A splicing variant in EFCAB7 hinders ciliary transport and disrupts cardiac development

The Tetralogy of Fallot (TOF), the most prevalent form of cyanotic congenital heart disease, stems from abnormal development of the outflow tract during embryogenesis. Despite the crucial role played by primary cilia in heart development, there is currently insufficient evidence to establish a causal relationship between defects in genes related to primary cilia and non-syndromic TOF. Here, we performed Sanger sequencing on 131 Chinese patients diagnosed with TOF and identified a splicing variant (c.683-1G > C) in the EFCAB7 gene. This splicing variant triggered exon skipping, leading to the production of a non-functional protein both in vitro and in vivo. Mice carrying this variant exhibited abnormal cardiac development, impaired ciliogenesis, disrupted Hedgehog signaling, and hindered Shh/Gli pathway activity. Through the integration of CUT&Tag data on Glis and bulk RNA-seq profiles of embryonic hearts at E10.5, we found that transcriptional downregulation of Gli target genes, including Myh6, Zfpm1, and Nkx2-5, is a consequence of Shh signaling inhibition. Our findings implicate EFCAB7 as a potential causative gene for TOF, underscoring the indispensable function of primary cilia in the intricate process of cardiac septation during heart development.