基因檢測在肥厚型心肌病診斷治療及預(yù)后評價的應(yīng)用進(jìn)展

精選優(yōu)質(zhì)文檔傾情為你奉上精選優(yōu)質(zhì)文檔傾情為你奉上專心專注專業(yè)專心專注專業(yè)精選優(yōu)質(zhì)文檔傾情為你奉上專心專注專業(yè)基因檢測在肥厚型心肌病診斷、治療及預(yù)后評估的應(yīng)用進(jìn)展翟姍姍（1）樊朝美*（2）李一石（3）肥厚型心肌病（HypertrophicCardiomyopathy，HCM）是指并非完全因心臟負(fù)荷異常引起而發(fā)生的，以室壁厚度增加為表現(xiàn)的遺傳性心肌病ADDINEN.CITEADDINEN.CITE.DATA[1]，亦是青少年及運(yùn)動員心源性猝死（SuddenCardiacDeath，SCD）的主要原因，故盡早診斷、治療尤為重要?；驒z測有助于HCM早期診斷，但一代測序技術(shù)的低檢出率及高成本限制了其在臨床中的應(yīng)用，近年來二代測序技術(shù)（NextGenerationSequencing,NGS）的廣泛應(yīng)用彌補(bǔ)了一代測序技術(shù)的不足。本文就基因檢測在HCM診斷、治療及預(yù)后評估的應(yīng)用進(jìn)展做一綜述?；驒z測技術(shù)的進(jìn)展傳統(tǒng)的化學(xué)降解法、雙脫氧鏈終止法以及在它們的基礎(chǔ)上發(fā)展來的各種DNA測序技術(shù)統(tǒng)稱為第一代DNA測序技術(shù)。因?yàn)槌杀靖摺⑺俣嚷?、序列少的第一代測序技術(shù)已經(jīng)不能滿足深度測序和重復(fù)測序等大規(guī)?；蚪M測序的需求。所以，以高通量為特點(diǎn)的第二代測序技術(shù)應(yīng)運(yùn)而生，其原理為邊合成邊測序，可快速并低成本地獲得大規(guī)模DNA序列信息。第二代基因測序（NextGenerationSequencing，NGS）主要有以下方式：（1）靶向基因測序（TargetSequencingInCustomDisease-SpecificPanels，Target-NGS）是對特定疾病的所有已知致病基因進(jìn)行測序，主要用于診斷；（2）全外顯子測序（Whole-ExomeSequencing，WES）是對基因所有編碼區(qū)進(jìn)行測序，主要用于明確可疑遺傳性疾病的致病突變，尤其是Target-NGS無法測得突變時；（3）全基因組測序（Whole-GenomeSequencing,WGS）是指對全基因組30億bpDNA測序，包括編碼區(qū)及非編碼區(qū)，主要是用來明確新發(fā)致病基因與疾病的關(guān)系，在一個個體中可發(fā)現(xiàn)成千上萬的突變，其中大部分突變與臨床無明確相關(guān)性，應(yīng)用WGS最大的挑戰(zhàn)是如何找到與臨床密切相關(guān)的突變。如何處理二道測序所得龐大數(shù)據(jù)，如何嚴(yán)謹(jǐn)分析并解釋新發(fā)突變的致病性均是NGS所應(yīng)對的問題ADDINEN.CITEADDINEN.CITE.DATA[2]?；驒z測在HCM診斷與鑒別診斷中的作用肥厚型心肌病基因檢測最初僅限于實(shí)驗(yàn)室研究，現(xiàn)代基因測序不僅用于HCM的診斷與鑒別診斷，亦可用于優(yōu)生優(yōu)育及預(yù)后的評估。隨著NGS在HCM中的廣泛應(yīng)用，不僅能夠發(fā)現(xiàn)更多非常見的肌節(jié)蛋白突變，還能發(fā)現(xiàn)非HCM致病突變?nèi)鐦蛄５鞍淄蛔?、離子通常蛋白突變，另外NGS亦可檢出擬表型基因突變。如，F(xiàn)abry病的α半乳糖苷酶基因（α-galactosidaseA，GLA）突變ADDINEN.CITEADDINEN.CITE.DATA[3]，這有助于HCM的鑒別診斷。除此之外，NGS還能夠發(fā)現(xiàn)結(jié)構(gòu)變異（StructureVariants，SV）、拷貝數(shù)變異（Copynumbervariation,CNV）ADDINEN.CITE<EndNote><Cite><Author>Lopes</Author><Year>2015</Year><RecNum>231</RecNum><DisplayText><styleface="superscript">[4]</style></DisplayText><record><rec-number>231</rec-number><foreign-keys><keyapp="EN"db-id="vpvs2t0rjxvsriepf29xs9aswr525zzv95pw"timestamp="">231</key></foreign-keys><ref-typename="JournalArticle">17</ref-type><contributors><authors><author>Lopes,L.R.</author><author>Murphy,C.</author><author>Syrris,P.</author><author>Dalageorgou,C.</author><author>McKenna,W.J.</author><author>Elliott,P.M.</author><author>Plagnol,V.</author></authors></contributors><auth-address>InheritedCardiovascularDiseaseUnit,InstituteofCardiovascularScience,UCL,London,UK;CardiovascularCentre,UniversityofLisbon,Lisbon,Portugal. UCLGeneticsInstitute,UCL,London,UK. InheritedCardiovascularDiseaseUnit,InstituteofCardiovascularScience,UCL,London,UK. UCLGeneticsInstitute,UCL,London,UK.Electronicaddress:v.plagnol@ucl.ac.uk.</auth-address><titles><title>Useofhigh-throughputtargetedexome-sequencingtoscreenforcopynumbervariationinhypertrophiccardiomyopathy</title><secondary-title>EurJMedGenet</secondary-title><alt-title>Europeanjournalofmedicalgenetics</alt-title></titles><periodical><full-title>EurJMedGenet</full-title><abbr-1>Europeanjournalofmedicalgenetics</abbr-1></periodical><alt-periodical><full-title>EurJMedGenet</full-title><abbr-1>Europeanjournalofmedicalgenetics</abbr-1></alt-periodical><dates><year>2015</year><pub-dates><date>Oct9</date></pub-dates></dates><isbn>1878-0849(Electronic) 1769-7212(Linking)</isbn><accession-num></accession-num><urls><related-urls><url>/pubmed/</url></related-urls></urls><electronic-resource-num>10.1016/j.ejmg.2015.10.001</electronic-resource-num></record></Cite></EndNote>[4]，以及表觀遺傳學(xué)中DNA甲基化水平和組蛋白修飾因子的改變，探討這些結(jié)果的臨床意義將有助于解釋HCM的異質(zhì)性?；驒z測有助于解釋HCM的異質(zhì)性HCM異質(zhì)性突出是臨床面臨的重大挑戰(zhàn)。HCM患者可無癥狀，也可早期發(fā)生心力衰竭和猝死，這種異質(zhì)性可能受以下因素的影響：（1）致病基因不同；（2）致病突變所累及氨基酸位置不同；（3）修飾因子的影響ADDINEN.CITEADDINEN.CITE.DATA[5]。致病突變可能與心室形態(tài)相關(guān)：早期研究提示HCM的室間隔呈反向曲線形者較乙狀形者的突變陽性率更高（79%比8%），BosJM等ADDINEN.CITE<EndNote><Cite><Author>Bos</Author><Year>2007</Year><RecNum>236</RecNum><IDText>193-9</IDText><DisplayText><styleface="superscript">[6]</style></DisplayText><record><rec-number>236</rec-number><foreign-keys><keyapp="EN"db-id="vpvs2t0rjxvsriepf29xs9aswr525zzv95pw"timestamp="">236</key></foreign-keys><ref-typename="JournalArticle">17</ref-type><contributors><authors><author>Bos,J.M.</author><author>Ommen,S.R.</author><author>Ackerman,M.J.</author></authors></contributors><auth-address>MayoClinicWindlandSmithRiceSuddenDeathGenomicsLaboratory,MayoClinicCollegeofMedicine,Rochester,MN,USA.</auth-address><titles><title>Geneticsofhypertrophiccardiomyopathy:one,two,ormorediseases?</title><secondary-title>CurrOpinCardiol</secondary-title><alt-title>Currentopinionincardiology</alt-title></titles><periodical><full-title>CurrOpinCardiol</full-title><abbr-1>Currentopinionincardiology</abbr-1></periodical><alt-periodical><full-title>CurrOpinCardiol</full-title><abbr-1>Currentopinionincardiology</abbr-1></alt-periodical><pages>193-9</pages><volume>22</volume><number>3</number><keywords><keyword>ActinCytoskeleton</keyword><keyword>Cardiomyopathy,Hypertrophic/diagnosis/*genetics/physiopathology</keyword><keyword>Death,Sudden,Cardiac/etiology</keyword><keyword>GeneticResearch</keyword><keyword>Genotype</keyword><keyword>HeartSeptum/physiopathology</keyword><keyword>Humans</keyword><keyword>Mutation</keyword><keyword>Phenotype</keyword></keywords><dates><year>2007</year><pub-dates><date>May</date></pub-dates></dates><isbn>0268-4705(Print) 0268-4705(Linking)</isbn><accession-num></accession-num><urls><related-urls><url>/pubmed/</url></related-urls></urls><electronic-resource-num>10.1097/HCO.0b013e3280e1cc7f</electronic-resource-num></record></Cite></EndNote>[6]發(fā)現(xiàn)其原因在于反向曲線形肥厚的HCM患者多為肌節(jié)蛋白基因突變所致，乙狀形肥厚的HCM患者多為Z盤基因突變所致。LopesLR等ADDINEN.CITEADDINEN.CITE.DATA[7]進(jìn)一步發(fā)現(xiàn)細(xì)胞膜錨蛋白基因（ankyrin-B，ANK2）所致的HCM患者室間隔最大厚度增加。HCM基因型與心臟核磁共振成像對照研究表明，局部心肌纖維化在基因型陽性的HCM患者中較基因型陰性者中更為常見，而彌漫心肌纖維化與之相反ADDINEN.CITEADDINEN.CITE.DATA[8]。以上研究表明，特定蛋白突變或突變數(shù)量的改變與HCM心室形態(tài)有一定相關(guān)性。肥厚型心肌病與其他遺傳性心肌病的致病基因突變重疊：HaasJ等ADDINEN.CITEADDINEN.CITE.DATA[9]應(yīng)用Target-NGS技術(shù)發(fā)現(xiàn)擴(kuò)張型心肌病、肥厚型心肌病、離子通道心肌病等致病突變的重疊比例很高。SchaeferE等ADDINEN.CITEADDINEN.CITE.DATA[10]對一個6月大小猝死的左室致密化不全患者進(jìn)行NGS測序分析，發(fā)現(xiàn)其攜帶肌球蛋白結(jié)合蛋白C（MyosinBindingProteinC，MYBPC3）雙復(fù)合突變（Lys505del,、Pro955fs）。GirolamiF等ADDINEN.CITEADDINEN.CITE.DATA[11]對一HCM合并早發(fā)房性心律失常的家系進(jìn)行Target-NGS分析，檢測到新發(fā)的α-輔肌動蛋白-2（actininalpha2，ACTN2）為其致病突變，WangLF等ADDINEN.CITEADDINEN.CITE.DATA[12]對一HCM合并長QT綜合征（LongQTsyndrome，LQT）的家系進(jìn)行分析，發(fā)現(xiàn)該家系同時存在LQT1與HCM致病突變。通過對SCD高危人群的基因型進(jìn)行分析發(fā)現(xiàn)，其多突變比例較多ADDINEN.CITE<EndNote><Cite><Author>Kelly</Author><Year>2009</Year><RecNum>102</RecNum><IDText>182-90</IDText><DisplayText><styleface="superscript">[13]</style></DisplayText><record><rec-number>102</rec-number><foreign-keys><keyapp="EN"db-id="vpvs2t0rjxvsriepf29xs9aswr525zzv95pw"timestamp="">102</key><keyapp="ENWeb"db-id="">0</key></foreign-keys><ref-typename="JournalArticle">17</ref-type><contributors><authors><author>Kelly,M.</author><author>Semsarian,C.</author></authors></contributors><auth-address>AgnesGingesCentreforMolecularCardiology,CentenaryInstitute,Newtown,Sydney,NSW2042,Australia.</auth-address><titles><title>Multiplemutationsingeneticcardiovasculardisease:amarkerofdiseaseseverity?</title><secondary-title>CircCardiovascGenet</secondary-title><alt-title>Circulation.Cardiovasculargenetics</alt-title></titles><periodical><full-title>CircCardiovascGenet</full-title><abbr-1>Circulation.Cardiovasculargenetics</abbr-1></periodical><alt-periodical><full-title>CircCardiovascGenet</full-title><abbr-1>Circulation.Cardiovasculargenetics</abbr-1></alt-periodical><pages>182-90</pages><volume>2</volume><number>2</number><keywords><keyword>Animals</keyword><keyword>CardiovascularDiseases/*genetics/*pathology</keyword><keyword>GeneticMarkers</keyword><keyword>Humans</keyword><keyword>*Mutation</keyword><keyword>SeverityofIllnessIndex</keyword></keywords><dates><year>2009</year><pub-dates><date>Apr</date></pub-dates></dates><isbn>1942-3268(Electronic) 1942-3268(Linking)</isbn><accession-num></accession-num><urls><related-urls><url>/pubmed/</url></related-urls></urls><electronic-resource-num>10.1161/CIRCGENETICS.108.</electronic-resource-num></record></Cite></EndNote>[13]。隨著NGS在臨床中的進(jìn)一步應(yīng)用，有可能發(fā)現(xiàn)更多不同心肌病之間致病基因的重疊現(xiàn)象，這很有可能是所有遺傳性心臟病異質(zhì)性的一個重要原因。目前關(guān)于基因型-表型的關(guān)系暫無定論，相信隨著大樣本多中心HCM基因型隨訪研究的開展，將有助于揭示基因型-表型的關(guān)系。基因檢測在HCM治療中的作用4.1藥物治療的新視點(diǎn)藥物、酒精消融術(shù)及手術(shù)治療可以改善HCM患者的癥狀并提高生活質(zhì)量。但并不能夠逆轉(zhuǎn)有病變的心肌，亦不能改善HCM患者的長期預(yù)后。為解決以上問題，已開展了一些新治療藥物的探索性研究，并發(fā)現(xiàn)氯沙坦、辛伐他汀、螺內(nèi)酯以及抗氧化劑N-乙酰半胱氨酸等可以減輕HCM小鼠心肌纖維化程度和減少膠原成分，而這些HCM小鼠均是特定致病突變轉(zhuǎn)基因所建立的模型。因此，將來基因檢測結(jié)果可以影響HCM的治療ADDINEN.CITE<EndNote><Cite><Author>Ho</Author><Year>2010</Year><RecNum>155</RecNum><IDText>2430-40;discussion2440</IDText><DisplayText><styleface="superscript">[14]</style></DisplayText><record><rec-number>155</rec-number><foreign-keys><keyapp="EN"db-id="vpvs2t0rjxvsriepf29xs9aswr525zzv95pw"timestamp="">155</key><keyapp="ENWeb"db-id="">0</key></foreign-keys><ref-typename="JournalArticle">17</ref-type><contributors><authors><author>Ho,C.Y.</author></authors></contributors><auth-address>CardiovascularGeneticsCenter,CardiovascularDivision,BrighamandWomen'sHospital,HarvardMedicalSchool,Boston,MA02115,USA.cho@</auth-address><titles><title>Geneticsandclinicaldestiny:improvingcareinhypertrophiccardiomyopathy</title><secondary-title>Circulation</secondary-title><alt-title>Circulation</alt-title></titles><periodical><full-title>Circulation</full-title><abbr-1>Circulation</abbr-1></periodical><alt-periodical><full-title>Circulation</full-title><abbr-1>Circulation</abbr-1></alt-periodical><pages>2430-40;discussion2440</pages><volume>122</volume><number>23</number><keywords><keyword>Cardiomyopathy,Hypertrophic/*diagnosis/*genetics/therapy</keyword><keyword>GeneticPredispositiontoDisease/*genetics</keyword><keyword>GeneticTesting/methods/*trends</keyword><keyword>Humans</keyword><keyword>PatientCare/methods/*trends</keyword><keyword>TreatmentOutcome</keyword></keywords><dates><year>2010</year><pub-dates><date>Dec7</date></pub-dates></dates><isbn>1524-4539(Electronic) 0009-7322(Linking)</isbn><accession-num></accession-num><urls><related-urls><url>/pubmed/</url></related-urls></urls><custom2></custom2><electronic-resource-num>10.1161/CIRCULATIONAHA.110.</electronic-resource-num></record></Cite></EndNote>[14]。另外，亦有研究表明在MYH7-Arg403Gln或MYH7-Arg719Trp轉(zhuǎn)基因小鼠發(fā)生左室肥厚前，分別給予地爾硫卓、氯沙坦，可以減輕心肌纖維化程度并可延緩左室肥厚的進(jìn)程ADDINEN.CITE<EndNote><Cite><Author>Ho</Author><Year>2010</Year><RecNum>155</RecNum><IDText>2430-40;discussion2440</IDText><DisplayText><styleface="superscript">[14]</style></DisplayText><record><rec-number>155</rec-number><foreign-keys><keyapp="EN"db-id="vpvs2t0rjxvsriepf29xs9aswr525zzv95pw"timestamp="">155</key><keyapp="ENWeb"db-id="">0</key></foreign-keys><ref-typename="JournalArticle">17</ref-type><contributors><authors><author>Ho,C.Y.</author></authors></contributors><auth-address>CardiovascularGeneticsCenter,CardiovascularDivision,BrighamandWomen'sHospital,HarvardMedicalSchool,Boston,MA02115,USA.cho@</auth-address><titles><title>Geneticsandclinicaldestiny:improvingcareinhypertrophiccardiomyopathy</title><secondary-title>Circulation</secondary-title><alt-title>Circulation</alt-title></titles><periodical><full-title>Circulation</full-title><abbr-1>Circulation</abbr-1></periodical><alt-periodical><full-title>Circulation</full-title><abbr-1>Circulation</abbr-1></alt-periodical><pages>2430-40;discussion2440</pages><volume>122</volume><number>23</number><keywords><keyword>Cardiomyopathy,Hypertrophic/*diagnosis/*genetics/therapy</keyword><keyword>GeneticPredispositiontoDisease/*genetics</keyword><keyword>GeneticTesting/methods/*trends</keyword><keyword>Humans</keyword><keyword>PatientCare/methods/*trends</keyword><keyword>TreatmentOutcome</keyword></keywords><dates><year>2010</year><pub-dates><date>Dec7</date></pub-dates></dates><isbn>1524-4539(Electronic) 0009-7322(Linking)</isbn><accession-num></accession-num><urls><related-urls><url>/pubmed/</url></related-urls></urls><custom2></custom2><electronic-resource-num>10.1161/CIRCULATIONAHA.110.</electronic-resource-num></record></Cite></EndNote>[14]。目前HCM的早期干預(yù)臨床研究相對較少，近期有人將HCM基因型陽性攜帶者隨機(jī)分為地爾硫卓治療組與安慰劑組，2年后發(fā)現(xiàn)治療組左心室壁厚度和質(zhì)量、舒張期充盈、心肌肌鈣蛋白I水平均較安慰劑組有所改善ADDINEN.CITEADDINEN.CITE.DATA[15]。相信隨著基因型陽性攜帶者的大規(guī)模隨訪隊(duì)列研究的增多將能證實(shí)HCM早期干預(yù)是否有益。4.2組織工程和再生醫(yī)學(xué)HCM新藥開發(fā)與設(shè)計目前受到兩個方面制約，一是缺少能夠精準(zhǔn)體現(xiàn)HCM病理生理的體外模型；二是業(yè)已建立的小鼠動物模型與人類基因組存在一定差異。應(yīng)用相似于正常心肌結(jié)構(gòu)、生物力學(xué)的仿生成分與可分化為HCM心肌細(xì)胞的多能干細(xì)胞進(jìn)行研究不僅可以加深對HCM發(fā)病機(jī)制、基因型與表型相關(guān)性的理解。而且，還可行特異突變HCM的藥物研究，達(dá)到精準(zhǔn)治療的目的ADDINEN.CITE<EndNote><Cite><Author>VunjakNovakovic</Author><Year>2014</Year><RecNum>285</RecNum><DisplayText><styleface="superscript">[16]</style></DisplayText><record><rec-number>285</rec-number><foreign-keys><keyapp="EN"db-id="vpvs2t0rjxvsriepf29xs9aswr525zzv95pw"timestamp="">285</key></foreign-keys><ref-typename="JournalArticle">17</ref-type><contributors><authors><author>VunjakNovakovic,G.</author><author>Eschenhagen,T.</author><author>Mummery,C.</author></authors></contributors><auth-address>MikatiFoundationMikatiFoundation,ColumbiaUniversity,NewYork,NewYork10032.</auth-address><titles><title>Myocardialtissueengineering:invitromodels</title><secondary-title>ColdSpringHarbPerspectMed</secondary-title><alt-title>ColdSpringHarborperspectivesinmedicine</alt-title></titles><periodical><full-title>ColdSpringHarbPerspectMed</full-title><abbr-1>ColdSpringHarborperspectivesinmedicine</abbr-1></periodical><alt-periodical><full-title>ColdSpringHarbPerspectMed</full-title><abbr-1>ColdSpringHarborperspectivesinmedicine</abbr-1></alt-periodical><volume>4</volume><number>3</number><keywords><keyword>BiocompatibleMaterials/therapeuticuse</keyword><keyword>CellDifferentiation</keyword><keyword>Humans</keyword><keyword>Models,Biological</keyword><keyword>Myocardium/*cytology</keyword><keyword>Myocytes,Cardiac/cytology</keyword><keyword>*TissueEngineering</keyword><keyword>ToxicityTests/methods</keyword></keywords><dates><year>2014</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>2157-1422(Electronic)</isbn><accession-num></accession-num><urls><related-urls><url>/pubmed/</url></related-urls></urls><electronic-resource-num>10.1101/cshperspect.a</electronic-resource-num></record></Cite></EndNote>[16]。心臟再生工程中成纖維細(xì)胞逆轉(zhuǎn)為正常心肌細(xì)胞對于HCM尤為重要，假如在HCM早期就能夠成功逆轉(zhuǎn)左心室肥厚，就可以減少心肌纖維化、延緩病程、減少心源性猝死，盡管這種逆轉(zhuǎn)可以實(shí)現(xiàn)，但其難度大、效率低。納米技術(shù)可攜帶包含逆轉(zhuǎn)所需的miRNA和轉(zhuǎn)錄因子的載體靶向定位于HCM患者的成纖維細(xì)胞并促其逆轉(zhuǎn)，從而達(dá)到治療目的ADDINEN.CITE<EndNote><Cite><Author>Yi</Author><Year>2013</Year><RecNum>298</RecNum><IDText>a</IDText><DisplayText><styleface="superscript">[17]</style></DisplayText><record><rec-number>298</rec-number><foreign-keys><keyapp="EN"db-id="vpvs2t0rjxvsriepf29xs9aswr525zzv95pw"timestamp="">298</key></foreign-keys><ref-typename="JournalArticle">17</ref-type><contributors><authors><author>Yi,B.A.</author><author>Mummery,C.L.</author><author>Chien,K.R.</author></authors></contributors><auth-address>CardiovascularResearchCenter,MassachusettsGeneralHospital,Boston,Massachusetts02114.</auth-address><titles><title>Directcardiomyocytereprogramming:anewdirectionforcardiovascularregenerativemedicine</title><secondary-title>ColdSpringHarbPerspectMed</secondary-title><alt-title>ColdSpringHarborperspectivesinmedicine</alt-title></titles><periodical><full-title>ColdSpringHarbPerspectMed</full-title><abbr-1>ColdSpringHarborperspectivesinmedicine</abbr-1></periodical><alt-periodical><full-title>ColdSpringHarbPerspectMed</full-title><abbr-1>ColdSpringHarborperspectivesinmedicine</abbr-1></alt-periodical><pages>a</pages><volume>3</volume><number>9</number><keywords><keyword>Animals</keyword><keyword>CellTransdifferentiation/*physiology</keyword><keyword>Cells,Cultured</keyword><keyword>CellularReprogramming/physiology</keyword><keyword>Humans</keyword><keyword>Mice</keyword><keyword>Models,Animal</keyword><keyword>Myoblasts,Cardiac/*cytology</keyword><keyword>Myocytes,Cardiac/*cytology</keyword><keyword>Regeneration/*physiology</keyword></keywords><dates><year>2013</year><pub-dates><date>Sep</date></pub-dates></dates><isbn>2157-1422(Electronic)</isbn><accession-num></accession-num><urls><related-urls><url>/pubmed/</url></related-urls></urls><custom2></custom2><electronic-resource-num>10.1101/cshperspect.a</electronic-resource-num></record></Cite></EndNote>[17]，此外，納米技術(shù)憑借其高濃度、高選擇性、高通透性、高聯(lián)合性等四大優(yōu)勢，不僅可將特異藥物運(yùn)送到靶向細(xì)胞，還可運(yùn)送特異的基因，可用于研究HCM特異基因致病機(jī)制以及相應(yīng)的治療方案ADDINEN.CITE<EndNote><Cite><Author>Kumar</Author><Year>2014</Year><RecNum>300</RecNum><IDText>247–298</IDText><DisplayText><styleface="superscript">[18]</style></DisplayText><record><rec-number>300</rec-number><foreign-keys><keyapp="EN"db-id="vpvs2t0rjxvsriepf29xs9aswr525zzv95pw"timestamp="">300</key></foreign-keys><ref-typename="JournalArticle">17</ref-type><contributors><authors><author>Kumar,Narenda</author><author>Kumar,Rajiv</author></authors></contributors><titles><title>NanomedicineforTreatmentofCardiovascularDiseasesandStroke-NanotechnologyandNanomaterialsintheTreatmentofLife-ThreateningDiseases-Chapter5</title><secondary-title>NanotechnologyandNanomaterialsintheTreatmentofLife-ThreateningDiseases</secondary-title></titles><periodical><full-title>NanotechnologyandNanomaterialsintheTreatmentofLife-ThreateningDiseases</full-title></periodical><pages>247–298</pages><dates><year>2014</year></dates><urls></urls></record></Cite></EndNote>[18]?；驒z測在預(yù)后評估中的作用5.1基因檢測可否確定良性與惡性突變早期認(rèn)為肌鈣蛋白T（TroponinTtype2，TNNT2）、β肌球蛋白重鏈（myosin,heavychain7，MYH7）為“惡性突變”，MYBPC3為“良性突變”，以上均為家族性HCM研究，隨后大樣本散發(fā)HCM研究發(fā)現(xiàn)上述結(jié)論并不成立。MYBPC3與MYH7在發(fā)病年齡、肥厚程度、外科手術(shù)比例、HCM及猝死家族史等方面并無差異,隨后PageSP等ADDINEN.CITEADDINEN.CITE.DATA[19]也發(fā)現(xiàn)MYBPC3并非均晚期發(fā)病、預(yù)后好，這類基因型的HCM臨床表型仍存在極大異質(zhì)性，故不能認(rèn)為MYBPC3屬于“良性突變”。TNNT2基因型的大樣本隊(duì)列研究ADDINEN.CITEADDINEN.CITE.DATA[20]發(fā)現(xiàn)該突變患者的心血管死亡風(fēng)險與正常人群無異，將其認(rèn)為是“惡性突變”亦不合理的。BosJM等ADDINEN.CITEADDINEN.CITE.DATA[21]發(fā)現(xiàn)非肌節(jié)蛋突變（MLP/TCAP）所致臨床表型與肌節(jié)蛋白突變所致HCM并無明顯差別。目前的研究發(fā)現(xiàn)HCM基因型陽性者比基因型陰性者預(yù)后差A(yù)DDINEN.CITEADDINEN.CITE.DATA[7]，更易發(fā)展為心力衰竭，且發(fā)病年齡更早、HCM及SCD家族史更為多見、非對稱性左室肥厚比例較多、左室肥厚程度更重、心血管死亡風(fēng)險加重。目前HCM的良、惡性基因之分還存在很多爭議，還不能單純依據(jù)基因測序來決定HCM的預(yù)后，仍需用傳統(tǒng)臨床危險分層的指標(biāo)來識別HCM的SCD高風(fēng)險患者。5.2多突變與預(yù)后的關(guān)系即使在沒有傳統(tǒng)SCD危險因素時，多突變HCM患者的惡性心律失常、心源性猝死、左室極度肥厚、終末期心力衰竭的發(fā)生率等心血管死亡風(fēng)險均較單基因突變的HCM患者明顯升高ADDINEN.CITEADDINEN.CITE.DATA[22]。GirolamiF等ADDINEN.CITEADDINEN.CITE.DATA[23]提出多突變HCM的臨床表型加重為基因劑量效應(yīng)所致，即兩種或以上異常基因過度表達(dá)疊加產(chǎn)生的效應(yīng)。但另有研究表明基因突變之間存在相互作用，雙突變或多突變在HCM中的致病機(jī)制并非為單純的劑量疊加，而是第二個突變與第一個突變相互作用從而加重表型ADDINEN.CITE<EndNote><Cite><Author>Dorn</Author><Year>2014</Year><RecNum>105</RecNum><IDText>208-10</IDText><DisplayText><styleface="superscript">[24]</style></DisplayText><record><rec-number>105</rec-number><foreign-keys><keyapp="EN"db-id="vpvs2t0rjxvsriepf29xs9aswr525zzv95pw"timestamp="">105</key><keyapp="ENWeb"db-id="">0</key></foreign-keys><ref-typename="JournalArticle">17</ref-type><contributors><authors><author>Dorn,G.W.,2nd</author><author>McNally,E.M.</author></authors></contributors><auth-address>FromtheCenterforPharmacogenomics,DepartmentofInternalMedicine,WashingtonUniversitySchoolofMedicine,St.Louis,MO(G.W.D.);andInstituteforCardiovascularResearch,DepartmentofMedicine,TheUniversityofChicago,IL(E.M.M.).emcnally@gdorn@.</auth-address><titles><title>Twostrikesandyou'reout:gene-genemutationinteractionsinHCM</title><secondary-title>CircRes</secondary-title><alt-title>Circulationresearch</alt-title></titles><periodical><full-title>CircRes</full-title><abbr-1>Circulationresearch</abbr-1></periodical><alt-periodical><full-title>CircRes</full-title><abbr-1>Circulationresearch</abbr-1></alt-periodical><pages>208-10</pages><volume>115</volume><number>2</number><keywords><keyword>*AminoAcidSubstitution</keyword><keyword>Animals</keyword><keyword>CardiacMyosins</keyword><keyword>Cardiomyopathy,Hypertrophic,Familial/*genetics</keyword><keyword>Humans</keyword><keyword>*Mutation,Missense</keyword><keyword>MyosinHeavyChains/*genetics</keyword><keyword>*PointMutation</keyword></keywords><dates><year>2014</year><pub-dates><date>Jul7</date></pub-dates></dates><isbn>1524-4571(Electronic) 0009-7330(Linking)</isbn><accession-num></accession-num><urls><related-urls><url>/pubmed/</url></related-urls></urls><custom2></custom2><electronic-resource-num>10.1161/CIRCRESAHA.114.</electronic-resource-num></record></Cite></EndNote>[24]。多突變引起表型加重的機(jī)制需在分子、細(xì)胞、動物實(shí)驗(yàn)中進(jìn)一步分析，現(xiàn)已發(fā)現(xiàn)鈣離子通道調(diào)節(jié)基因表達(dá)下調(diào)以及轉(zhuǎn)錄因子STAT-3的上調(diào)與雙突變致病性相關(guān)ADDINEN.CITE<EndNote><Cite><Author>Kelly</Author><Year>2009</Year><RecNum>102</RecNum><IDText>182-90</IDText><DisplayText><styleface="superscript">[13]</style></DisplayText><record><rec-number>102</rec-number><foreign-keys><keyapp="EN"db-id="vpvs2t0rjxvsriepf29xs9aswr525zzv95pw"timestamp="">102</key><keyapp="ENWeb"db-id="">0</key></foreign-keys><ref-typename="JournalArticle">17</ref-type><contributors><authors><author>Kelly,M.</author><author>Semsarian,C.</author></authors></contributors><auth-address>AgnesGingesCentreforMolecularCardiology,CentenaryInstitute,Newtown,Sydney,NSW2042,Australia.</auth-address><titles><title>Multiplemutationsingeneticcardiovasculardisease:amarkerofdiseaseseverity?</title><secondary-title>CircCardiovascGenet</secondary-title><alt-title>Circulation.Cardiovasculargenetics</alt-title></titles><periodical><full-title>CircCardiovascGenet</full-title><abbr-1>Circulation.Cardiovasculargenetics</abbr-1></periodical><alt-periodical><full-title>CircCardiovascGenet</full-title><abbr-1>Circulation.Cardiovasculargenetics</abbr-1></alt-periodical><pages>182-90</pages><volume>2</volume><number>2</number><keywords><keyword>Animals</keyword><keyword>CardiovascularDiseases/*genetics/*pathology</keyword><keyword>GeneticMarkers</keyword><keyword>Humans</keyword><keyword>*Mutation</keyword><keyword>SeverityofIllnessIndex</keyword></keywords><dates><year>2009</year><pub-dates><date>Apr</date></pub-dates></dates><isbn>1942-3268(Electronic) 1942-3268(Linking)</isbn><accession-num></accession-num><urls><related-urls><url>/pubmed/</url></related-urls></urls><electronic-resource-num>10.1161/CIRCGENETICS.108.</electronic-resource-num></record></Cite></EndNote>[13]，這一發(fā)現(xiàn)對今后的研究將有極大幫助。隨著NGS的應(yīng)用，HCM雙突變率從一代測序技術(shù)所發(fā)現(xiàn)的5%上升到38%，三突變或更多突變達(dá)12.8%ADDINEN.CITEADDINEN.CITE.DATA[9]。雖然還未有研究能證明多突變?yōu)楠?dú)立的危險因素。但是，未來的大樣本長期隨訪研究將給出明確答案?；驒z測與一級親屬的篩查先證者親屬基因篩查的前提是先證者的致病突變已明確，值得注意的是，采用一代測序技術(shù)能夠明確突變的先證者僅占50%，其中很多突變致病性質(zhì)仍不確定。因此，僅有有限的先證者所在家系可以進(jìn)行基因篩查。目前基因篩查的主要應(yīng)用目的為在家族性HCM的家系成員中篩查出基因型陰性的成員并宣告其無發(fā)病可能，這樣可以減少其心理負(fù)擔(dān)和不必要的長期隨訪。但是，HCM的“無罪宣告”需要特別謹(jǐn)慎。同時還需向基因型陰性的成員告知如有不適，也需及時就診。究其原因歸為以下四點(diǎn)：（1）既往認(rèn)為無或不確定致病性的突變有可能為致病突變;（2）先證者可能為多突變，而基因篩查僅進(jìn)行單個突變的篩查，遺漏了第二個或第三個致病突變;（3）實(shí)驗(yàn)室等因素的人為錯誤;（4）原始突變，初期先證者并無突變，子代新生的原始突變?？傊琀CM家系成員基因篩查的應(yīng)用看似容易，但其結(jié)果的解釋與建議需要多學(xué)科合作方能最為優(yōu)化ADDINEN.CITEADDINEN.CITE.DATA[25]?；驕y序與優(yōu)生優(yōu)育產(chǎn)前遺傳診斷是指在妊娠初期對患者外周血、羊水及臍帶血等進(jìn)行基因檢測，有助于早期發(fā)現(xiàn)胎兒是否攜帶致病基因，但是該方法除在檢測時機(jī)、準(zhǔn)確性、安全性諸多方面仍存在問題外，如何處理基因型陽性攜帶者還存在醫(yī)學(xué)倫理問題。因?yàn)椴⒎撬兄虏』驍y帶者在其一生中均會出現(xiàn)臨床表型。由于產(chǎn)前遺傳診斷在大部分國家非合法，其他手段如收養(yǎng)、人工授精、使用捐贈的配子以及胚胎植入前遺傳學(xué)診斷（Pre-ImplantationGeneticDiagnosis，PGD）等有助于優(yōu)生優(yōu)育。其中，PGD??可以協(xié)助遺傳性心肌病的患者孕育不攜帶致病基因的受精卵胚胎，近期AnverKuliev等對9對遺傳性心臟病的夫妻行PGD發(fā)現(xiàn)其應(yīng)用的優(yōu)勢及安全性，尤其是對有青年心源性猝死、ICD植入、室性心動過速、心臟移植等家族史的夫妻有一定幫助，但應(yīng)用PGD之前必須仔細(xì)權(quán)衡夫妻的需求ADDINEN.CITEADDINEN.CITE.DATA[26]?？偨Y(jié)與展望基因檢測有助于HCM早期診斷，二代測序技術(shù)不僅能提高致病突變檢出率與經(jīng)濟(jì)效益比值，還可發(fā)現(xiàn)新發(fā)的致病突變及突變形式，并進(jìn)一步揭示基因型與表型的關(guān)聯(lián)性?；驒z測在評價HCM預(yù)后方面亦有幫助，多突變有可能是HCM患者SCD危險因素之一。盡管心臟組織工程、再生醫(yī)學(xué)、納米技術(shù)處于起步研究階段，但聯(lián)合研究將有助于深入了解HCM的發(fā)病機(jī)制和開發(fā)新的治療藥物。參考文獻(xiàn)ADDINEN.REFLIST[1] 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