Sequential Defects in Cardiac Lineage Commitment and Maturation Cause Hypoplastic Left Heart Syndrome

Circulation, vol. 144, pp. 1409–1428

Abstract

BACKGROUND: Complex molecular programs in specific cell lineages govern human heart development. Hypoplastic left heart syndrome (HLHS) is the most common and severe manifestation within the spectrum of left ventricular outflow tract obstruction defects occurring in association with ventricular hypoplasia. The pathogenesis of HLHS is unknown, but hemodynamic disturbances are assumed to play a prominent role. METHODS: To identify perturbations in gene programs controlling ventricular muscle lineage development in HLHS, we performed whole-exome sequencing of 87 HLHS parent-offspring trios, nuclear transcriptomics of cardiomyocytes from ventricles of 4 patients with HLHS and 15 controls at different stages of heart development, single cell RNA sequencing, and 3D modeling in induced pluripotent stem cells from 3 patients with HLHS and 3 controls. RESULTS: Gene set enrichment and protein network analyses of damaging de novo mutations and dysregulated genes from ventricles of patients with HLHS suggested alterations in specific gene programs and cellular processes critical during fetal ventricular cardiogenesis, including cell cycle and cardiomyocyte maturation. Single-cell and 3D modeling with induced pluripotent stem cells demonstrated intrinsic defects in the cell cycle/unfolded protein response/autophagy hub resulting in disrupted differentiation of early cardiac progenitor lineages leading to defective cardiomyocyte subtype differentiation/maturation in HLHS. Premature cell cycle exit of ventricular cardiomyocytes from patients with HLHS prevented normal tissue responses to developmental signals for growth, leading to multinucleation/polyploidy, accumulation of DNA damage, and exacerbated apoptosis, all potential drivers of left ventricular hypoplasia in absence of hemodynamic cues. CONCLUSIONS: Our results highlight that despite genetic heterogeneity in HLHS, many mutations converge on sequential cellular processes primarily driving cardiac myogenesis, suggesting novel therapeutic approaches.

Authors 46

1. Markus Krane corresponding

   TUM Klinikum · German Centre for Cardiovascular Research · Technical University of Munich

   Affiliation as printed

   DZHK (German Centre for Cardiovascular Research)–partner site Munich Heart Alliance, Germany (M.K., A.D., C.K., R.L., T.M., D.S., K.-L.L., A.M.)

   Department of Cardiovascular Surgery, Institute Insure (M.K., M.D., H.L., S.A.D., N.P., I.N., Z.Z., C.A.-A., R.L.),Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

2. Martina Dreßen corresponding

   TUM Klinikum · Technical University of Munich

   Affiliation as printed

   Department of Cardiovascular Surgery, Institute Insure (M.K., M.D., H.L., S.A.D., N.P., I.N., Z.Z., C.A.-A., R.L.),Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

3. Gianluca Santamaria corresponding

   TUM Klinikum · Technical University of Munich

   Affiliation as printed

   Department of Internal Medicine I, Cardiology (G.S., I.M., C.M.S., T.D., S.L., E.M., H.R., T.B., A.G., C.K., D.S., K.-L.L., A.M.), Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

   Gianluca Santamaria https://orcid.org/0000-0001-9284-7492 Department of Internal Medicine I, Cardiology (G.S., I.M., C.M.S., T.D., S.L., E.M., H.R., T.B., A.G., C.K., D.S., K.-L.L., A.M.), Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

4. Ilaria My corresponding

   TUM Klinikum · Technical University of Munich

   Affiliation as printed

   Department of Internal Medicine I, Cardiology (G.S., I.M., C.M.S., T.D., S.L., E.M., H.R., T.B., A.G., C.K., D.S., K.-L.L., A.M.), Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

   Ilaria My Department of Internal Medicine I, Cardiology (G.S., I.M., C.M.S., T.D., S.L., E.M., H.R., T.B., A.G., C.K., D.S., K.-L.L., A.M.), Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

5. Christine M. Schneider corresponding

   TUM Klinikum · Technical University of Munich

   Affiliation as printed

   Department of Internal Medicine I, Cardiology (G.S., I.M., C.M.S., T.D., S.L., E.M., H.R., T.B., A.G., C.K., D.S., K.-L.L., A.M.), Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

   Christine M. Schneider https://orcid.org/0000-0001-8492-2982 Department of Internal Medicine I, Cardiology (G.S., I.M., C.M.S., T.D., S.L., E.M., H.R., T.B., A.G., C.K., D.S., K.-L.L., A.M.), Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

6. Tatjana Dorn corresponding

   TUM Klinikum · Technical University of Munich

   Affiliation as printed

   Department of Internal Medicine I, Cardiology (G.S., I.M., C.M.S., T.D., S.L., E.M., H.R., T.B., A.G., C.K., D.S., K.-L.L., A.M.), Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

   Tatjana Dorn Department of Internal Medicine I, Cardiology (G.S., I.M., C.M.S., T.D., S.L., E.M., H.R., T.B., A.G., C.K., D.S., K.-L.L., A.M.), Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

7. Svenja Laue corresponding

   TUM Klinikum · Technical University of Munich

   Affiliation as printed

   Department of Internal Medicine I, Cardiology (G.S., I.M., C.M.S., T.D., S.L., E.M., H.R., T.B., A.G., C.K., D.S., K.-L.L., A.M.), Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

   Svenja Laue Department of Internal Medicine I, Cardiology (G.S., I.M., C.M.S., T.D., S.L., E.M., H.R., T.B., A.G., C.K., D.S., K.-L.L., A.M.), Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

8. Elisa Mastantuono

   TUM Klinikum · Helmholtz Munich · Deutsches Herzzentrum München · Institut für Humangenetik · Technical University of Munich

   Affiliation as printed

   Department of Internal Medicine I, Cardiology (G.S., I.M., C.M.S., T.D., S.L., E.M., H.R., T.B., A.G., C.K., D.S., K.-L.L., A.M.), Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

   German Heart Center Munich, and Institute of Human Genetics (E.M., R.B., T.M.), Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

   Helmholtz Zentrum München, Neuherberg, Germany (E.M., R.B., T.M.)

9. Riccardo Berutti

   TUM Klinikum · Helmholtz Munich · Deutsches Herzzentrum München · Institut für Humangenetik · Technical University of Munich

   Affiliation as printed

   German Heart Center Munich, and Institute of Human Genetics (E.M., R.B., T.M.), Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

   Helmholtz Zentrum München, Neuherberg, Germany (E.M., R.B., T.M.)

10. Hilansi Rawat

    TUM Klinikum · Technical University of Munich

    Affiliation as printed

    Department of Internal Medicine I, Cardiology (G.S., I.M., C.M.S., T.D., S.L., E.M., H.R., T.B., A.G., C.K., D.S., K.-L.L., A.M.), Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

    Hilansi Rawat Department of Internal Medicine I, Cardiology (G.S., I.M., C.M.S., T.D., S.L., E.M., H.R., T.B., A.G., C.K., D.S., K.-L.L., A.M.), Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

11. Ralf Gilsbach

    Goethe University Frankfurt · University of Freiburg · German Centre for Cardiovascular Research

    Affiliation as printed

    DZHK (German Centre for Cardiovascular Research)–partner site RheinMain, Frankfurt am Main, Germany (R.G.)

    Institute for Cardiovascular Physiology, Goethe University, Frankfurt am Main, Germany (R.G.)

    Institute of Experimental and Clinical Pharmacology and Toxicology (R.G., P.S., L.H.), University of Freiburg, Germany

12. Pedro Schneider

    University of Freiburg

    Affiliation as printed

    Institute of Experimental and Clinical Pharmacology and Toxicology (R.G., P.S., L.H.), University of Freiburg, Germany

    Pedro Schneider https://orcid.org/0000-0002-1525-7816 Institute of Experimental and Clinical Pharmacology and Toxicology (R.G., P.S., L.H.), University of Freiburg, Germany

13. Harald Lahm

    TUM Klinikum · Technical University of Munich

    Affiliation as printed

    Department of Cardiovascular Surgery, Institute Insure (M.K., M.D., H.L., S.A.D., N.P., I.N., Z.Z., C.A.-A., R.L.),Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

    Harald Lahm https://orcid.org/0000-0002-4477-3406 Department of Cardiovascular Surgery, Institute Insure (M.K., M.D., H.L., S.A.D., N.P., I.N., Z.Z., C.A.-A., R.L.),Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

14. Sascha Schwarz

    Munich University of Applied Sciences

    Affiliation as printed

    Center for Applied Tissue Engineering and Regenerative Medicine (CANTER), Munich University of Applied Sciences, Germany (S. Schwarz, S. Sudhop)

    Sascha Schwarz Center for Applied Tissue Engineering and Regenerative Medicine (CANTER), Munich University of Applied Sciences, Germany (S. Schwarz, S. Sudhop)

15. Stefanie A. Doppler

    TUM Klinikum · Technical University of Munich

    Affiliation as printed

    Department of Cardiovascular Surgery, Institute Insure (M.K., M.D., H.L., S.A.D., N.P., I.N., Z.Z., C.A.-A., R.L.),Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

    Stefanie A. Doppler Department of Cardiovascular Surgery, Institute Insure (M.K., M.D., H.L., S.A.D., N.P., I.N., Z.Z., C.A.-A., R.L.),Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

16. Sharon L. Paige

    Stanford Medicine · Stanford Cardiovascular Institute · Stanford University

    Affiliation as printed

    Cardiovascular Institute, Stanford University School of Medicine, CA (S.P., S.W.)

    Sharon Paige https://orcid.org/0000-0001-6720-5957 Cardiovascular Institute, Stanford University School of Medicine, CA (S.P., S.W.)

17. Nazan Puluca

    TUM Klinikum · Technical University of Munich

    Affiliation as printed

    Department of Cardiovascular Surgery, Institute Insure (M.K., M.D., H.L., S.A.D., N.P., I.N., Z.Z., C.A.-A., R.L.),Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

    Nazan Puluca Department of Cardiovascular Surgery, Institute Insure (M.K., M.D., H.L., S.A.D., N.P., I.N., Z.Z., C.A.-A., R.L.),Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

18. Sophia Doll

    Max Planck Society · Max Planck Institute of Biochemistry

    Affiliation as printed

    Proteomics and Signal Transduction, Max-Planck Institute of Biochemistry, Martinsried, Germany (S.D., M.M.)

    Sophia Doll Proteomics and Signal Transduction, Max-Planck Institute of Biochemistry, Martinsried, Germany (S.D., M.M.)

19. Irina Neb

    TUM Klinikum · Technical University of Munich

    Affiliation as printed

    Department of Cardiovascular Surgery, Institute Insure (M.K., M.D., H.L., S.A.D., N.P., I.N., Z.Z., C.A.-A., R.L.),Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

    Irina Neb Department of Cardiovascular Surgery, Institute Insure (M.K., M.D., H.L., S.A.D., N.P., I.N., Z.Z., C.A.-A., R.L.),Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

20. Thomas Brade

    TUM Klinikum · Technical University of Munich

    Affiliation as printed

    Department of Internal Medicine I, Cardiology (G.S., I.M., C.M.S., T.D., S.L., E.M., H.R., T.B., A.G., C.K., D.S., K.-L.L., A.M.), Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

    Thomas Brade Department of Internal Medicine I, Cardiology (G.S., I.M., C.M.S., T.D., S.L., E.M., H.R., T.B., A.G., C.K., D.S., K.-L.L., A.M.), Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

21. Zhong Zhang

    TUM Klinikum · Technical University of Munich

    Affiliation as printed

    Department of Cardiovascular Surgery, Institute Insure (M.K., M.D., H.L., S.A.D., N.P., I.N., Z.Z., C.A.-A., R.L.),Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

    Zhong Zhang Department of Cardiovascular Surgery, Institute Insure (M.K., M.D., H.L., S.A.D., N.P., I.N., Z.Z., C.A.-A., R.L.),Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

22. Claudia Abou‐Ajram

    TUM Klinikum · Technical University of Munich

    Affiliation as printed

    Department of Cardiovascular Surgery, Institute Insure (M.K., M.D., H.L., S.A.D., N.P., I.N., Z.Z., C.A.-A., R.L.),Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

    Claudia Abou-Ajram Department of Cardiovascular Surgery, Institute Insure (M.K., M.D., H.L., S.A.D., N.P., I.N., Z.Z., C.A.-A., R.L.),Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

23. Bernd H. Northoff

    LMU Klinikum · Institut für Laboratoriumsmedizin · Ludwig-Maximilians-Universität München

    Affiliation as printed

    Institute of Laboratory Medicine (B.N., L.M.H.), University Hospital, LMU Munich, Germany

    Bernd Northoff https://orcid.org/0000-0002-7333-3231 Institute of Laboratory Medicine (B.N., L.M.H.), University Hospital, LMU Munich, Germany

24. Lesca Miriam Holdt

    LMU Klinikum · Institut für Laboratoriumsmedizin · Ludwig-Maximilians-Universität München

    Affiliation as printed

    Institute of Laboratory Medicine (B.N., L.M.H.), University Hospital, LMU Munich, Germany

    Lesca M. Holdt Institute of Laboratory Medicine (B.N., L.M.H.), University Hospital, LMU Munich, Germany

25. Stefanie Sudhop

    Munich University of Applied Sciences

    Affiliation as printed

    Center for Applied Tissue Engineering and Regenerative Medicine (CANTER), Munich University of Applied Sciences, Germany (S. Schwarz, S. Sudhop)

    Stefanie Sudhop https://orcid.org/0000-0002-0838-9503 Center for Applied Tissue Engineering and Regenerative Medicine (CANTER), Munich University of Applied Sciences, Germany (S. Schwarz, S. Sudhop)

26. Makoto Sahara

    Karolinska Institutet

    Affiliation as printed

    Department of Cell and Molecular Biology, Karolinska Institute, Stockholm, Sweden (M.S.)

    Makoto Sahara Department of Cell and Molecular Biology, Karolinska Institute, Stockholm, Sweden (M.S.)

27. Alexander Goedel

    TUM Klinikum · Technical University of Munich

    Affiliation as printed

    Department of Internal Medicine I, Cardiology (G.S., I.M., C.M.S., T.D., S.L., E.M., H.R., T.B., A.G., C.K., D.S., K.-L.L., A.M.), Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

    Alexander Goedel Department of Internal Medicine I, Cardiology (G.S., I.M., C.M.S., T.D., S.L., E.M., H.R., T.B., A.G., C.K., D.S., K.-L.L., A.M.), Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

28. Andreas Dendorfer

    German Centre for Cardiovascular Research · Institut für Chirurgische Forschung · Ludwig-Maximilians-Universität München

    Affiliation as printed

    DZHK (German Centre for Cardiovascular Research)–partner site Munich Heart Alliance, Germany (M.K., A.D., C.K., R.L., T.M., D.S., K.-L.L., A.M.)

    Walter-Brendel-Centre of Experimental Medicine (A.D.), University Hospital, LMU Munich, Germany

29. Fleur V.Y. Tjong

    Amsterdam University Medical Centers · University of Amsterdam

    Affiliation as printed

    Heart Centre, Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, The Netherlands (F.V.Y.T., C.B.)

    Fleur V.Y. Tjong https://orcid.org/0000-0001-9608-0081 Heart Centre, Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, The Netherlands (F.V.Y.T., C.B.)

30. Maria E. Rijlaarsdam Aachen Department of Pediatric Cardiology Maria E. Rijlaarsdam Department of Pediatric Cardiology

    Leiden University Medical Center

    Affiliation as printed

    Department of Pediatric Cardiology, Leiden University Medical Center, The Netherlands (M.E.R.)

    Maria E. Rijlaarsdam Department of Pediatric Cardiology, Leiden University Medical Center, The Netherlands (M.E.R.)

31. Julie Cleuziou

    TUM Klinikum · Technical University of Munich

    Affiliation as printed

    Department of Congenital and Paediatric Heart Surgery, Institute Insure (J.C.), Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

    Julie Cleuziou https://orcid.org/0000-0002-1971-4375 Department of Congenital and Paediatric Heart Surgery, Institute Insure (J.C.), Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

32. Nora Lang

    TUM Klinikum · Technical University of Munich

    Affiliation as printed

    Department of Paediatric Cardiology and Congenital Heart Defects (N.L.), Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

    Nora Lang Department of Paediatric Cardiology and Congenital Heart Defects (N.L.), Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

33. Christian Kupatt

    TUM Klinikum · German Centre for Cardiovascular Research · Technical University of Munich

    Affiliation as printed

    DZHK (German Centre for Cardiovascular Research)–partner site Munich Heart Alliance, Germany (M.K., A.D., C.K., R.L., T.M., D.S., K.-L.L., A.M.)

    Department of Internal Medicine I, Cardiology (G.S., I.M., C.M.S., T.D., S.L., E.M., H.R., T.B., A.G., C.K., D.S., K.-L.L., A.M.), Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

34. Connie R. Bezzina

    Amsterdam University Medical Centers · University of Amsterdam

    Affiliation as printed

    Heart Centre, Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, The Netherlands (F.V.Y.T., C.B.)

    Connie Bezzina https://orcid.org/0000-0002-0633-3514 Heart Centre, Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, The Netherlands (F.V.Y.T., C.B.)

35. Rüdiger Lange

    TUM Klinikum · German Centre for Cardiovascular Research · Technical University of Munich

    Affiliation as printed

    DZHK (German Centre for Cardiovascular Research)–partner site Munich Heart Alliance, Germany (M.K., A.D., C.K., R.L., T.M., D.S., K.-L.L., A.M.)

    Department of Cardiovascular Surgery, Institute Insure (M.K., M.D., H.L., S.A.D., N.P., I.N., Z.Z., C.A.-A., R.L.),Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

36. Neil E. Bowles

    University of Utah

    Affiliation as printed

    Department of Pediatrics (Division of Cardiology), University of Utah School of Medicine, Salt Lake City (N.E.B.)

    Neil E. Bowles Department of Pediatrics (Division of Cardiology), University of Utah School of Medicine, Salt Lake City (N.E.B.)

37. Matthias Mann

    Max Planck Society · Max Planck Institute of Biochemistry

    Affiliation as printed

    Proteomics and Signal Transduction, Max-Planck Institute of Biochemistry, Martinsried, Germany (S.D., M.M.)

    Matthias Mann Proteomics and Signal Transduction, Max-Planck Institute of Biochemistry, Martinsried, Germany (S.D., M.M.)

38. Bruce D. Gelb

    Icahn School of Medicine at Mount Sinai

    Affiliation as printed

    The Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York (B.D.G.)

    Bruce D. Gelb https://orcid.org/0000-0001-8527-5027 The Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York (B.D.G.)

39. Lia Crotti

    IRCCS Istituto Auxologico Italiano · University of Milano-Bicocca

    Affiliation as printed

    Cardiomyopathies Unit, Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, San Luca Hospital, Milan, Italy (L.C.)

    Center for Cardiac Arrhythmias of Genetic Origin and Laboratory of Cardiovascular Genetics, Istituto Auxologico Italiano, IRCCS, Milan, Italy (L.C.)

    Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy (L.C.)

    Lia Crotti https://orcid.org/0000-0001-8739-6527 Center for Cardiac Arrhythmias of Genetic Origin and Laboratory of Cardiovascular Genetics, Istituto Auxologico Italiano, IRCCS, Milan, Italy (L.C.). Cardiomyopathies Unit, Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, San Luca Hospital, Milan, Italy (L.C.). Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy (L.C.)

40. Lutz Hein

    University of Freiburg

    Affiliation as printed

    BIOSS, Center for Biological Signaling Studies (L.H.), University of Freiburg, Germany

    Institute of Experimental and Clinical Pharmacology and Toxicology (R.G., P.S., L.H.), University of Freiburg, Germany

    Lutz Hein https://orcid.org/0000-0003-1297-0007 Institute of Experimental and Clinical Pharmacology and Toxicology (R.G., P.S., L.H.), University of Freiburg, Germany. BIOSS, Center for Biological Signaling Studies (L.H.), University of Freiburg, Germany

41. Thomas Meitinger

    TUM Klinikum · Helmholtz Munich · German Centre for Cardiovascular Research · Deutsches Herzzentrum München · Institut für Humangenetik · Technical University of Munich

    Affiliation as printed

    DZHK (German Centre for Cardiovascular Research)–partner site Munich Heart Alliance, Germany (M.K., A.D., C.K., R.L., T.M., D.S., K.-L.L., A.M.)

    German Heart Center Munich, and Institute of Human Genetics (E.M., R.B., T.M.), Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

    Helmholtz Zentrum München, Neuherberg, Germany (E.M., R.B., T.M.)

42. Sean M. Wu

    Stanford Medicine · Stanford Cardiovascular Institute · Stanford University

    Affiliation as printed

    Cardiovascular Institute, Stanford University School of Medicine, CA (S.P., S.W.)

    Sean Wu https://orcid.org/0000-0002-0000-3821 Cardiovascular Institute, Stanford University School of Medicine, CA (S.P., S.W.)

43. Daniel Sinnecker

    TUM Klinikum · German Centre for Cardiovascular Research · Technical University of Munich

    Affiliation as printed

    DZHK (German Centre for Cardiovascular Research)–partner site Munich Heart Alliance, Germany (M.K., A.D., C.K., R.L., T.M., D.S., K.-L.L., A.M.)

    Department of Internal Medicine I, Cardiology (G.S., I.M., C.M.S., T.D., S.L., E.M., H.R., T.B., A.G., C.K., D.S., K.-L.L., A.M.), Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

44. Peter J. Gruber

    Yale University

    Affiliation as printed

    Department of Surgery, Yale University, New Haven, CT (P.J.G.)

45. Karl‐Ludwig Laugwitz

    TUM Klinikum · German Centre for Cardiovascular Research · Technical University of Munich

    Affiliation as printed

    DZHK (German Centre for Cardiovascular Research)–partner site Munich Heart Alliance, Germany (M.K., A.D., C.K., R.L., T.M., D.S., K.-L.L., A.M.)

    Department of Internal Medicine I, Cardiology (G.S., I.M., C.M.S., T.D., S.L., E.M., H.R., T.B., A.G., C.K., D.S., K.-L.L., A.M.), Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany

46. Alessandra Moretti

    TUM Klinikum · German Centre for Cardiovascular Research · Technical University of Munich

    Affiliation as printed

    DZHK (German Centre for Cardiovascular Research)–partner site Munich Heart Alliance, Germany (M.K., A.D., C.K., R.L., T.M., D.S., K.-L.L., A.M.)

    Department of Internal Medicine I, Cardiology (G.S., I.M., C.M.S., T.D., S.L., E.M., H.R., T.B., A.G., C.K., D.S., K.-L.L., A.M.), Klinikum rechts der Isar, School of Medicine & Health, Technical University of Munich, Germany