eMedicine Specialties > Cardiology > Congenital Heart Disease in the Adult

Holt-Oram Syndrome: Differential Diagnoses & Workup

Author: Craig T Basson, MD, PhD, FAHA, FACC, Gladys and Roland Harriman Professor of Medicine, Weill Cornell Medical College; Director, Cardiovascular Research, Greenberg Division of Cardiology, Department of Medicine, The New York Presbyterian Hospital
Coauthor(s): Carl J Vaughan, MD, MRCPI, Adjunct Assistant Professor, Department of Internal Medicine, Division of Cardiology, Weill Medical College of Cornell University; Consulting Cardiologist, Mercy University Hospital, Ireland; Luke K Kim, MD, Fellow, Department of Internal Medicine, Division of Cardiology, New York Presbyterian Hospital, Weill Cornell Medical Center; Deborah A McDermott, MS, CGC, Genetic Counselor/Research Associate, Department of Medicine, Division of Cardiology, Weill Medical College of Cornell University
Contributor Information and Disclosures

Updated: May 28, 2009

Differential Diagnoses

Atrial Septal Defect

Other Problems to Be Considered

Chromosomal anomaly
Duane radial ray syndrome (Okihiro syndrome)
Fanconi anemia
Teratogen exposure
Thrombocytopenia with absence of radius (TAR) syndrome
Townes-Brocks syndrome
Ulnar-mammary syndrome
Vertebral defects, anal atresia, tracheoesophageal fistula with esophageal atresia, and radial and renal anomalies complex (ie, VATER complex)

Workup

Imaging Studies

Wrist radiography

  • Limb involvement is determined by physical examination in some cases.
  • If limb involvement is not grossly obvious, obtain upper limb and hand radiographs to detect subtle anomalies of the wrist bones, as shown below.

    • Posteroanterior radiograph of the hands of a pati...

      Posteroanterior radiograph of the hands of a patient with Holt-Oram syndrome. The distal phalanx of the left thumb is hypoplastic. The carpal bones of both hands are abnormal, but the abnormalities on the left side are greater than those on the right side. Left-sided upper limb radial ray abnormalities are often greater than those on the right side. The scaphoid and trapezium of the left hand are enlarged and misshapen, resulting in a distal displacement of the thumb. Note the marked abnormalities of the left capitate and hamate. The left radial stylus is flattened.

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      Posteroanterior radiograph of the hands of a pati...

      Posteroanterior radiograph of the hands of a patient with Holt-Oram syndrome. The distal phalanx of the left thumb is hypoplastic. The carpal bones of both hands are abnormal, but the abnormalities on the left side are greater than those on the right side. Left-sided upper limb radial ray abnormalities are often greater than those on the right side. The scaphoid and trapezium of the left hand are enlarged and misshapen, resulting in a distal displacement of the thumb. Note the marked abnormalities of the left capitate and hamate. The left radial stylus is flattened.

  • Individuals without carpal bone abnormalities in the preaxial radial bones do not have Holt-Oram syndrome.

Chest radiography

  • Findings may demonstrate enlarged pulmonary arteries due to pulmonary hypertension or cardiomegaly.
  • Evidence of congestive heart failure may be present.

Echocardiography

  • This is the procedure of choice to define the presence of septal defects or other cardiac anomalies.
  • The most common cardiac anomaly is ostium secundum ASD.
  • Some patients also may have an isolated VSD.
  • Severely affected individuals may present with multiple VSDs (Swiss-cheese septum).
  • Other cardiac anomalies may include abnormal isomerism and anomalous pulmonary venous return.
  • While rare, numerous varieties of complex congenital heart disease may be associated with Holt-Oram syndrome.

Other Tests

  • Perform an ECG to define involvement of the conduction system.
  • If intermittent dysrhythmia is considered, 24-hour Holter monitoring may be useful.
  • Periodic evaluation for conduction system involvement, even in the absence of cardiac structural disease, is important given the progressive nature of this finding.
  • Genetic evaluation is important.8,9
    • Arrange for patients who may possibly have Holt-Oram syndrome to be evaluated by a cardiologist or geneticist with experience in the management of inherited cardiovascular disease.
    • Obtain a detailed family history to ascertain if the disease represents a new mutation or if it is part of a familial syndrome.
    • Consider wrist radiography of the parents of the patient with Holt-Oram syndrome to establish a familial versus sporadic nature of the syndrome in the family.
    • Mutational analysis of TBX5 is not available on a routine clinical basis and remains a research tool.
      • TBX5 mutations are detected in about 75% of individuals meeting strict clinical criteria for Holt-Oram syndrome.3
      • On a case-by-case basis, specifics regarding genotype-phenotype correlations are not available.
      • The ability to identify the disease causing mutation in a family may allow for expanded reproductive options such as preimplantation genetic diagnosis for couples at 50% risk of having an affected child.10

Procedures

Cardiac catheterization can be considered to define the nature and severity of intracardiac shunts in patients at high risk for Eisenmenger syndrome because these patients may require surgical intervention.

More on Holt-Oram Syndrome

Overview: Holt-Oram Syndrome
Differential Diagnoses & Workup: Holt-Oram Syndrome
Treatment & Medication: Holt-Oram Syndrome
Follow-up: Holt-Oram Syndrome
Multimedia: Holt-Oram Syndrome
References
Further Reading
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References

  1. HOLT M, ORAM S. Familial heart disease with skeletal malformations. Br Heart J. Apr 1960;22:236-42. [Medline].

  2. Basson CT, Huang T, Lin RC, et al. Different TBX5 interactions in heart and limb defined by Holt-Oram syndrome mutations. Proc Natl Acad Sci U S A. Mar 16 1999;96(6):2919-24. [Medline].

  3. McDermott DA, Hatcher CJ, Basson CT. Atrial Fibrillation and Other Clinical Manifestations of Altered TBX5 Dosage in Typical Holt-Oram Syndrome. Circ Res. Sep 26 2008;103(7):e96. [Medline].

  4. Cerbai E, Sartiani L. Holt-oram syndrome and atrial fibrillation: opening the (T)-box. Circ Res. Jun 6 2008;102(11):1304-6. [Medline].

  5. Basson CT, Cowley GS, Solomon SD, et al. The clinical and genetic spectrum of the Holt-Oram syndrome (heart-hand syndrome). N Engl J Med. Mar 31 1994;330(13):885-91. [Medline].

  6. Basson CT, Solomon SD, Weissman B, et al. Genetic heterogeneity of heart-hand syndromes. Circulation. Mar 1 1995;91(5):1326-9. [Medline].

  7. McDermott DA, Bressan MC, He J, Lee JS, Aftimos S, Brueckner M. TBX5 genetic testing validates strict clinical criteria for Holt-Oram syndrome. Pediatr Res. Nov 2005;58(5):981-6. [Medline].

  8. Pete B, Harmath A, Szigeti Z, Papp C, Hajdú J. [Holt-Oram syndrome: genetic counseling and diagnosis with prenatal ultrasonography]. Orv Hetil. Nov 18 2007;148(46):2173-6. [Medline].

  9. Sunagawa S, Kikuchi A, Sano Y, Kita M, Ono K, Horikoshi T, et al. Prenatal diagnosis of Holt-Oram syndrome: role of 3-D ultrasonography. Congenit Anom (Kyoto). Mar 2009;49(1):38-41. [Medline].

  10. He J, McDermott DA, Song Y, Gilbert F, Kligman I, Basson CT. Preimplantation genetic diagnosis of human congenital heart malformation and Holt-Oram syndrome. Am J Med Genet A. Apr 1 2004;126A(1):93-8. [Medline].

  11. Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA, et al. ACC/AHA 2008 Guidelines for the Management of Adults with Congenital Heart Disease: Executive Summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to develop guidelines for the management of adults with congenital heart disease). Circulation. Dec 2 2008;118(23):2395-451. [Medline].

  12. Caglayan AO, Koklu E, Saatci C, Gunes T, Ozkul Y, Narin N, et al. Holt-Oram syndrome in two generations with translocation t(9;15)(p12;q11.2). Ann Saudi Med. May-Jun 2008;28(3):209-12. [Medline].

  13. Saura D, Campos JV, Villegas M, Picó F, de la Morena G, Valdés-Chávarri M. Heart-hand syndrome. Int J Cardiol. Sep 16 2008;129(1):e7-9. [Medline].

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Further Reading

Clinical guidelines
Recommendations for physical activity and recreational sports participation for young patients with genetic cardiovascular disease.
American Heart Association - Professional Association. 2004 Jun 8. 10 pages. NGC:003778

ACR Appropriateness Criteria® suspected congenital heart disease in the adult.
American College of Radiology - Medical Specialty Society. 1998 (revised 2007). 8 pages. NGC:005988

Clinical trials

Clinical and Genetic Studies of VACTERL Association

Modified Perfusion for Neonatal Aortic Arch Reconstruction

Related eMedicine topics

Holt-Oram Syndrome (Pediatrics)

Syndactyly

Hand, Congenital Hand Deformities

Atrial Septal Defect

Radial Clubhand

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Keywords

Holt-Oram syndrome, heart-hand syndrome, hand-heart syndrome, heart hand syndrome, hand heart syndrome, congenital heart defect, congenital cardiac defect, atrial septal defect, ASD, ventricular septal defect, VSD, thumb abnormality, heart malformation, upper limb malformation, pseudothalidomide syndrome, carpal bone malformation, carpal bone fusion, carpal bone abnormality, inherited cardiovascular disease, inherited heart disease, inherited cardiac disease, Eisenmenger syndrome

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Contributor Information and Disclosures

Author

Craig T Basson, MD, PhD, FAHA, FACC, Gladys and Roland Harriman Professor of Medicine, Weill Cornell Medical College; Director, Cardiovascular Research, Greenberg Division of Cardiology, Department of Medicine, The New York Presbyterian Hospital
Craig T Basson, MD, PhD, FAHA, FACC is a member of the following medical societies: American College of Cardiology and American Heart Association
Disclosure: Nothing to disclose.

Coauthor(s)

Carl J Vaughan, MD, MRCPI, Adjunct Assistant Professor, Department of Internal Medicine, Division of Cardiology, Weill Medical College of Cornell University; Consulting Cardiologist, Mercy University Hospital, Ireland
Carl J Vaughan, MD, MRCPI is a member of the following medical societies: American College of Cardiology, American College of Physicians, and American Heart Association
Disclosure: Nothing to disclose.

Luke K Kim, MD, Fellow, Department of Internal Medicine, Division of Cardiology, New York Presbyterian Hospital, Weill Cornell Medical Center
Disclosure: Nothing to disclose.

Deborah A McDermott, MS, CGC, Genetic Counselor/Research Associate, Department of Medicine, Division of Cardiology, Weill Medical College of Cornell University
Deborah A McDermott, MS, CGC is a member of the following medical societies: American Society of Human Genetics
Disclosure: Nothing to disclose.

Medical Editor

Russell F Kelly, MD, Program Director, Assistant Professor, Department of Internal Medicine, Division of Cardiology, Cook County Hospital, Rush Medical College
Russell F Kelly, MD is a member of the following medical societies: American College of Cardiology
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Frank M Sheridan, MD, Cardiology, Providence Everett Medical Center
Frank M Sheridan, MD is a member of the following medical societies: American College of Cardiology, American Heart Association, and Society for Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

CME Editor

Amer Suleman, MD, Consultant in Electrophysiology and Cardiovascular Medicine, Department of Internal Medicine, Division of Cardiology, Medical City Dallas Hospital
Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Chief Editor

Park W Willis IV, MD, Sarah Graham Distinguished Professor of Medicine and Pediatrics, University of North Carolina at Chapel Hill School of Medicine
Park W Willis IV, MD is a member of the following medical societies: American Society of Echocardiography
Disclosure: Nothing to disclose.

 
 
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