Calcification of the aortic valve is the third leading cause of heart disease in adults1. The incidence increases with age, and it is often associated with a bicuspid aortic valve present in 1–2% of the population2. Despite the frequency, neither the mechanisms of valve calcification nor the developmental origin of a two, rather than three, leaflet aortic valve is known. Here, we show that mutations in the signalling and transcriptional regulator NOTCH1 cause a spectrum of developmental aortic valve anomalies and severe valve calcification in non-syndromic autosomal-dominant human pedigrees. Consistent with the valve calcification phenotype, Notch1 transcripts were most abundant in the developing aortic valve of mice, and Notch1 repressed the activity of Runx2, a central transcriptional regulator of osteoblast cell fate. The hairy-related family of transcriptional repressors (Hrt), which are activated by Notch1 signalling, physically interacted with Runx2 and repressed Runx2 transcriptional activity independent of histone deacetylase activity. These results suggest that NOTCH1 mutations cause an early developmental defect in the aortic valve and a later de-repression of calcium deposition that causes progressive aortic valve disease.
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The authors thank the families for their participation; the Divisions of Pediatric Cardiology and Pediatric Cardiothoracic Surgery at Children's Medical Center Dallas for assistance with clinical information; McDermott Center for Human Growth and Development for assistance with linkage analysis and allelic discrimination assays; Dallas Heart Study participants and investigators for DNA samples; members of the Molecular Histology Core laboratory for radioactive-section in situ hybridization; J. C. Cohen and H. H. Hobbs for discussions and critical review of this manuscript; K. Ivey for graphics assistance; C. Butler, A. Garg and D. Srivastava for assistance with blood collection; G. Karsenty for Runx2 expression and p6OSE2 reporter plasmids; and L. Kedes for the GST–Hrt2 expression plasmid. This work was supported by grants from NICHD/NIH and March of Dimes Birth Defects Foundation to V.G., and NHLBI/NIH, March of Dimes Birth Defects Foundation and the Donald W. Reynolds Cardiovascular Clinical Research Center to D.S. J.F.R. was supported by a training grant from NIH; I.N.K. is an NICHD/NIH fellow of the Pediatric Scientist Development Program; and D.S. is an Established Investigator of the American Heart Association.
Reprints and permissions information is available at npg.nature.com/reprintsandpermissions. The authors declare no competing financial interests.
Text to accompany the below Supplementary Figures. (DOC 20 kb)
Clinical phenotype of Family A and Family B. (PDF 1217 kb)
Pedigree of Family A with haplotype data. (PDF 155 kb)
Ethnicity data for NOTCH1 polymorphisms. (PDF 111 kb)
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Garg, V., Muth, A., Ransom, J. et al. Mutations in NOTCH1 cause aortic valve disease. Nature 437, 270–274 (2005). https://doi.org/10.1038/nature03940
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