eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Cardiology
Velocardiofacial Syndrome
Updated: Feb 4, 2009
Introduction
Background
Velocardiofacial syndrome (VCFS) is a genetic condition characterized by abnormal pharyngeal arch development that results in defective development of the parathyroid glands, thymus, and conotruncal region of the heart. Shprintzen and colleagues first described the syndrome in 1978.1 More than 180 different clinical features are associated with velocardiofacial syndrome, with no single anomaly present in every patient. Some abnormalities are more common than others. Affected individuals may present with structural or functional palatal abnormalities, cardiac defects, unique facial characteristics, hypernasal speech, hypotonia, and defective thymic development.
An estimated 75% of patients with velocardiofacial syndrome have cardiac anomalies.2 The cardiac defects are usually of the conotruncal type, which occur secondary to abnormal development of the outflow portion of the developing heart. The most common cardiac defects include interrupted aortic arch type B (50%), truncus arteriosus (34.5%) and tetralogy of Fallot (16%). Other cardiac defects include pulmonary atresia with ventricular septal defect, absent pulmonary valve syndrome, ventricular septal defect (especially when accompanied by aortic arch anomalies), aortic stenosis, anomalies of the aortic arch or its major branches, and pulmonary artery anomalies.3 D-transposition of the great arteries is rare.
Palatal abnormalities predispose to speech and feeding difficulties.
The defective thymic development is associated with impaired immune function. This condition not only predisposes to an increased risk of infection but also predisposes some individuals to develop autoimmunity. Parathyroid and immune deficiencies can progress or resolve with time.
In addition, affected individuals may present with learning disabilities, overt developmental delay, psychiatric disorders, and renal and musculoskeletal defects.
Ophthalmologic abnormalities are seen in 70% of patients with velocardiofacial syndrome, such as posterior embryotoxon, bilateral cataracts, tortuous retinal vessels, and small optic disks. Other rare anomalies include congenital absence of the nasolacrimal duct.4
About 10% of patients with velocardiofacial syndrome have DiGeorge syndrome, which consists of at least 2 of the following features:
- Conotruncal cardiac anomaly
- Hypoparathyroidism, hypocalcemia
- Thymic aplasia, immune deficiency
As many as 15-20% of patients have Pierre Robin syndrome, which includes small jaw, U-shaped cleft palate, and glossoptosis. Reports indicate that some patients with velocardiofacial syndrome may be mistakenly categorized as having CHARGE syndrome (ie, coloboma, heart defect, atresia choanae, retarded growth and development, and/or CNS anomalies, genital hypoplasia, and ear anomalies and/or deafness). Velocardiofacial syndrome is a specific syndrome that includes as part of its phenotypic spectrum the DiGeorge sequence, the Pierre Robin sequence, and disorders associated with CHARGE syndrome.
Pathophysiology
This congenital disorder is caused by a deletion (microdeletion) at the q11.2 band, which is located on the long arm (q) of chromosome 22. This microdeletion causes an abnormality of morphogenesis that, in part, affects the migration of the neural crest cells and the early development of branchial arches.
In 90% of cases, the disorder occurs as the result of a new mutation in the form of a de-novo 3-megabase microdeletion or translocation. This 3-megabase microdeletion encompasses a region that contains 40 genes.5 These genes have a role in organ development, including the heart and the CNS. These genes likely affect coronary artery development, given the number of coronary artery abnormalities associated with conotruncal defects.6
In 10% of cases, the disorder is inherited from a parent in an autosomal dominant fashion.
The 22q11.2 microdeletion is more common in patients with aortic arch or major aortic branch vessel or pulmonary vessel anomalies.3 Therefore, these patients should undergo genetic testing. However, a wide spectrum of clinical findings is reported among subjects with the 22q11.2 deletion, without genotype or phenotype correlation, even among affected family members and between patients with identical deletions.7,8
Patients have a 50% chance of passing velocardiofacial syndrome to each offspring. The microdeletion is detectable with current cytogenetic and fluorescence in situ hybridization (FISH) techniques.
Frequency
United States
The prevalence of velocardiofacial syndrome in the United States is approximately 1:2,000.5
International
Velocardiofacial syndrome occurs in 1 per 4000 births worldwide, according to estimates. Among those with conotruncal heart defects, the incidence is 10-30%. Among those with cleft palate without an associated cleft lip, the frequency of velocardiofacial syndrome is 8%.
Mortality/Morbidity
Truncus arteriosus, absent pulmonary valve syndrome, and interrupted aortic arch type B are the most serious defects. Surgical correction, which must be performed in the infant, carries a higher risk. Unrecognized hypocalcemia can be associated with seizures.
Abnormal vessel course can increase morbidity. For example, abnormal course of the internal carotid arteries and other blood vessels in the pharynx can create a significant surgical risk during pharyngoplasty for velopharyngeal incompetence. An anomalously oriented ascending aorta may cause severe left main bronchus obstruction secondary to external compression.9
Complete DiGeorge syndrome with total absence of the thymus and a severe T-cell immunodeficiency accounts for less than 0.5% of patients with velocardiofacial syndrome. Instead, most patients with 22q11.2 deletion syndromes have partial defects with impaired thymic development with variable defects in T-cell numbers. In these patients, immunodeficiency may also be secondary to proliferative responses. In addition, humoral deficiencies have also been identified, and this particular group of patients is at increased risk of developing various autoimmune diseases.8 Patients with sufficient CD4(+) T cells but low numbers of cytotoxic CD3(+)CD8(+) T cells are more susceptible to noncardiac mortality secondary to lymphoproliferative disorders and lethal infections.10
Race
No racial predilection is noted.
Sex
No sexual predilection is observed.
Age
Velocardiofacial syndrome is present at birth but may not be recognized until childhood or later. A heart defect or overt cleft palate may be detected prenatally or at birth. A submucous cleft palate, velopharyngeal incompetence (VPI), or speech and developmental delay may not be recognized until the child is older than 1 year. Hypernasal speech is common. Learning disorders and psychiatric illness may become apparent between school age and adulthood.
Clinical
History
- Cyanosis may be present in individuals with velocardiofacial syndrome (VCFS) if cardiac disease is also present (eg, truncus arteriosus, tetralogy of Fallot).
- Feeding difficulty and slow growth may occur due to congestive heart failure, palatal abnormality, or hypotonia.
- Nasal regurgitation of formula in infancy is common in patients later diagnosed with submucous cleft palate.
- Delayed speech development associated with poor articulation and hypernasality can be caused by velopharyngeal incompetence (VPI). Patients may be unresponsive to speech therapy.
- Recurrent otitis media associated with palatal abnormality can contribute to speech delay and hearing loss, which often require the placement of ventilating tubes.
- Developmental delay in infants with a learning disorder becomes apparent in childhood. Attention deficit hyperactivity disorder (ADHD) occurs in 35-55% of persons with velocardiofacial syndrome.
- Poor social interaction or behavioral difficulties are common. Psychiatric disorders (including obsessive-compulsive disorder and schizophrenia) are reported in at least 10% of patients.
- Seizures related to hypocalcemia generally occur in the first year of life. The hypocalcemia generally resolves spontaneously over time, although a small number of patients present with hypocalcemia in the teen years. Frequent upper respiratory infections are commonly reported.
- Short stature has been reported in approximately 30% of patients with velocardiofacial syndrome.
Physical
- Cyanosis may be present if an obligate systemic-to-pulmonic (right-to-left) shunt is present.
- A heart murmur is present in most patients with a cardiac defect.
- Craniofacial dysmorphism is often observed as a round face in infancy with prominent parietal bones and a bulbous nasal tip. The face appears long and hypotonic with narrow palpebral fissures, puffy upper eyelids, a squared nasal root, and a narrow alar base with thin alae nasi. Facial asymmetry, microcephaly, and small, often unusually shaped, ears may be noted at any age.
- A palatal abnormality can manifest as an overt cleft palate affecting the hard or soft palate or as a submucous cleft palate that can be detected upon palpation of the hard palate. Even a normal-appearing palate can be associated with velopharyngeal incompetence.
- Hypernasal speech and poor articulation often are observed.
- Hypospadias or cryptorchidism may be present in males.
- Varying degrees of hypotonia are observed in patients and may be associated with delay of motor, speech, and feeding skills. The presence of developmental delays is independent from the presence of a hearing defect.
- Long and tapering fingers are a common sign of velocardiofacial syndrome.
Causes
- Most patients with velocardiofacial syndrome have a microdeletion at the q11.2 locus of the long arm of chromosome 22. About 10% of patients inherit this deletion from a parent, and the rest have it as the result of a new mutation.
- Abnormal exchange between chromosome 22s during meiosis is the predominant mechanism for this deletion.
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| References |
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References
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Further Reading
Keywords
velocardiofacial syndrome, VCFS, DiGeorge sequence, Shprintzen syndrome, Shprintzen's syndrome, 22q11.2 deletion, cardiac defects, hypernasal speech, hypotonia, interrupted aortic arch, truncus arteriosus, tetralogy of Fallot, pulmonary atresia, ventricular septal defect, VSD, absent pulmonary valve syndrome, aortic stenosis, learning disabilities, developmental delay, posterior embryotoxon, bilateral cataracts, tortuous retinal vessels, small optic disks, Pierre Robin syndrome, CHARGE syndrome, lymphoproliferative disorders, cleft palate, velopharyngeal incompetence, congestive heart failure, hypotonia, recurrent otitis media, attention deficit hyperactivity disorder, ADHD, obsessive-compulsive disorder, schizophrenia, heart murmur, cryptorchidism, hypospadias
