Abnormal developmental trajectory and vulnerability to cardiac arrhythmias in tetralogy of Fallot with DiGeorge syndrome

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. Ventricular dysfunction and cardiac arrhythmias are well-documented complications in patients with repaired TOF. Whether intrinsic abnormalities exist in TOF cardiomyocytes is unknown. We establish human induced pluripotent stem cells (hiPSCs) from TOF patients with and without DiGeorge (DG) syndrome, the latter being the most commonly associated syndromal association of TOF. TOF-DG hiPSC-derived cardiomyocytes (hiPSC-CMs) show impaired ventricular specification, downregulated cardiac gene expression and upregulated neural gene expression. Transcriptomic profiling of the in vitro cardiac progenitors reveals early bifurcation, as marked by ectopic RGS13 expression, in the trajectory of TOF-DG-hiPSC cardiac differentiation. Functional assessments further reveal increased arrhythmogenicity in TOF-DG-hiPSC-CMs. These findings are found only in the TOF-DG but not TOF-with no DG (ND) patient-derived hiPSC-CMs and cardiac progenitors (CPs), which have implications on the worse clinical outcomes of TOF-DG patients. Using hiPSC, the authors report impaired ventricular specification, altered cardiac gene expression and ectopic neuronal gene expression in tetralogy of Fallot with DiGeorge syndrome cardiomyocytes (TOF-DG-hiPSC-CMs) and increased arrhythmogenicity in cardiac anisotropic sheet derived from TOF-DG-hiPSC-CMs.

Automated summary

This study reveals functional abnormalities in cardiomyocytes derived from Tetralogy of Fallot patients with DiGeorge syndrome, including impaired ventricular specification, altered cardiac gene expression, upregulated neural gene expression, and increased arrhythmogenicity. These findings are specific to patients with DiGeorge syndrome and have implications for their clinical outcomes.