AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

Holt-Oram syndrome, also called heart-hand syndrome, is an inherited disorder characterized by abnormalities of the upper limbs and heart. Holt and Oram first described this condition in 1960 in a 4-generation family with atrial septal defects (ASDs) and thumb abnormalities.

Pathophysiology

The syndrome is inherited as an autosomal dominant trait that is completely penetrant. The disease is due to mutations in the transcription factor TBX5, which is important in the development of both the heart and upper limbs. The pathophysiologic sequelae are a direct result of malformations of the heart and upper limbs. No contributory environmental factors are known.

Upper limb involvement

Although the clinical manifestations are variable, upper limb abnormalities are always present. Abnormalities may be unilateral or bilateral and asymmetric and may involve the radial, carpal, and thenar bones. Aplasia, hypoplasia, fusion, or anomalous development of these bones produces a spectrum of phenotypes, including triphalangeal or absent thumbs. Occasionally, upper limb malformation can be sufficiently severe to produce phocomelia (a malformation in which the hands are attached close to the body); this has been termed pseudothalidomide syndrome. The most prevalent findings in persons with Holt-Oram syndrome are malformations or fusions of the carpal bones. Carpal bone abnormalities are the only findings present in every affected individual, although these anomalies may be evident only radiographically in some patients.

Cardiac involvement

Approximately 75% of patients have some cardiac abnormality. In most patients, the abnormality is either an ASD or a ventricular septal defect (VSD), which varies in number, size, and location. ASDs are usually of the secundum variety, while VSDs tend to occur in the muscular trabeculated septum. Cardiac anomalies also may include cardiac conduction defects such as progressive atrioventricular block and atrial fibrillation. These anomalies are frequently present even in the absence of septal defects.

Frequency

United States

Holt-Oram syndrome is the most common form of heart-hand syndrome, with prevalence estimated at 0.95 cases per 100,000 total births. Approximately 85% of cases are attributed to new mutations.

Mortality/Morbidity

Structural lesions are present at birth. Prognosis depends on the severity of the cardiac lesions.

• Significant intracardiac shunts can be associated with sudden death or the development of pulmonary hypertension and Eisenmenger syndrome.
• The first clinical manifestation of the disease may be heart failure, cardiac arrhythmias (including heart block), or infective endocarditis.
• Considerable physical and psychologic morbidity may be associated with limb abnormalities, particularly in severe cases.

Sex

• Holt-Oram syndrome has no sexual predilection.

Age

• A congenital disease, Holt-Oram syndrome is present at birth. Subtle limb involvement may not become clinically apparent until later in life when the cardiac symptoms of the disease manifest or when an individual has a child with a more severe presentation of the syndrome.
• Cardiac conduction disease is progressive with aging.
• Middle-aged individuals often present with significant atrioventricular block or atrial fibrillation.

CLINICAL

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

History

• Patients may have a family history of cardiac and/or limb malformation.
• Patients may present in infancy with obvious limb malformations and/or signs of cardiac failure secondary to ASD, VSD, or cardiac conduction disease.

Physical

• Upper limb deformity
• • Always present but may be unilateral or bilateral
  • Left-sided abnormalities often more severe than right arm or hand abnormalities
  • Unequal arm lengths due to aplasia, hypoplasia, fusion, or anomalous development of the radial, carpal, and thenar bones
  • Abnormal forearm pronation and supination
  • Triphalangeal or absent thumbs
  • Possible abnormal opposition of thumb
  • Possible sloping shoulders and restriction of shoulder joint movement
  • Phocomelia
• Cardiac involvement
• • Bradycardia
  • Irregular pulse (ectopy)
  • Irregular pulse that occurs irregularly (atrial fibrillation)
  • Wide, fixed splitting of the second heart sound
  • Pulmonary systolic flow murmur
  • Holosystolic murmur (should raise consideration for a VSD)
• Anomalies involving any of the following are indicators that a diagnosis of Holt-Oram syndrome
  can be excluded:
• • Ulnar bone
  • Lower limbs
  • Kidneys
  • Eyes
  • Auditory
  • Craniofacial
  • Vertebrae (may or may not occur in Holt-Oram syndrome)

Causes

• Holt-Oram syndrome is a genetic disorder that is autosomal dominant and highly penetrant.
• Initial linkage studies demonstrate that the gene defect resides on the long arm of chromosome 12.
• Recent molecular genetic studies reveal that the disease is caused by mutations that inactivate the transcription factor TBX5.
• Sporadic disease may represent a de novo germline mutation in TBX5.
• Recognizing that individuals who present with sporadic disease may transmit the disease to offspring is important.
• The identification of the role of TBX5 in Holt-Oram syndrome suggests an important but as yet undefined role for TBX5 in human cardiac septation, isomerization, and upper limb development.

DIFFERENTIALS

Section 4 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Other Problems to be Considered

Chromosomal anomaly
Duane radial ray syndrome (Okihiro syndrome)
Fanconi anemia
Teratogen exposure
Thrombocytopenia with absence of radius (TAR) syndrome
Townes-Brocks syndrome
Ulnar-mammary syndrome
Vertebral defects, anal atresia, tracheoesophageal fistula with esophageal atresia, and radial and renal anomalies complex (ie, VATER complex)

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Imaging Studies

• Wrist radiography
• • Limb involvement is determined by physical examination in some cases.
  • If limb involvement is not grossly obvious, obtain upper limb and hand radiographs to detect subtle anomalies of the wrist bones (Image 1).
  • Individuals without carpal bone abnormalities in the preaxial radial bones do not have Holt-Oram syndrome.
• Chest radiography
• • Findings may demonstrate enlarged pulmonary arteries due to pulmonary hypertension or cardiomegaly.
  • Evidence of congestive heart failure may be present.
• Echocardiography
• • This is the procedure of choice to define the presence of septal defects or other cardiac anomalies.
  • The most common cardiac anomaly is ostium secundum ASD.
  • Some patients also may have an isolated VSD.
  • Severely affected individuals may present with multiple VSDs (Swiss-cheese septum).
  • Other cardiac anomalies may include abnormal isomerism and anomalous pulmonary venous return.
  • While rare, numerous varieties of complex congenital heart disease may be associated with Holt-Oram syndrome.

Other Tests

• Perform an ECG to define involvement of the conduction system.
• If intermittent dysrhythmia is considered, 24-hour Holter monitoring may be useful.
• Periodic evaluation for conduction system involvement, even in the absence of cardiac structural disease, is important given the progressive nature of this finding.
• Genetic evaluation is important.
• • Arrange for patients who may possibly have Holt-Oram syndrome to be evaluated by a cardiologist or geneticist with experience in the management of inherited cardiovascular disease.
  • Obtain a detailed family history to ascertain if the disease represents a new mutation or if it is part of a familial syndrome.
  • Consider wrist radiography of the parents of the patient with Holt-Oram syndrome to establish a familial versus sporadic nature of the syndrome in the family.
  • Mutational analysis of TBX5 is not available on a routine clinical basis and remains a research tool.
  • • TBX5 mutations are detected in about 75% of individuals meeting strict clinical criteria for Holt-Oram syndrome.
    • On a case-by-case basis, specifics regarding genotype-phenotype correlations are not available.
    • The ability to identify the disease causing mutation in a family may allow for expanded reproductive options such as preimplantation genetic diagnosis for couples at 50% risk of having an affected child.

Procedures

• Cardiac catheterization can be considered to define the nature and severity of intracardiac shunts in patients at high risk for Eisenmenger syndrome because these patients may require surgical intervention.

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical Care

• Evaluation can usually be performed in an outpatient setting, but inpatient studies and surgical treatment may be necessary.
• Patients with advanced heart block may require a permanent pacemaker.
• Surgical therapy can be used to correct cardiac defects or to possibly improve limb function.

Surgical Care

• Most cardiac lesions such as ASD and VSD are amenable to complete surgical correction if pulmonary hypertension or ventricular failure has not developed. Several percutaneous transcatheter devices that can be placed to occlude the septum are in US Food and Drug Administration–approved clinical trials and may be nonsurgical options in the future.
• Septal defects without hemodynamically significant shunts do not require correction.
• Children with severe limb anomalies can be referred to orthopedic surgeons for consideration of procedures such as pollicization of the fifth digit (to improve upper limb function).
• Children with severe limb shortening may benefit from prostheses.

Consultations

• Cardiologist
• Geneticist
• Cardiothoracic surgeon
• Orthopedic surgeon

Diet

• No special diet is required.

Activity

• Limit activity if heart failure or persistent cardiac sequelae are present.

MEDICATION

Section 7 of 11  

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• Follow-up
• Miscellaneous
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• References

No medications are effective in treating the anatomical defects of patients with Holt-Oram syndrome. Antibiotic prophylaxis should be applied following standard American Heart Association/American College of Cardiology guidelines for patients with congenital heart disease. Anticoagulation should be considered in patients with pulmonary hypertension. Cardioversion, antiarrhythmic drug therapy, or anticoagulation should be considered in patients with Atrial Fibrillation.

FOLLOW-UP

Section 8 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Further Inpatient Care

• Admit for cardiovascular testing and surgical intervention.

Further Outpatient Care

• Follow up with patients with significant congenital heart disease at least annually.
• Periodic follow-up for cardiac conduction disease is warranted in all affected individuals.

In/Out Patient Meds

• No specific medications are indicated for this condition.
• Antibiotic prophylaxis and anticoagulation may be required depending on the severity of congenital heart disease.

Transfer

• Transfer may be required for further diagnostic evaluation and surgical intervention.

Deterrence/Prevention

• No known causative environmental factors are described; therefore, no particular deterrent is available.

Complications

• Congestive heart failure
• Arrhythmia
• Heart block
• Atrial fibrillation
• Infectious endocarditis
• Sudden death

Prognosis

• Prognosis is generally good, but it depends on the severity of the cardiac malformations.

Patient Education

• Ensure that family members are aware that this is an autosomal dominant disorder and that the chance is 50% that offspring of an affected individual will also have the disorder.
• Explain that the severity of a lesion in a parent is not an indication of the potential severity in offspring.
• For excellent patient education resources, visit eMedicine's Heart Center. Also, see eMedicine's patient education articles Atrial Fibrillation and Ventricular Septal Defect.

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal Pitfalls

• Failure to recognize structural cardiac disease or potential for arrhythmias
• Failure to provide appropriate genetic counseling or properly inform the patient of the heritable nature of the disorder
• Failure to institute appropriate antibiotic prophylaxis

Special Concerns

• Children with very subtle limb abnormalities may mistakenly be assumed to be unaffected. However, all children or siblings of an affected individual, even those who have normal findings upon physical examination of the limbs, should undergo echocardiography and upper limb radiography.

MULTIMEDIA

Section 10 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
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• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  Posteroanterior radiograph of the hands of a patient with Holt-Oram syndrome. The distal phalanx of the left thumb is hypoplastic. The carpal bones of both hands are abnormal, but the abnormalities on the left side are greater than those on the right side. Left-sided upper limb radial ray abnormalities are often greater than those on the right side. The scaphoid and trapezium of the left hand are enlarged and misshapen, resulting in a distal displacement of the thumb. Note the marked abnormalities of the left capitate and hamate. The left radial stylus is flattened.
	View Full Size Image
Media type:  X-RAY

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

• Basson CT, Cowley GS, Solomon SD, et al. The clinical and genetic spectrum of the Holt-Oram syndrome (heart-hand syndrome). N Engl J Med. Mar 31 1994;330(13):885-91. [Medline].
• Basson CT, Solomon SD, Weissman B, et al. Genetic heterogeneity of heart-hand syndromes. Circulation. Mar 1 1995;91(5):1326-9. [Medline].
• Basson CT, Huang T, Lin RC, et al. Different TBX5 interactions in heart and limb defined by Holt-Oram syndrome mutations. Proc Natl Acad Sci U S A. Mar 16 1999;96(6):2919-24. [Medline].
• He J, McDermott DA, Song Y, et al. Preimplantation genetic diagnosis of human congenital heart malformation and Holt-Oram syndrome. Am J Med Genet A. Apr 1 2004;126(1):93-8.
• McDermott DA, Bressan MC, He J, et al. TBX5 genetic testing validates strict clinical criteria for Holt-Oram syndrome. Pediatr Res. Nov 2005;58(5):981-6.

Article Last Updated: May 26, 2006