.3
DiGeorge TBX1 22q11.21
Periventricular heterotopia FLNA Xq28
Figure 1 Increasing incidence of patent ductus arteriosus with de-
creasing gestational age. Adapted fromdata released by the Vermont
Oxford Network, 2006-2009 (used with permission).
100 H. Hajj and J.M. Dagle
study by Bhandari et al included 864 infants (99 monozy-
gotic twin pairs and 333 dizygotic twin pairs) and used
mixed-effects logistic analysis to identify risk factors for
PDA.
43
The investigators reported that genetic factors or a
shared environmental factor accounted for 76% of the vari-
ance in liability to PDA, with only 12% being accounted for
by genetic factors. Thus, both twin studies identied a famil-
ial/heritable contribution to PDA, but disagreed on the mag-
nitude of the actual genetic contribution.
In addition to twin studies of PDAconcordance, which can
quantify overall heritability (but not risk from a specic lo-
cus), candidate gene studies have identied specic gene
polymorphisms associated with PDA in preterminfants. Der-
zbach et al studied 141 low-birth-weight infants (69 male
and 72 female) and found that male infants carrying the p
allele of the PvuII pP polymorphism (rs2234693) in the es-
trogen receptor- gene had a decreased risk for PDA (OR:
0.24; 95% condence interval [CI]: 0.05-0.97).
44
Bokodi et
al studied 153 low-birth-weight infants and found a poly-
morphism in the interferon- gene (874) (rs2430561, T
allele) that was associated with a decreased risk for both PDA
(OR: 0.43; 95% CI: 0.19-0.97) and bronchopulmonary dys-
plasia (OR: 0.35; 95% CI: 0.12-0.99).
45
Finally, our group
investigated 366 infants and their parents (in 2 stages) using
a family-based genetic approach, which examines nonran-
dom allele transmission from parent to an affected child.
46
We identied genetic single polymorphisms in TFAP2B
(rs987237, G allele; P 0.003) and in TRAF1 (tumor necro-
sis factor receptor-associated factor 1) (rs1056567, T allele;
P 0.005) that are associated with the presence of a PDA.
A haplotype analysis that considered combinations of
neighboring alleles identied PTGIS (prostaglandin I2 [pro-
stacyclin] synthase) as a gene containing polymorphisms
(rs493694, G allele and rs693649, A allele; P 0.01) asso-
ciated with the absence of a PDA (ie, protective). The associ-
ation of sequence variants in TFAP2B with PDA in preterm
infants supports the concept that common variants in the
same genes that are responsible for syndromic forms of PDA
may be responsible for isolated, nonsyndromic forms of PDA,
given the right environment. Waleh et al subsequently dem-
onstrated that TFAP2B genotype is associated with altered
levels of mRNAencoding 3 ion channels that are expressed in
the DA: CACNB2 (calcium L channel subunit), CACNA1
(calcium T channel), and KCNA2, (Kv1.2 potassium chan-
nel).
47
Interestingly, expression of these ion channels in the
DA of baboon fetuses is regulated by both gestational age and
antenatal glucocorticoid administration, known risk factors
for PDA in preterm human neonates.
Fewer studies have addressed PDA in preterminfants with
respect to medical management. Treszl et al investigated
whether the genotype of the angiotensin II type 1 receptor
inuenced DA closure after early indomethacin therapy. In-
fants with the CC genotype at angiotensin II type 1 receptor
A1166C (rs5186) had a lower risk of PDA than those infants
with either AA or CA genotype after early indomethacin ad-
ministration.
48
In addition, data from our group also sug-
gested an association between sequence polymorphisms in
TFAP2B and EPAS1 and the need for surgical ligation of the
PDA (ie, lack of response to indomethacin therapy).
46
The
ultimate goal of these types of studies is to predict infants
who will either (1) experience spontaneous closure of the DA
without treatment, or (2) not respond to medical therapy and
may require surgical intervention. In both cases, this phar-
macogenomics-based information would allow a more per-
sonalized approach to PDA treatment, avoiding unnecessary
exposure to indomethacin or ibuprofen.
PDA and
Environmental Risk Factors
As seen in other complex human diseases, environmental
factors play a signicant role in PDA. A number of maternal
factors that alter fetal environment have been reported to
affect closure of the DA, including maternal hypertension,
49
antenatal steroid administration,
50,51
antenatal indomethacin
administration,
52,53
and intrauterine growth restriction.
53,54
The association of PDA with intrauterine growth restriction,
which results in a number of adaptive fetal changes,
55
sup-
ports the presence of an epigenetic etiology for PDA. Postna-
tal environmental factors are also important in regulating
patency of the DA. A recent meta-analysis, for example, dem-
onstrated a decrease in PDA in preterm infants receiving re-
stricted versus liberal intravenous uids (OR: 0.52; 95% CI:
0.37-0.73).
56
In addition, neonatal bacterial infections are
associated with both reduced ductal closure and reopening of
the PDA after functional closure but before anatomic closure.
This nding supports the concept that increasing levels of
vasodilatory prostaglandins and inammatory mediators
play a role in ductal patency.
57
Animal Models of PDA
PDA in Mice
Advances in gene knockout (KO) technology have made the
mouse a common model system for the study of genes in-
volved in the physiology of the DA. Several KO mouse mod-
els have been created to investigate specic genes important
in determining the patency of the DA.
Prostaglandin E2 plays a major role in patency of the DA in
utero, and a postnatal decline in prostaglandin E2 levels is
one factor involved in closure of the DA in humans. Prosta-
glandin-endoperoxide synthase 1 (Ptgs1 or Cox-1; PTGS1 in
humans) and prostaglandin-endoperoxide synthase 2 (Ptgs2
or Cox-2; PTGS2 in humans) encode enzymes that catalyze
the rate-limiting step in the production of prostaglandins
from arachidonic acid. Reese et al reported that newborn
mice with combined deciencies of Ptgs1 and Ptgs2 have
PDA and increased perinatal mortality.
58
Loftin et al subse-
quently demonstrated that KOmice lacking either isoformof
Ptgs do not have premature closure of the DA in utero.
59
Neonatal mortality from PDA was 35% in Ptgs2 (/) mice
and 100% in Ptgs1/2 (/) mice. Interestingly, the absence
of Ptgs1 did not affect neonatal closure of the DA. However,
mortality and incidence of PDAwas increased in Ptgs2 (/)
mice when one copy of the gene encoding Ptgs1 was also
Genetics of PDA susceptibility and treatment 101
inactivated, indicating a gene dosage-dependent contribu-
tion of Ptgs1 in Ptgs2 KO mice. Yu and Funk created a Ptgs2
mouse model in which the cyclooxygenase activity of the
bifunctional enzyme was inhibited without affecting the per-
oxidase activity.
60
These mice showed normal DA closure
and remodeling after birth, suggesting that a Ptgs1/2 het-
erodimer may play a role in the postnatal remodeling of the
DA.
Ptgs2 expression is decreased in the DAof mice decient in
the prostaglandin receptor EP4, suggesting the importance of
this receptor for the induction of Ptgs2.
61
Mice lacking the
gene encoding EP4 (Ptger4; PTGER4 in humans) have PDAs
resulting in death in the neonatal period.
62,63
Interestingly,
Yokoyama et al demonstrated that stimulation of EP4 pro-
motes DA closure by enhancing hyaluronic acid-mediated
intimal cushion formation (ICF).
64
Thus, prostaglandin E2
binding to EP4 may have opposing effects with respect to
closure of the DA: direct dilatation and increased ICF. If this
observation represents what actually occurs in human pre-
term infants, then treatment with indomethacin to induce
initial constriction of the DA may actually inhibit anatomic
closure to some extent by delaying ICF. Finally, mice in
which the prostaglandin transporter gene has been deleted
fail to close the DA after birth and die before postnatal day
2.
65
These mice can be rescued, however, with antenatal ad-
ministration of indomethacin to the dams. Despite an exten-
sive literature demonstrating the importance of the prosta-
glandin pathway on closure of the DA, PTGIS is the only
prostaglandin-related gene with polymorphisms reported to
be associated with PDA in humans.
46
Smooth muscle myosin heavy chain (encoded by Myh11;
MYH11 in humans), discussed previously as a cause of a
thoracic aortic aneurysm/PDA syndrome, contracts in re-
sponse to the postnatal rise in oxygen levels. Myh11 KOmice
have delayed closure of the DA (6-12 h after birth compared
with 3 h in wild mice), but full closure does occur.
66
Urinary
bladder preparations from these KO mice demonstrate con-
tractility mediated by nonmuscle myosin heavy chain. Al-
though not actually demonstrated, closure of the DA in these
mice (although delayed) suggests that vascular smooth mus-
cle cells may also contract using nonmuscle myosin compo-
nents.
Coceani et al used KO mice to investigate the role of the
ET-1 receptor (Ednra; EDNRA in humans) in the physiology
of the DA.
67
In vitro, DA isolated from Ednra (/) mice
showed little response to oxygen and ET-1, but did contract
normally when exposed to a thromboxane A2 analog. In vivo,
during a hyperoxic exposure to pregnant dams, Ednra (/)
fetuses showed no constriction of the DA, whereas Ednra
(/) fetuses showed a range of constriction phenotypes.
After birth, the DA fromboth Ednra (/) and Ednra (/)
mice showed normal structural morphology and physiologic
closure.
The myocardin gene (Myocd; MYOCD in humans) en-
codes a transcriptional coactivator that is important in both
cardiovascular development and adaptation of the cardiovas-
cular system to hemodynamic stress. Huang et al created a
KO mouse in which Myocd was selectively deleted in neural
crest-derived smooth muscle cells populating the cardiac
outow tract and great arteries.
68
These KO mice are born
alive, but they die before postnatal day 3 secondary to a PDA.
Feng et al recently generated a KO mouse with a smooth
muscle cell-specic deletion of Jag1 (encoding jagged-1), a
Notch ligand.
69
Mice containing an endothelial cell-specic
deletion of Jag1 die around embryonic day 10.5. In contrast,
mice with the smooth muscle cell-specic deletion of Jag1 are
alive at birth but become cyanotic in the early neonatal pe-
riod. The mortality of these mice was 50% on day 1 and
100% by day 2. These mice exhibited a signicant defect in
smooth muscle cell differentiation in the wall of the DA and
descending aorta, and 95% of the mice had an identiable
PDA on postmortem examination.
Tcfap2b (TFAP2B in humans) encodes a transcriptional
factor highly expressed in the neural crest cells from which
the DA originates. Tcfap2b (/) mice are born alive, but
they die secondary to renal abnormalities.
70
Ivey et al re-
ported no embryonic changes in the morphology of the DA
beyond mid-gestation between Tcfap2b (/) and wild type
mice; however, postnatal ductal morphology was not re-
ported.
37
The Tcfap2b KO mice lose ductal expression of
calponin and hypoxia-inducible factor 2 (EPAS1 in hu-
mans), which are markers of differentiated contractile
smooth muscle cells. Thus, Tcfap2b in mice appears to play a
role in maturation of the muscular layer of the DA.
PDA in Rats
Bkenkamp et al previously reported hereditary PDA in the
Brown Norway rat.
71
A related phenotype present in this rat
strain is increased vascular fragility, thought to result from
abnormal elastin production and its subsequent effects on
vascular smooth muscle cell proliferation/migration. Kota et
al performed a genomewide scan with linkage analysis,
showing that PDAin the Brown Norway rats was signicantly
linked to 2 different quantitative trait loci on chromosomes 8
and 9.
72
PDA in Rabbits
Developmental changes in oxygen-sensitive, voltage-gated
potassium channels (Kv1.5, encoded by KCNA5 and Kv2.1,
encoded by KCNB1) have been studied in preterm rabbits.
Thbaud et al demonstrated that in vitro oxygen-sensitive Kv
channel gene transfer to preterm rabbits induces oxygen re-
sponsiveness.
73
Similarly, Kv1.5 gene transfer increased ox-
ygen-mediated constriction in human DA. Fan et al recently
used the rabbit model systemto demonstrate opposite effects
of prostaglandin E2 on preterm (dilation) compared with
term (constriction) DA.
74
This effect may be mediated by
differential binding to developmentally regulated prostaglan-
din receptor subtypes, as has been previously suggested in a
porcine model.
75
PDA in Dogs
PDA is the most common cardiac malformation reported in
dogs.
76
Patterson et al have examined hereditary PDA in
dogs, concluding that, as is the case in humans, PDA is not a
102 H. Hajj and J.M. Dagle
simple Mendelian trait.
77
Liability to defective closure of the
DA was shown to increase with the proportion of the genome
received from dogs with PDA. In 1989, de Reeder et al re-
ported that prostacyclin is involved in regulating ductal pa-
tency in the dog, possibly by inuencing ICF.
78
This nding
is quite interesting, given the recent report linking polymor-
phisms in PTGIS to PDA in preterm infants.
Conclusions
Closure of the DA shortly after birth is driven by intricate
interactions of molecular events. The concept that PDA is a
complex, developmentally inuenced disease with both ge-
netic and environmental risk factors is gaining increasing
support. Results from several animal studies have revealed
specic genes and pathways important in determining ductal
patency. Studies in humans have also identied a number of
genes associated with PDA, some of which are involved in the
regulation of prostaglandin activity as well as pathways driv-
ing smooth muscle cell development and/or contraction.
These ndings are not surprising because these suspected
pathways have been intentionally interrogated in previous
studies using traditional gene discovery strategies. The appli-
cation of more advanced genotyping technologies (ie, GWA
studies and whole-exome sequencing), representing model-
free approaches, is expected to identify novel genes and path-
ways regulating patency of the human DA. These ndings
will both drive the more rational use of current therapies and
identify currently unknown targets for future therapeutic
manipulation.
Acknowledgments
The authors thank Dr Jeffrey Segar, University of Iowa, for
critically reading the manuscript.
References
1. Schneider DJ, Moore JW: Patent ductus arteriosus. Circulation 114:
1873-1882, 2006
2. Hermes-DeSantis ER, Clyman RI: Patent ductus arteriosus: Pathophys-
iology and management. J Perinatol 26 (suppl 1):S14-S18, 2006; dis-
cussion S22-S23
3. Pennell CE, Jacobsson B, Williams SM, et al: Genetic epidemiological
studies of preterm birth: Guidelines for research. Am J Obstet Gynecol
196:107-118, 2007
4. Zeggini E, Scott LJ, Saxena R, et al: Meta-analysis of genome-wide
association data and large-scale replication identies additional suscep-
tibility loci for type 2 diabetes. Nat Genet 40:638-645, 2008
5. International Multiple Sclerosis Genetics Consortium, Haer DA,
Compston A, et al: Risk alleles for multiple sclerosis identied by a
genomewide study. N Engl J Med 357:851-862, 2007
6. Moffatt MF, Kabesch M, Liang L, et al: Genetic variants regulating
ORMDL3 expression contribute to the risk of childhood asthma. Na-
ture 448:470-473, 2007
7. Zanke BW, Greenwood CM, Rangrej J, et al: Genome-wide association
scan identies a colorectal cancer susceptibility locus on chromosome
8q24. Nat Genet 39:989-994, 2007
8. Hunter DJ, Kraft P, Jacobs KB, et al: A genome-wide association study
identies alleles in FGFR2 associated with risk of sporadic postmeno-
pausal breast cancer. Nat Genet 39:870-874, 2007
9. Burgner D, Davila S, Breunis WB, et al: A genome-wide association
study identies novel and functionally related susceptibility loci for
Kawasaki disease. PLoS Genet 5:e1000319, 2009
10. Thorleifsson G, Magnusson KP, Sulem P, et al: Common sequence
variants in the LOXL1 gene confer susceptibility to exfoliation glau-
coma. Science 317:1397-1400, 2007
11. Manolio TA, Brooks LD, Collins FS: A HapMap harvest of insights into
the genetics of common disease. J Clin Invest 118:1590-1605, 2008
12. International HapMap Consortium, Frazer KA, Ballinger DG, et al: A
second generation human haplotype map of over 3.1 million SNPs.
Nature 449:851-861, 2007
13. International HapMap Consortium: A haplotype map of the human
genome. Nature 437:1299-1320, 2005
14. Pritchard JK, Cox NJ: The allelic architecture of human disease genes:
Common disease-common variant . . . or not? Hum Mol Genet 11:
2417-2423, 2002
15. Zheng SL, Sun J, Wiklund F, et al: Cumulative association of ve
genetic variants with prostate cancer. NEngl J Med 358:910-919, 2008
16. Kathiresan S, Melander O, Anevski D, et al: Polymorphisms associated
with cholesterol and risk of cardiovascular events. N Engl J Med 358:
1240-1249, 2008
17. Flockhart DA, OKane D, Williams MS, et al: Pharmacogenetic testing
of CYP2C9 and VKORC1 alleles for warfarin. Genet Med 10:139-150,
2008
18. Lai-Goldman M, Faruki H: Abacavir hypersensitivity: A model system
for pharmacogenetic test adoption. Genet Med 10:874-878, 2008
19. SEARCH Collaborative Group, Link E, Parish S, et al: SLCO1B1 vari-
ants and statin-induced myopathyA genomewide study. N Engl
J Med 359:789-799, 2008
20. Mani A, Meraji SM, Houshyar R, et al: Finding genetic contributions to
sporadic disease: A recessive locus at 12q24 commonly contributes to
patent ductus arteriosus. Proc Natl Acad Sci U S A 99:15054-15059,
2002
21. Reller MD, Strickland MJ, Riehle-Colarusso T, et al: Prevalence of con-
genital heart defects in metropolitan Atlanta, 1998-2005. J Pediatr 153:
807-813, 2008
22. Botto LD, Correa A, Erickson JD: Racial and temporal variations in the
prevalence of heart defects. Pediatrics 107:E32, 2001
23. Samnek M, Vorskov M: Congenital heart disease among 815,569
children born between 1980 and 1990 and their 15-year survival: A
prospective Bohemia survival study. Pediatr Cardiol 20:411-417, 1999
24. Grech V: Patent ductus arteriosus in a population-based study. Asian
Cardiovasc Thorac Ann 7:301-304, 1999
25. Fixler DE, Pastor P, Sigman E, et al: Ethnicity and socioeconomic sta-
tus: Impact on the diagnosis of congenital heart disease. J Am Coll
Cardiol 21:1722-1726, 1993
26. Cascos AS, Sagredo JM: Genetics of patent ductus arteriosus. Basic Res
Cardiol 70:456-466, 1975
27. Sletten LJ, Pierpont ME: Familial occurrence of patent ductus arterio-
sus. Am J Med Genet 57:27-30, 1995
28. Glancy DL, Wegmann M, Dhurandhar RW: Aortic dissection and pat-
ent ductus arteriosus in three generations. Am J Cardiol 87:813-815,
2001;A9
29. Khau Van Kien P, Wolf JE, Mathieu F, et al: Familial thoracic aortic
aneurysm/dissection with patent ductus arteriosus: Genetic arguments
for a particular pathophysiological entity. Eur J Hum Genet 12:173-
180, 2004
30. Khau Van Kien P, Mathieu F, Zhu L, et al: Mapping of familial thoracic
aortic aneurysm/dissection with patent ductus arteriosus to 16p12.2-
p13.13. Circulation 112:200-206, 2005
31. Zhu L, Vranckx R, Khau Van Kien P, et al: Mutations in myosin heavy
chain 11 cause a syndrome associating thoracic aortic aneurysm/aortic
dissection and patent ductus arteriosus. Nat Genet 38:343-349, 2006
32. Guo DC, Pannu H, Tran-Fadulu V, et al: Mutations in smooth muscle
alpha-actin (ACTA2) lead to thoracic aortic aneurysms and dissections.
Nat Genet 39:1488-1493, 2007
33. Satoda M, Pierpont ME, Diaz GA, et al: Char syndrome, an inherited
disorder with patent ductus arteriosus, maps to chromosome 6p12-
p21. Circulation 99:3036-3042, 1999
34. Chen YW, Zhao W, Zhang ZF, et al: Familial nonsyndromic patent
ductus arteriosus caused by mutations in TFAP2B. Pediatr Cardiol
32:958-965, 2011
Genetics of PDA susceptibility and treatment 103
35. Khetyar M, Syrris P, Tinworth L, et al: Novel TFAP2B mutation in
nonsyndromic patent ductus arteriosus. Genet Test 12:457-459, 2008
36. Waldo KL, Kirby ML: Cardiac neural crest contribution to the pulmo-
nary artery and sixth aortic arch artery complex in chick embryos aged
6 to 18 days. Anat Rec 237:385-399, 1993
37. Ivey KN, Sutcliffe D, Richardson J, et al: Transcriptional regulation
during development of the ductus arteriosus. Circ Res 103:388-395,
2008
38. Drougia A, Giapros V, Krallis N, et al: Incidence and risk factors for
cerebral palsy in infants with perinatal problems: A 15-year review.
Early Hum Dev 83:541-547, 2007
39. Chorne N, Leonard C, Piecuch R, et al: Patent ductus arteriosus and its
treatment as risk factors for neonatal and neurodevelopmental morbid-
ity. Pediatr Res 119:1165-1174, 2007
40. Horbar JD: The Vermont-Oxford Neonatal Network: Integrating re-
search and clinical practice to improve the quality of medical care.
Semin Perinatol 19:124-131, 1995
41. Lavoie PM, Pham C, Jang KL: Heritability of bronchopulmonary dys-
plasia, dened according to the consensus statement of the National
Institutes of Health. Pediatrics 122:479-485, 2008
42. Walsh MC, Yao Q, Gettner P, et al: Impact of a physiologic denition on
bronchopulmonary dysplasia rates. Pediatrics 114:1305-1311, 2004
43. Bhandari V, Zhou G, Bizzarro MJ, et al: Genetic contribution to patent
ductus arteriosus in the premature newborn. Pediatrics 123:669-673,
2009
44. Derzbach L, Treszl A, Balogh A, et al: Gender dependent association
between perinatal morbidity and estrogen receptor-alpha Pvull poly-
morphism. J Perinat Med 33:461-462, 2005
45. Bokodi G, Derzbach L, Bnysz I, et al: Association of interferon gamma
T874A and interleukin 12 p40 promoter CTCTAA/GC polymor-
phism with the need for respiratory support and perinatal complica-
tions in low birth weight neonates. Arch Dis Child Fetal Neonatal Ed
92:F25-F29, 2007
46. Dagle JM, Lepp NT, Cooper ME, et al: Determination of genetic pre-
disposition to patent ductus arteriosus in preterm infants. Pediatrics
123:1116-1123, 2009
47. Waleh N, Hodnick R, Jhaveri N, et al: Patterns of gene expression in the
ductus arteriosus are related to environmental and genetic risk factors
for persistent ductus patency. Pediatr Res 68:292-297, 2010
48. Treszl A, Szabo M, Dunai G, et al: Angiotensin II type 1 receptor
A1166C polymorphism and prophylactic indomethacin treatment in-
duced ductus arteriosus closure in very low birth weight neonates.
Pediatr Res 54:753-755, 2003
49. Itabashi K, Ohno T, Nishida H: Indomethacin responsiveness of patent
ductus arteriosus and renal abnormalities in preterm infants treated
with indomethacin. J Pediatr 143:203-207, 2003
50. Elimian A, Verma U, Beneck D, et al: Histologic chorioamnionitis,
antenatal steroids, and perinatal outcomes. Obstet Gynecol 96:333-
336, 2000
51. Eronen M, Kari A, Pesonen E, et al: The effect of antenatal dexameth-
asone administration on the fetal and neonatal ductus arteriosus. A
randomized double-blind study. Am J Dis Child 147:187-192, 1993
52. Hammerman C, Glaser J, Kaplan M, et al: Indomethacin tocolysis in-
creases postnatal patent ductus arteriosus severity. Pediatrics 102:E56,
1998
53. Souter D, Harding J, McCowan L, et al: Antenatal indomethacin
Adverse fetal effects conrmed. Aust N Z J Obstet Gynaecol 38:11-16,
1998
54. Rakza T, Magnenant E, Klosowski S, et al: Early hemodynamic conse-
quences of patent ductus arteriosus in preterminfants with intrauterine
growth restriction. J Pediatr 151:624-628, 2007
55. Beltrand J, Verkauskiene R, Nicolescu R, et al: Adaptive changes in
neonatal hormonal and metabolic proles induced by fetal growth
restriction. J Clin Endocrinol Metab 93:4027-4032, 2008
56. Bell EF, Acarregui MJ: Restricted versus liberal water intake for prevent-
ing morbidity and mortality in preterminfants. Cochrane Database Syst
Rev 1: CD000503, 2008
57. Gonzalez A, Sosenko IR, Chandar J, et al: Inuence of infection on
patent ductus arteriosus and chronic lung disease in premature infants
weighing 1000 grams or less. J Pediatr 128:470-478, 1996
58. Reese J, Paria BC, Brown N, et al: Coordinated regulation of fetal and
maternal prostaglandins directs successful birth and postnatal adapta-
tion in the mouse. Proc Natl Acad Sci U S A 97:9759-9764, 2000
59. Loftin CD, Trivedi DB, Tiano HF, et al: Failure of ductus arteriosus
closure and remodeling in neonatal mice decient in cyclooxygenase-1
and cyclooxygenase-2. Proc Natl Acad Sci U S A 98:1059-1064, 2001
60. Yu Y, Funk CD: A novel genetic model of selective COX-2 inhibition:
Comparison with COX-2 null mice. Prostaglandins Other Lipid Mediat
82:77-84, 2007
61. Trivedi DB, Sugimoto Y, Loftin CD: Attenuated cyclooxygenase-2 ex-
pression contributes to patent ductus arteriosus in preterm mice. Pedi-
atr Res 60:669-674, 2006
62. Nguyen M, Camenisch T, Snouwaert JN, et al: The prostaglandin re-
ceptor EP4 triggers remodelling of the cardiovascular system at birth.
Nature 390:78-81, 1997
63. Segi E, Sugimoto Y, Yamasaki A, et al: Patent ductus arteriosus and
neonatal death in prostaglandin receptor EP4-decient mice. Biochem
Biophys Res Commun 246:7-12, 1998
64. Yokoyama U, Minamisawa S, Quan H, et al: Chronic activation of the
prostaglandin receptor EP4 promotes hyaluronan-mediated neointimal
formation in the ductus arteriosus. J Clin Invest 116:3026-3034, 2006
65. Chang HY, Locker J, Lu R, et al: Failure of postnatal ductus arteriosus
closure in prostaglandin transporter-decient mice. Circulation 121:
529-536, 2010
66. Morano I, Chai GX, Baltas LG, et al: Smooth-muscle contraction with-
out smooth-muscle myosin. Nat Cell Biol 2:371-375, 2000
67. Coceani F, Liu YA, Seidlitz E, et al: Deletion of the endothelin-A-
receptor suppresses oxygen-induced constriction but not postnatal clo-
sure of the ductus arteriosus. J Cardiovasc Pharmacol 36:S75-S77,
2000
68. Huang J, Cheng L, Li J, et al: Myocardin regulates expression of con-
tractile genes in smooth muscle cells and is required for closure of the
ductus arteriosus in mice. J Clin Invest 118:515-525, 2008
69. Feng X, Krebs LT, Gridley T: Patent ductus arteriosus in mice with
smooth muscle-specic Jag1 deletion. Development 137:4191-4199,
2010
70. Moser M, Pscherer A, Roth C, et al: Enhanced apoptotic cell death of
renal epithelial cells in mice lacking transcription factor AP-2beta.
Genes Dev 11:1938-1948, 1997
71. Bkenkamp R, Gittenberger-De Groot AC, Van Munsteren CJ, et al:
Persistent ductus arteriosus in the Brown-Norway inbred rat strain.
Pediatr Res 60:407-412, 2006
72. Kota L, Osborne-Pellegrin M, Schulz H, et al: Quantitative genetic basis
of arterial phenotypes in the Brown Norway rat. Physiol Genomics
30:17-25, 2007
73. Thbaud B, Michelakis ED, Wu XC, et al: Oxygen-sensitive Kv channel
gene transfer confers oxygen responsiveness to preterm rabbit and
remodeled human ductus arteriosus: Implications for infants with pat-
ent ductus arteriosus. Circulation 110:1372-1379, 2004
74. Fan FL, Zhu S, Chen LH, et al: Role of prostaglandin E and its receptors
in the process of ductus arteriosus maturation and functional closure in
the rabbit. Clin Exp Pharmacol Physiol 37:574-580, 2010
75. Bhattacharya M, Asselin P, Hardy P, et al: Developmental changes in
prostaglandin E(2) receptor subtypes in porcine ductus arteriosus. Pos-
sible contribution in altered responsiveness to prostaglandin E(2). Cir-
culation 100:1751-1756, 1999
76. Patterson DF: Epidemiologic and genetic studies of congenital heart
disease in the dog. Circ Res 23:171-202, 1968
77. Patterson DF, Pyle RL, Buchanan JW, et al: Hereditary patent ductus
arteriosus and its sequelae in the dog. Circ Res 29:1-13, 1971
78. de Reeder EG, Gittenberger-de Groot AC, van Munsteren JC, et al:
Distribution of prostacyclin synthase, 6-keto-prostaglandin F1 alpha,
and 15-hydroxy-prostaglandin dehydrogenase in the normal and per-
sistent ductus arteriosus of the dog. Am J Pathol 135:881-887, 1989
104 H. Hajj and J.M. Dagle