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Two families are described in which there is possible monogenic inheritance of congenital cardiac defects within the spectrum of faulty conotruncal septation (CTS). Evidence for a genetic control of conotruncal septation arises from genetic and embryologic studies of similar defects in the Keeshond dog model, the excess of sibship pairs with conotruncal septation defects in sibship pairs with congenital heart diseases, and previously reported pedigrees of families with multiple affected individuals with conotruncal septation defects. It is suggested that in the small number of cases of congenital cardiac defects in which there is a strong family history for CTS defects, a higher recurrence risk should be considered rather than the usual polygenic recurrence risk of 3% that is usually given in such situations.

Four members of a family with juvenile colonic polyposis in two generations were examined by the authors. The disease showed a very marked dominant mode of inheritance, not sex-linked, in this family. At the same time, the same members of the family had congenital heart disease, including atrial septal defects and pulmonary stenosis. This disease also resulted from a dominant, highly penetrating gene, not sex-linked. The occurrence of both these hereditary diseases at the same time suggests a close relationship or link between the responsible genes. This combination may represent the emergence of a new syndrome.

After an introduction dealing with the "historical evolution" of the Noonan syndrome (NS), we try to define the NS phenotype based on clinical descriptions published since 1883. The theories concerning the cause of the NS are discussed fully. The peculiar cardiac involvement deserves special attention and raises the question of whether the Watson and LEOPARD syndromes are indistinguishable from NS. Finally, the recent contributions to the variability of the NS phenotype (reports on lymphatic dysplasia, partial deficiency of factor XI, malignant hyperthermia, perceptual-motor disabilities, and endocrine evaluation) are also described.

The multiple lentigines syndrome is reviewed and a new case is presented. The major features of this syndrome are lentigines and other cutaneous abnormalities, cardiac defects, meurologic defects, cephalofacila dysmorphism, shortness of stature, skeletal anomalies, genitourinary abnormalities, and a family history consistent with an autosomal dominant mode of inheritance. The multiple lentigines syndrome manifests markedly variable expressivity; no single finding is pathognomonic and few patients have all major features. We propose specific criteria for diagnosis.

We report a father and son with the syndrome of cholestasis and peripheral pulmonic stenosis. These cases demonstrate the clinical and biochemical features noted in previous reports of this entity and allows us to differentiate clearly this syndrome, with its benign course, from other more progressive forms of intrahepatic cholestasis. The vertical transmission supports a genetic etiology for this disease. Although serum bile acid levels are elevated in these patients, the individual bile acids do not display a distinctive pattern and no abnormal bile acids are identified.

Pairs of siblings with congenital heart malformations of different types were analyzed for evidence of nonrandom association of defects within families that might suggest a genetic predisposition common to two or more kinds of malformations. An excess of pairs was noted for tetralogy of Fallot and pulmonary stenosis, tetralogy of Fallot and transposition of the great vessels, and tetralogy of Fallot and ventricular septal defect, thus suggesting that there may be a developmental relation between these lesions. This finding is supported by a recent study in the Keeshond dog demonstrating a genetic predisposition common to tetralogy of Fallot, pulmonary stenosis and ventricular septal defect. Thus the method does seem capable of revealing etiologic relations, probably genetic, among different types of cardiac lesions. Data on risks of recurrence for siblings of children with these defects will now have to be refined to take into account the possible recurrence of related lesions.

A 13-year-old slightly mentally retarded female is reported with diffuse calcification of the cartilage, brachytelephalangy, mixed hearing loss and peripheral pulmonary stenosis. The present observation confirms the existence of the Keutel syndrome as a distinct syndrome, with probable autosomal recessive inheritance.

We report four new cases of Keutel syndrome. Clinical manifestation included abnormal cartilage ossification, multiple peripheral pulmonary stenosis (PPS), brachytelephalangism, subnormal IQ, repeated respiratory infections, otitis media and hearing loss. All four children have a typical facial appearance and are of consanguineous parents. Father and the fifth offspring exhibit a normal phenotype; the mother has pulmonary stenosis. This observation confirms Keutel syndrome as a distinct autosomal recessive syndrome.

Three siblings out of two families -- the mothers being sisters -- have signs of WBS: a girl shows the complete picture of elfin's face syndrome; a boy who needed surgical treatment for severe supravalvular aortic stenosis, presents only with minimal signs of the peculiar facies like his mother. His brother has slight supravalvular aortic stenosis. The three children described show trivial peripheral pulmonary stenosis. It is known that SVAS and WBS may show a dominant mode of inheritance with variable expressivity. The purpose of this study was to find signs which would prove a dominant inheritance in this kinship. Dental malpositions and coarse upperlip with shallow philtrum where the only symptomes found in the patients and their mothers. If we accept this traits as markers for the syndrome than we could assume a dominant way of inheritance.

Numerous reports of familial cardiac disorders associated with abnormalities of cutaneous pigmentation have appeared in the literature. In some of these there have been other somatic malformations including retardation of growth and anomalous development of the genitalia. In this paper we review the literature and describe another family with multiple lentigines occurring in six members out of eight examined. They were reported to occur in 10 other members not seen by us. The trait showed an autosomal dominant mode of inheritance and appeared to be transmitted by affected fathers. In previous reports transmission has usually been through an affected mother. In five of the six patients examined, only skin abnormalities were detected, but in the propositus the lentigines were associated with retardation of growth, hypertelorism, abnormal genitalia and complete atrioventricular block. The possible explanations for the lack of pleomorphy in other members of the family are discussed.

Peripheral pulmonary arterial stenosis, either alone or in combination with supravalvular aortic stenosis, is described in two generations of one family. The last child born in the first generation ws the only fatal case and showed severe narrowing and thrombosis of the pulmonary arteries and significant narrowing of the descending aorta. Physical and mental development were normal in the seven surviving patients. Five had slight dyspnea on effort. Hemodynamic and angiocardiogrphic studies showed multiple peripheral pulmonary stenosis in six patients and supravalvular aortic stenosis or aortic hypoplasia in the last three of the first generation and in one of the second generation. The younger children were more severely affected. A marked systolodiastolic caliber variation of the main pulmonary arteries was noted angiographically in all those studied. We suggest that this finding can be used as an indirect sign of the presence of peripheral pulmonary arterial stenosis.

We treated three unrelated patients with hemophilia A and congenital pulmonary valve stenosis. In two patients, the occurrence of the cardiac malformation was sporadic and in one familial. The coexistence of hemophilia A and pulmonary valve stenosis might suggest a genetic linkage for both disorders. Review of the literature supports the hypothesis that the inheritance of pulmonary valve stenosis is dominant and X-linked.

Four Collie littermates had multiple cardiac and diaphragmatic anomalies. Ventricular septal defect was found in 3, pulmonic stenosis in 2, atrial septal defect in 1, mitral regurgitaion in 1, and pericardial diaphragmatic hernia in 3. Five additional littermates died within 72 hours of birth but were not necropsied. On the basis of available evidence, it was believed that the defects were congenital but not hereditary.

A syndrome consisting of chronic intrahepatic cholestasis with retention of bile acids but with normalization of bile pigment excretion ahd blood lipids, peripheral pulmonary stenosis, vertebral anomalies and a characteristic facies is described in six patients, including a father and his daughter. An autosomal dominant mode of inheritance is suggested.

Echocardiography has been used for cardiovascular evaluation of individuals and families with Ullrich-Noonan syndrome. Previously undiagnosed left ventricular disease has been found as a discrete lesion or in association with other cardiac abnormalities. This raises the estimated frequency of heart disease in the Ullrich-Noonan syndrome to about 50%. Since left ventricular disease in this syndrome may not be entirely typical of asymmetric septal hypertrophy, caution should be exercised in the echocardiographic diagnosis. To date, one notable difference between the echocardiograms in these patients and other patients with asymmetric septal hypertrophy is the absence of systolic anterior motion of the mitral valve. Since the most common cardiac lesion the the Ullrich-Noonan syndrome is pulmonary stenosis, the potential for septal thickening produced by severe pulmonary stenosis must also be taken into account.

This is the fifth family in the literature with siblings having the prune belly syndrome. It is the first with associated pulmonary stenosis, mental retardation, and hearing deficit. A genetic factor is suggested as the primary cause of the syndrome.

The distribution of congenital heart lesions was studied in 238 families with at least 2 affected members. A statistical analysis was performed. Concordant lesions were found in 48% of the affected first degree relatives and in 28% of the affected second and third degree relatives. The concordance rate is highly significant for all lesions studied in the first degree relatives, with the exception of ventricular septal defect (VSD). Among the discordant pairs of lesions, some occur significantly more often than expected (tetralogy of Fallot associated with VSD, pulmonary stenosis, and transposition of the great arteries); others, such as the association between VSD and pulmonary stenosis, are significantly less common than would be expected on a random hypothesis. An explanation is proposed suggesting that malformations anatomically dissimilar but resulting from the same heart segment disorder may have some common genes, and that interaction between genes may be responsible for "antagonism" between 2 defects. The embryologic segmental approach to congenital heart disease is reinforced by this genetic study.