Congenital Heart Disease–Causing Gata4 Mutation
Displays Functional Deficits In Vivo
Chaitali Misra1, Nita Sachan2¤, Caryn Rothrock McNally2, Sara N. Koenig1, Haley A. Nichols2,
Anuradha Guggilam1,3, Pamela A. Lucchesi1,3, William T. Pu4, Deepak Srivastava5,6,7, Vidu Garg1,3,8*
1Center for Cardiovascular and Pulmonary Research and the Heart Center, Nationwide Children’s Hospital, The Ohio State University, Columbus, Ohio, United States of
America, 2Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America, 3Department of Pediatrics, The Ohio State
University, Columbus, Ohio, United States of America, 4Department of Cardiology, Children’s Hospital Boston and Harvard Medical School, Boston, Massachusetts, United
States of America, 5Gladstone Institute of Cardiovascular Disease, University of California San Francisco, San Francisco, California, United States of America, 6Department of
Pediatrics, University of California San Francisco, San Francisco, California, United States of America, 7Department Biochemistry and Biophysics, University of California San
Francisco, San Francisco, California, United States of America, 8Department of Molecular Genetics, The Ohio State University, Columbus, Ohio, United States of America
all cases. We previously reported that a heterozygous G296S missense mutation of GATA4 caused atrial and ventricular septal
defects and pulmonary valve stenosis in humans. GATA4 encodes a cardiac transcription factor, and when deleted in mice it
results in cardiac bifida and lethality by embryonic day (E)9.5. In vitro, the mutant GATA4 protein has a reduced DNA binding
affinityandtranscriptional activity and abolishesa physical interactionwith TBX5,a transcriptionfactorcritical fornormalheart
formation. To characterize the mutation in vivo, we generated mice harboring the same mutation, Gata4 G295S. Mice
homozygous for the Gata4 G295S mutant allele have normal ventral body patterning and heart looping, but have a thin
ventricular myocardium, single ventricular chamber, and lethality by E11.5. While heterozygous Gata4 G295S mutant mice are
viable, a subset of these mice have semilunar valve stenosis and small defects of the atrial septum. Gene expression studies of
homozygous mutant mice suggest the G295S protein can sufficiently activate downstream targets of Gata4 in the endoderm
butnotinthedevelopingheart.Cardiomyocyteproliferationdeficitsand decreasedcardiacexpressionof CCND2, a memberof
the cyclinfamilyanda directtarget of Gata4, were found inembryos both homozygousand heterozygousfor the Gata4G295S
allele. To further define functions of the Gata4 G295S mutation in vivo, compound mutant mice were generated in which
specific cell lineages harbored both the Gata4 G295S mutant and Gata4 null alleles. Examination of these mice demonstrated
that the Gata4 G295S protein has functional deficits in early myocardial development. In summary, the Gata4 G295S mutation
functions as a hypomorph in vivo and leads to defects in cardiomyocyte proliferation during embryogenesis, which may
contribute to the development of congenital heart defects in humans.
Citation: Misra C, Sachan N, McNally CR, Koenig SN, Nichols HA, et al. (2012) Congenital Heart Disease–Causing Gata4 Mutation Displays Functional Deficits In
Vivo. PLoS Genet 8(5): e1002690. doi:10.1371/journal.pgen.1002690
Editor: Scott Baldwin, Vanderbilt University, United States of America
Received November 16, 2011; Accepted March 20, 2012; Published May 10, 2012
Copyright: ? 2012 Misra et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This work was supported by grants from the March of Dimes Birth Defects Foundation (5-FY03-157) and the NIH/NHLBI (R01 HL088965). The funders
had no role in study design, data collection and analysis, decision to publish or preparation of manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: firstname.lastname@example.org
¤ Current address: Indian School of Business (ISB), Hyderabad, India
Congenital heart defects (CHD) are the most prevalent of all
human birth defects with an estimated incidence of 6–8 per 1,000
live births [1,2]. Defects of cardiac septation, which encompass
atrial and ventricular septal defects, may occur as an isolated
defect or in combination with other cardiac malformations.
Defects of atrial and ventricular septation are the most common
type of CHD and account for 50% of all cases of CHD. If
unrepaired, these defects result in ventricular dilation and heart
failure, pulmonary overcirculation leading to pulmonary vascular
disease, atrial enlargement predisposing to atrial arrhythmias and
ultimately a decreased life expectancy. The etiology for atrial and
ventricular septal defects is multifactorial with genetic and
environmental factors playing important roles [3,4].
Monogenic etiologies for atrial and ventricular septal defects
have been primarily discovered by studying large families with
autosomal dominant forms of septal defects using traditional
linkage approaches [5,6]. The first genetic etiology for atrial septal
defects was the disovery that mutations in the transcription factor,
TBX5, are a cause of septation defects in the setting of Holt-Oram
syndrome, which is characterized by cardiac and upper limb
malformations . Tbx5 haploinsufficiency in mice accurately
mimics the phenotype found in patients with Holt-Oram
syndrome . Mutations in the cardiac transcription factor,
NKX2-5, were identified in families who primarily exhibited non-
syndromic atrial septal defects and atrioventricular conduction
abnormalities . While targeted deletion of Nkx2-5 in mice causes
developmental arrest during heart tube looping, haploinsufficiency
of Nkx2-5 results in only subtle defects of atrial septation [10,11].
Similarly, mutations in the cardiac transcription factor, GATA4,
have also been linked to atrial and ventricular septal defects
[12,13,14,15,16]. Gata4 is necessary for normal cardiac develop-
ment as mice with targeted deletion of Gata4 display embryonic
PLoS Genetics | www.plosgenetics.org1May 2012 | Volume 8 | Issue 5 | e1002690
lethality and defects in ventral morphogenesis associated with
failure to form a single ventral heart tube [17,18]. Subsequent
studies have demonstrated that Tbx5, Nkx2-5, and Gata4 interact
to regulate distinct developmental processes during heart devel-
opment [19,20,21]. While many of the human mutations are
predicted to result in haploinsufficiency, little is understood about
the underlying mechanism by which reduced transcription factor
dosage causes defects in cardiac septation.
We reported a large pedigree with autosomal dominant
congenital heart disease that was associated with a mutation of a
highly conserved glycine residue to a serine at codon 296 (G296S)
. The affected family members had a spectrum of cardiac
phenotypes, primarily atrial and ventricular septal defects and
pulmonary valve stenosis . In vitro experiments demonstrated
that the mutant Gata4 protein had a greatly reduced affinity for its
binding element with an associated decrease in transcriptional
activity and disrupted a novel interaction between Gata4 and
Tbx5 . Subsequently, two other families have been reported
with a GATA4 G296S mutation, and affected members display a
similar phenotype of atrial septal defects and incompletely
penetrant pulmonary valve stenosis . While Gata4 has been
shown to be important for several critical processes during heart
development [23,24,25,26], the pathogenesis of heart malforma-
tions in humans with the G296S missense mutation in GATA4 is
not as well understood.
To identify the functional deficits of the GATA4 G296S mutation
in vivo, we generated and characterized transgenic mice that
contain the orthologous G295S mutation in the Gata4 murine
locus. Here, we show that homozygous Gata4 G295S knock-in (ki)
mice (Gata4 G295Ski/ki) display normal ventral morphogenesis but
early embryonic lethality after the linear heart tube stage.
Histologic analysis demonstrates a thin ventricular myocardium
in the Gata4 G295Ski/kiembryos, which is associated with a
cardiomyocyte proliferation defect. Molecular characterization of
these mutant embryos demonstrates that expression of Gata4
target genes is decreased in the heart. Echocardiographic
examination of heterozygote (Gata4 G295Ski/wt) mice found subtle
atrial septal defects and semilunar valve stenosis. Embryonic
cardiomyocytes from heterozygote mice display cardiac prolifer-
ation deficits. Consistent with functional deficits for the Gata4
G295S mutation, compound heterozygote mice harboring only a
single Gata4 G295S mutant allele in the early myocardium
recapitulated the phenotype seen in Gata4 G295Ski/kiembryos.
These studies demonstrate the generation of a mouse model for
human cardiac malformations and suggest that abnormal cardio-
myocyte proliferation may contribute to human atrial and
ventricular septal defects caused by mutations in GATA4.
Generation and phenotypic characterization of
heterozygote Gata4 G295Ski/wtmice
In order to determine the in vivo functional deficits of the human
CHD-causing GATA4 G296S mutation, we generated mice
harboring the orthologus mutation at codon 295 in the murine
Gata4 gene (G295S). Using a previously published targeting
construct, we mutated the nucleotide from G to A resulting in a
glycine to serine substitution in exon 3 which contains the C-
terminal zinc finger of Gata4  (Figure 1A). Successfully
targeted ES cell clones were identified by Southern analysis and
direct sequencing and injected into host blastocysts to generate
chimeras. Germline transmission of the targeted G295S knock-in
allele (G295Ski) was detected by Southern blotting in chimeric
mice and confirmed by direct sequencing in heterozygous and
homozygous mice (Figure 1B–1C and data not shown).
Although the Gata4 G295Ski/wtheterozygote mice appeared
grossly normal, we examined these mutant mice for cardiac
structural and functional abnormalities using transthoracic echo-
cardiography. In a genotype-blinded fashion, M-Mode, 2-D
pulsed and color-flow Doppler studies were performed in 8 and
16 week old Gata4 G295Ski/wtmice and their wildtype littermates.
Intermittent shunting of blood was noted between the left and
right atria in 10/12 Gata4 G295Ski/wtmice as compared to only 1/
9 wildtype littermates (p value,0.05) (Figure 2A–2C). The
intermittent atrial communication defect is a patent foramen
ovale, which was also found in mice heterozygous for Nkx2-5, a
gene also implicated in human atrial septal defects .
Quantitative pulsed Doppler recordings across the pulmonary
and aortic valves demonstrated mild aortic stenosis in 4/12 Gata4
G295Ski/wtmice and pulmonary stenosis in 2/12 Gata4 G295Ski/wt
mouse (Figure 2A and 2D–2M). No evidence of aortic or
pulmonary valve stenosis was noted in wildtype littermates (p
value,0.05). The left ventricular function, chamber size and wall
thickness in Gata4 G295Ski/wtmice was not statistically different
from wildtype littermates (Figure S1). Histologic analysis of Gata4
G295Ski/wthearts demonstrated the patent foramen ovale (Figure
S2A–S2D) along with thickened aortic (Figure S2E–S2F) and
pulmonary valve leaflets (Figure S2G–S2H).
Phenotypic characterization of homozygous Gata4
To determine the in vivo functional deficits of the Gata4 G295S
mutation, we interbred Gata4 G295Ski/wtto generate Gata4
G295Ski/kimice. Analysis at postnatal day 7 demonstrated no
G295Ski/kipups indicating that the homozygous knock-in allele is
embryonic or early neonatal lethal. To determine the timing of
lethality, we performed timed mating and found that Gata4
G295Ski/kiembryos did not survive beyond embryonic day (E)11.5,
and normal Mendelian ratios were noted from E8.5–E10.5
Cardiac malformations occur due to abnormal heart
development and are the most prevalent human birth
defect. Defects of atrial and ventricular septation are the
most common type of congenital heart defect and are the
result of incomplete closure of the atrial and ventricular
septa, a process required for formation of a four-
chambered heart. The molecular mechanisms that underlie
atrial and ventricular septal defects are unknown. We
previously published a highly penetrant autosomal dom-
inant mutation (G296S) in GATA4, which was associated
with atrial and ventricular septal defects in a large kindred.
The disease-causing mutation has a spectrum of biochem-
ical deficits affecting both DNA binding and protein–
protein interactions. Here, we report the generation and
phenotypic characterization of mice harboring the ortho-
logous mutation in Gata4 (G295S). While homozygous
mutant mice display embryonic lethality and cardiac
defects, the phenotype is less severe than Gata4-null mice.
A subset of Gata4 G295S heterozygote mice display a
persistent interatrial communication (patent foramen
ovale) and stenosis of the semilunar valves. Molecular
characterization of the mutant mice suggests that the
Gata4 G295S mutant protein results in diminished expres-
sion of Gata4 target genes in the heart and functional
deficits in cardiomyocyte proliferation. Thus, cardiomyo-
cyte proliferation defects may contribute to defects of
cardiac septation found in humans with GATA4 mutations.
Mouse Model of Human GATA4 Mutation
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(Table 1). To determine the expression levels of Gata4 mutant
protein in Gata4 G295Ski/kiembryos, we extracted protein from the
hearts of E9.5 Gata4 G295Ski/kiembryos and wildtype littermates.
Immunoblotting demonstrated that total Gata4 protein levels in
G295Ski/kiembryos were unchanged as compared to wildtype
littermates, suggesting that the G295S mutant mRNA was not
undergoing decay and resulting in a Gata4-deficient mouse
(Figure 1D) .
Gross examination of Gata4 G295Ski/kiembryos demonstrated
severe growth retardation compared to wildtype and heterozygote
littermates at E9.5 and E10.5 (Figure 3 and Figure S3). The
mutant embryos did not display defective heart tube fusion or
cardiac bifida, as described in mice with targeted deletion of Gata4
[17,18]. The mutant embryos displayed a linear heart tube and
variable amounts of cardiac looping, with some appearing normal
while othersdemonstrate incomplete
(Figure 3A–3I and Figure S3).
To further define the morphologic defects in Gata4 G295Ski/ki
embryos, histologic examination of wildtype and mutant embryos
was performed. The embryonic hearts of knock-in homozygotes
did not reveal any obvious defects in cardiac morphogenesis at
E9.0 and E9.5 (Figure 3J, 3L and 3N and data not shown).
However by E10.5, severe thinning of myocardium and associated
decreased wall thickness was noted in the ventricles of Gata4
G295Ski/kiembryos compared with heterozygote littermate con-
trols (Figure 3K, 3M and 3O). The delayed lethality and the
presence of a fused heart tube as compared to Gata4-null mice
suggested that the Gata4 G295S mutant protein was functioning
as a hypomorph in vivo.
Expression of Gata4 target genes
In the early embryo, Gata4 is expressed in developing heart
along with the visceral and parietal endoderm . Numerous
cardiac genes, including a-myosin heavy chain (a-MHC), cardiac
troponin-C (cTNC), atrial natriuretic factor (ANF), have been
shown to be direct transcriptional targets of Gata4 . In vitro
transactivation studies suggested that the Gata4 G295S mutation
had decreased ability to activate downstream target genes . To
determine if the expression of direct transcriptional targets of
Gata4 were altered in the Gata4 G295Ski/kimutant hearts, we
extracted RNA from E9.5 hearts and analyzed the expression of a-
MHC, cTnC, ANF, and myosin light chain 3 (Myl3) by
Figure 1. Targeting strategy for generation of Gata4 G295S knock-in mice. (A) Single nucleotide change resulting in the glycine to serine
mutation was introduced into the mouse Gata4 locus. Partial restriction map of the murine Gata4 wildtype allele (top), the Gata4 targeting vector
(middle), and successfully targeted allele (bottom) are shown. Homologous recombination results in replacement of wildtype Gata4 with genomic
DNA harboring a substitution of glycine to serine at position 295 into the mouse Gata4 locus, as well as the incorporation of neomycin cassette
surrounded by loxP sites. Gata4 coding exons are shown as empty boxes, whereas the exon used as a probe used for Southern blot analysis is
highlighted by a black bar. NZf, amino- terminal zinc finger (exon 2); CZf, carboxy- terminal zinc finger (exon 3); E4, exon 4; E5, exon 5; E6, exon 6; B,
BglI; S, SacI; E, EcoRV; and N, NotI. (B) Germline transmission of mutant allele was confirmed by Southern blotting after digestion of genomic DNA
from Gata4 G295Ski/wtand wiltype mice with BglI. A 3.8 kb wildtype band and a 12.5 kb mutant band using 39 external probe are shown (black bar in
A). (C) Direct sequencing confirmed the presence of mutated residue that altered glycine (GGC) to serine (AGC) in DNA from Gata4 G295Ski/ki
embryos. (D) Western blotting demonstrates that levels of Gata4 protein are equivalent in Gata4 G295Ski/kihearts (from three different embryos) as
compared to wildtype E9.5 hearts. Equal protein loading is shown by Western blotting to GAPDH.
Mouse Model of Human GATA4 Mutation
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quantitative RT-PCR. The expression levels of all four genes were
significantly decreased in Gata4 G295Ski/kimutant hearts as
compared to wildtype controls (Figure 4A). In contrast, the
expression of non-Gata4 target genes, Tbx5 and b-MHC, was
unchanged (Figure 4B). Of note, the expression of Nkx2.5, and
Mef2c, cardiac transcription factors which are proposed to be
direct Gata4 targets, was also unchanged (Figure 4B) [30,31]. We
also did not find any change in expression of Gata5 and Gata6 by
quantitative RT-PCR (Figure S4). Radioactive in situ hybridization
was performed to determine if cardiomyoctyes in Gata4 G295Ski/ki
hearts displayed normal markers of differentiation. At E9.5, the
expression of Tbx5, Hand1, and Hand2 was similar in G295Ski/ki
hearts as compared to control littermates (Figure S5).
The cardiac bifida found in Gata4-null embryos occurs
secondary to loss of Gata4 in the embryonic endoderm
[17,18,32,33,34]. Gata4 G295Ski/kiembryos undergo normal heart
tube fusion, suggesting that they overcome this endoderm-
mediated defect. We examined the expression of Gata4-responsive
endoderm genes, alpha-fetoprotein (Afp) and Sox17, along with the
endoderm transcription factors, Hex1 and Hnf4, that are not direct
Figure 2. Atrial septal defects and semilunar valve stenosis in Gata4 G295Ski/wtmice. (A) Table showing the frequency of cardiac
abnormalities identified in Gata4 G295Ski/wtmice (n=9) and wildtype littermates (n=12). Representative images of color (B, D, E, I, J) and pulsed wave
Doppler (C, F, G, K, L) findings are shown. Small atrial communication demonstrated by both (B) color and (C) pulsed wave Doppler in Gata4
G295Ski/wtmouse. Color Doppler recordings across normal aortic valve of a wildtype mouse (D) and stenotic aortic valve of Gata4 G295Ski/wtmouse
(E). Pulsed Doppler waveforms of flow across the aortic valve in wildtype (F) and Gata4 G295Ski/wt(G) mice demonstrate increased aortic velocity in
mutant mice. (H) Scatter plot showing aortic velocities in wildtype and Gata4 G295Ski/wtmice. Four Gata4 G295Ski/wtmice with aortic stenosis are
indicated in red. Color Doppler recordings across pulmonary valve of a wildtype (I) and stenotic pulmonary valve in Gata4 G295Ski/wtmice (J). Pulsed
Doppler waveforms across pulmonary valve of wildtype (K) and Gata4 G295Ski/wtmice (L) show increased velocity in mutant mice. (M) Scatter plot
showing velocity across pulmonary valve in wildtype and Gata4 G295Ski/wtmice. Two Gata4 G295Ski/wtmice with pulmonary stenosis indicated in red.
Mouse Model of Human GATA4 Mutation
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transcriptional targets of Gata4 [35,36]. Afp and Sox17 did not have
decreased levels of expression by qRT-PCR in Gata4 G295Ski/ki
embryos when compared to wildtype littermates at three different
embryonic timepoints (Figure S6). Actually, the expression levels of
Afp and Sox17 were somewhat increased in G295Ski/kiembryos
similar to Hex1 and Hnf4, but this maybe secondary to the growth
retardation found in mutant embryos (Figure S6).
Gata4 G295S mutation and deficits in cardiomyocyte
In order to determine the etiology of the thin ventricular
myocardium found in E10.5 Gata4 G295Ski/kihearts, we measured
the levels of cardiomyocyte proliferation and apoptosis in the
mutant hearts. In Gata4 G295Ski/ki
decreased cardiomyocyte proliferation, as assessed by phospho-
histone H3 staining at E9.5 in Gata4 G295Ski/kiembryos as
compared to littermate controls (Figure 5A–5C), but no differences
in apoptosis as assessed by TUNEL staining were found (data not
shown). Consistent with this finding, the mRNA levels of cyclin
D2, a direct transcriptional target of Gata4 that is critical for cell
proliferation, was downregulated in homozygous knock-in embry-
os by qRT-PCR (Figure 5D) . Additionally, the ability of the
Gata4 G295S mutant protein to activate cyclin D2 beta-gal
reporter in HeLa cells was significantly reduced as compared to
wildtype Gata4 (Figure 5E).
embryos, we observed
Table 1. Distribution of progeny obtained from intercrossing
Gata4 G295S heterozygote mice.
P7 21 (33%) 43 (67%)0 (0%)
E12.5–E14.510 (45%) 12 (55%)0 (0%)
E11.59 (20%)31 (71%) 4 (9%)
E10.5 16 (32%)24 (47%) 11 (21%)
E9.562 (25%) 134 (54%)52 (21%)
E8.5–E9.06 (22%) 15 (56%)6 (22%)
Figure 3. Gata4 G295Ski/kimice display growth retardation and a thin myocardium. Right (A,D,G), left (B,E,H) and frontal (C,F,I) views of
embryos are shown. Growth retardation of Gata4 G295Ski/kiE9.5 embryos (G,H) when compared to wildtype (A,B) and heterozygote littermates (D,E).
A fused heart tube with proper looping is found in Gata4 G295Ski/kiembryos (I) simlar to wildtype (C) and Gata4 G295Ski/wt(F) littermates. Coronal
sections through Gata4 G295Ski/wt(J,K) and Gata4 G295Ski/ki(L,M) embryos at E9.5 (J,L) and E10.5 (K,M). Normal myocardial thickness is found at E9.5 in
homozygous mutant embryos (L) while thin myocardium is seen at E10.5 (M) when compared to heterozygote littermate (K). Quantification of
ventricular wall thickness in Gata4 G295Ski/wtand Gata4 G295Ski/kiembryos at E9.5 (N) and 10.5 (O). RV, right ventricle; LV, left ventricle; red arrow,
heart; A, atria; V, ventricle; OFT, outflow tract. Scale bars indicate 200 mm.
Mouse Model of Human GATA4 Mutation
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Interestingly, we found that mRNA levels of cyclin D2 were also
decreased in the hearts of heterozygote Gata4 G295Ski/wtembryos
(Figure 5D). In order to determine if subtle cardiomyocyte
proliferation deficits existed in Gata4 G295Ski/wtembryos, we
assessed cell proliferation utilizing a fluorescence activated cell
sorting (FACS)-based strategy. Hearts were dissected from E11.5
and E13.5 embryos and cardiomyocytes were purified based on
cardiac troponin-T expression . Gata4 G295Ski/wtembryonic
atrial and ventricular cardiomyocytes displayed decreased cell
proliferation as compared to cardiomyocytes from wildtype
littermates at both E11.5 and E13.5 (Figure 6A–6K). Accordingly,
we found that Gata4 G295Ski/wtembryos had thinner atrial and
compact ventricular layers at E12.5 (Figure 6L–6Q).
In vivo analysis of cell lineage deficits of the Gata4 G295S
To assess the functional deficit of the Gata4 G295S mutant
protein in different cell lineages in vivo, we first generated mice that
were compound heterozygotes for the Gata4 G295S mutant allele
and a tissue-specific Cre, and lineage-specific deletion of the Gata4
was performed by crossing them with mice with a floxed Gata4
allele . One fourth of the resultant progeny were predicted to
harbor only the mutant allele in specific cardiac cell types. Tissue
specific deletion was obtained by expressing Cre under the
regulation of Tie2, which is expressed in endocardium, endothe-
lium along with a subset of hematopoietic cells (presumed to be
circulating endothelial progenitor cells); aMHC, which is specific
for late embryonic myocardium, with robust Cre-mediated
excision starting at E9.5; and Nkx2-5, which is expressed in early
embryonic myocardium starting at E8.0 and also in the pharynx
and liver [39,40,41]. Immunohistochemistry for Gata4 demon-
strated decreased Gata4 expression in E10.5 embryonic hearts
with the Nkx2-5 Cre (Figure S7A–S7B) and Tie2-Cre (Figure
S7C–S7D) in the myocardium and endocardium, respectively.
With the aMHC-Cre, expression of Gata4 was only mildly
decreased in the myocardium likely related to the later onset of
Figure 4. Decreased expression of Gata4 target genes in Gata4 G295Ski/kiembryonic hearts. (A) Downregulation of ANF, a-MHC, cTnC, and
Myl3 in homozygous mutant E9.5 hearts as compared to wildtype littermates as measured by qRT-PCR. *, p value,0.05. (B) Quantitative RT-PCR
demonstrates no significant change in expression levels of Tbx5, Nkx2.5, Mef2C and b-MHC in E9.5 Gata4 G295Ski/kihearts when compared to
Mouse Model of Human GATA4 Mutation
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Cre expression (Figure S7E–S7F). Analysis of these compound
heterozygotes allowed for the identification of functional deficits of
the Gata4 G295S protein that were present specific to the early
ta4G295S) and endocardium (enGata4G295S). We found that
only the emGata4G295S was lethal by post-natal day 10 while the
lmGata4G295S and enGata4G295S demonstrated partial lethality
(Table S1). Genotyping of E10.5 embryos from the crosses using
the Tie2-Cre (enGata4G295S) and aMHC-Cre (lmGata4G295S)
showed the expected genotypes were present in normal Mendelian
ratios with no evidence of growth retardation (Figure 7A–7I). This
contrasts with the severe growth retardation found in Ga-
ta4G295Ski/kiembryos (Figure 3 and Figure S3). However,
embryos obtained from crosses with Gata4flox/floxand Gata4
G295Ski/wt;Nkx2-5-Cre+(emGata4G295S) demonstrated partial
lethality by E10.5 and evidence of severe growth retardation
(Figure 7A and 7J–7M). Histologic examination of these three
genotypes demonstrated a normal myocardial thickness in
enGata4G295S and lmGata4G295S, but myocardial thinning in
emGata4G295S embryos (Figure 7E, 7I, and 7M), similar to Gata4
G295Ski/kiembryos (Figure 3K and 3M). These studies support
that the Gata4 G295S mutant protein has functional deficits in the
early myocardium that contributes to a thin myocardium.
The GATA4 G296S mutation has been associated with atrial
septal defects and pulmonary valve stenosis in multiple human
families [12,22]. In vitro studies suggested that GATA4 G296S
mutant protein resulted in specific functional deficits including
diminished DNA binding affinity, reduced transcriptional activity
and loss of a protein-protein interaction with TBX5. Here, we
have generated a knock-in mouse harboring the corresponding
G295S mutation in Gata4. Phenotypic characterization of these
mice demonstrate that the Gata4 G295S mutation functions as a
hypomorph in vivo as evidenced by the Gata4 G295Ski/kiembryos
displaying prolonged survival as compared to Gata4-null embryos
and decreased expression of Gata4 transcriptional target genes.
Consistent with the cardiac phenotype seen in humans with
GATA4 mutations, Gata4 G295Ski/wtmice also display cardiac
abnormalities. In addition, we found that the G295S mutation of
Gata4 results in defects of embryonic cardiomyocyte proliferation
both in vitro and in vivo. These findings suggest a potential role for
abnormal cardiomyocyte proliferation in the development of atrial
and ventricular septal defects caused by mutations in GATA4.
The G295S mutation in Gata4 may result in multiple functional
deficits in the embryonic heart. Mice homozygous for the Gata4
G295S mutation suffer embryonic lethality before E10.5, which
limited our analysis to early myocardial development and
precluded analysis of potential functional deficits at later stages
of heart development. Conditional deletion of Gata4 in the
endocardium results in defective endocardial-mesenchymal tran-
sition (EMT) and hypoplastic endocardial cushions . In
addition, we have previously shown the G295S mutation in Gata4
inhibits an interaction with Tbx5 and Gata4-Tbx5 compound
heterozygotes display atrioventricular septal defects [12,21]. It
remains unclear if the GATA4 G296S mutation has a role in
formation of the endocardial cushions but one family member
with the G296S mutation did have an atrioventricular septal
defect  and other non-related individuals with GATA4
Figure 5. G295S mutation in Gata4 results in cardiomyocyte proliferation defects. Immunofluorescent staining for phosphohistone H3
(red) along with desmin staining for cardiomyocytes (green) demonstrates decreased cardiomyocyte proliferation in Gata4 G295Ski/ki(B) as compared
to wildtype (A) in histologic sections of E9.5 hearts. V, ventricle. (C) Quantification of phosphohistone H3 (PH3) staining of cardiomyocytes is
decreased in Gata4 G295Ski/kiembryonic hearts when compared to wildtype. *, p value,0.05. (D) Quantitative RT-PCR demonstrates decreased cyclin
D2 expression in the E9.5 hearts of both Gata4 G295Ski/wtand Gata4 G295Ski/kiembryos.*, p value,0.05. (E) Cyclin D2 b-gal reporter assays using
wildtype Gata4 or Gata4 G295S mutant plasmids demonstrates that the G295S mutant protein has decreased transactivation ability as compared to
wildtype Gata4. Error bars represent the standard deviation at least three independent experiments each performed in triplicate. *, p value,0.05.
Scale bars indicate 200 mm.
Mouse Model of Human GATA4 Mutation
PLoS Genetics | www.plosgenetics.org7 May 2012 | Volume 8 | Issue 5 | e1002690
Figure 6. Proliferation deficits in Gata4 G295Ski/wtembryonic cardiomyocytes. (A–I) Cells were isolated from wildtype (WT) and Gata4
G295Ski/wtE11.5 and E13.5 hearts. FACS analyses for cardiac troponin T (cTnT)-positive cells was performed for (A, B) E11.5 atria, (C, D) E11.5 ventricles,
(E, F) E13.5 atria, and (G,H) E13.5 ventricles. Proliferating cells are detected by staining with Ki67. Representative data are shown in each panel. (I) FACS
analysis of unstained cells used as a control. Quantification of proliferative cardiomyocytes in Gata4 G295Ski/wtmutant hearts as compared to wildtype
littermate hearts at E11.5 (J) and E13.5 (K). Experiments were performed in triplicate using pooled hearts and all data are presented as means 6
standard deviation; *p value,0.05. Coronal sections through the heart of wildtype (L, N) and Gata4 G295Ski/wt(M, O) E12.5 hearts. High magnification
images of the atria (L,M) and ventricle (N, O) are shown. Quantitative analysis demonstrates decreased wall thickness in the (P) atria and (Q) compact
ventricular myocardium in Gata4 G295Ski/wtas compared to wildtype littermates (n=3 for each genotype). Arrowheads, representative site of
measurement; *, p value,0.05. Scale bars indicate 200 mm.
Mouse Model of Human GATA4 Mutation
PLoS Genetics | www.plosgenetics.org8May 2012 | Volume 8 | Issue 5 | e1002690
mutations have atrioventricular septal defects . In our analysis
of potential cell lineage deficits for the Gata4 G295S protein, we
did find that enGata4G295S mice, where the endocardium/
endothelium expresses only the mutant protein, have somewhat
hypocellular endocardial cushions and display partial lethality by
post-natal day 10. This finding suggests that the Gata4 G295S
mutation may have functional deficits in the endocardium,
potentially by disrupting EMT but additional study is required
Figure 7. Gata4 G295S mutation has in vivo functional deficits in the early embryonic myocardium. (A) Embryonic lethality by E10.5 was
found in compound heterozygote mice expressing only a Gata4 G295S mutant allele in early myocardium with the Nkx2-5-Cre, but normal Mendelian
ratios were seen when the Gata4 G295S mutant allele was expressed in endocardium and late myocardium using Tie2-Cre and a-MHC-Cre,
respectively. Images (B, D, F, H, J, L) and histologic sections (C, E, G, I, K, M) of E10.5 embryos generated with Tie2-Cre, which is specific for
endocardium (B–E); a-MHC-Cre, which is specific for late embryonic myocardium (F–I); and Nkx2.5-Cre, which is specific for early embryonic
myocardium (J–M), are shown. (L,M) Growth retardation and myocardial thinning were seen in Gata4 G295Ski/flox; Nkx2-5-Cre+E10.5 embryos similar to
the phenotype of the Gata4 G295Ski/kiembryo. (H,I) The hearts of Gata4 G295Ski/flox; a-MHC-Cre+appeared normal at E10.5. (D,E) While the Gata4
G295Ski/flox; Tie2-Cre+did not show growth retardation or myocardial thinning, hypocellular endocardial cushions were noted (*). A, atria; V, ventricle;
scale bars indicate 200 mm.
Mouse Model of Human GATA4 Mutation
PLoS Genetics | www.plosgenetics.org9 May 2012 | Volume 8 | Issue 5 | e1002690
(Figure 7). A role for Gata4 and Tbx5 in the endocardium for
formation of the atrial septum by regulation of endothelial nitric
oxide synthase (Nos3) has been proposed, but the early lethality of
the Gata4 G295Ski/kiembryos did not allow for analysis of this
pathway . While this early lethality precluded examination of
the development of the cardiac outflow tract and semilunar valves
in the Gata4 G295Ski/kiembryos, the Gata4 G295Ski/wtheterozy-
gotes did develop stenosis of the semilunar valves. This phenotype
along with recent publications demonstrating bicuspid aortic valve
and aortic valve stenosis in Gata5-null and Gata4;Gata5
compound heterozygote mice suggest that endocardial specific
deficits of the G296S protein may contribute to the aortic and
pulmonary valve stenosis [43,44].
The phenotypic analysis of Gata4 G295Ski/kimice demonstrates
that the Gata4 G295 mutant allele is not a loss of function allele.
Initial human genetic studies demonstrated that haploinsufficiency
of GATA4 resulted in cardiac malformations and there was a
possibility that the Gata4 G295 was a null allele . Our data
demonstrate that the G295S mutation in Gata4 results in a selective
loss of some Gata4 functions. Specifically, the Gata4 G295S protein
is able to activate downstream target genes in the developing
endoderm but not in the cardiac mesoderm. Potential mechanisms
for this difference may lie in the inability of Gata4 G295S protein to
interact with Tbx5 in the mesoderm to activate downstream targets
or that Gata4 may function as a transcriptional co-activator in the
endodermandDNAbindingisnotnecessary. The findingsfrom the
conditional deletion crosses, as discussed above, also support that
cell lineages. Additional investigation is needed to identify all the
potential functions of Gata4 and then determine which are loss with
the Gata4 G295S mutation.
Cardiomyocyte proliferation is critical for normal cardiac
development, and our findings provide evidence that the Gata4
G295S mutation results in myocardial hypoplasia due to dimin-
ished cardiac proliferation. This phenotype is at least partially
mediated by reduced expression of cyclin D2, a member of the D-
cyclin family of cell cycle regulators. Mice lacking any single D-
cyclin are viable and do not display obvious cardiac defects .
However, compound mutation of all three D-cyclin genes results
in embryonic lethality due to cellular proliferation defects,
including reduced cardiomyocyte cell division . Our data
demonstrate that both homozygote and heterozygote Gata4
G295Skimice display cardiomyocyte proliferation deficits and
suggest that this is a possible mechanism for the atrial septal defects
seen in these mice.
The generation of the Gata4 G295Skimice provides a mouse
model to study human congenital heart defects. This mouse model
will be of significant value to study genetic and environment
modifiers for cardiac malformations along with allowing for a
more mechanistic understanding of the embryologic basis of
septation and valvular defects. While the dosage sensitivity of
cardiac transcription factors for normal cardiac morphogenesis is
generally well accepted, this mouse model demonstrates that
specific mutations may have limited functional deficits. The Gata4
G295Skimice which encodes a partially functional mutant protein,
offers us a tool to define these abnormalities in vivo.
Materials and Methods
Research was approved by the Institutional Animal Care and
Use Committee at University of Texas Southwestern Medical
Center (Protocol No. 2008-0094) and Research Institute at
Nationwide Children’s Hospital (Protocol No. AR09-00040) and
conforms to the Guide for the Care and Use of Laboratory
A strategy similar to Crispino et al., 2001 was used to generate
knock-in mice harboring the Gata4 G295S mutation. The targeting
vector contains an 8.2 kb mouse genomic fragement, which has
the 2nd–6thexons of murine Gata4. The construct contains a
Neomycin resistance cassette flanked by loxP sites, as a positive
selection marker, and HSV-tk, as a negative selection marker.
Genomic DNA containing the N-terminal of the zinc finger
domain of Gata4 was subcloned into pBluescript II KS (+/2)
phagemid (Stratagene). By site-directed mutagenesis, glycine at
codon 295 was changed to serine (the codon GGC was changed to
AGC). The targeting construct was linearized with PvuI and
electroporated into 129SvES cells. Targeted clones were identified
by Southern blotting. Six successful targeted ES clones identified
by Southern blotting and direct sequencing for the G295S point
mutation. Three clones were injected into C57BL/6 blastocysts to
generate chimeric mice.
Mouse strains and genotyping
Germline transmission was achieved by mating to C57BL/6
mice. Mice used in this study were on a mixed 129SvEv/C57BL6
genetic background. For genotyping, allelic discrimination assay
was used to detect this single nucleotide change in Gata4 locus by
using fluorescent probes. This method combines PCR and
mutation detection in a single step. Two TaqMan (Applied
Biosystems, CA) probes were used, one for each allele. This
method is implemented using the Applied Biosystems 7500Fast
and TaqMan reagents to detect this point mutation in Gata4. The
probe and primer sequences are shown in Table S2.
Breeding and collection of mouse embryos
Mice were maintained on a 0600 to 1800h light–dark cycle,
with noon of the day of observation of a vaginal plug defined as
E0.5. Mice heterozygous for Gata4 G295S mutation were
generated and genotyped as described above. Mice heterozygote
for Gata4 G295S were mated to generate G295S homozygote
embryos. Pregnant mothers were sacrificed at various embryonic
timepoints. Littermates were used as controls for histologic
sections, gene expression studies and FACS analysis.
Two dimensional and Doppler in vivo ultrasound images were
obtained in 8 and 16 week old mice using a VisualSonics
Vevo2100 imaging system (Ontario, Canada) with a mechanical
transducer (MS400). Mice were anesthetized with isoflourane and
echocardiograms were performed in a genotype-blinded fashion.
Statistical analysis was performed using Fisher’s exact test.
Histologic section and radioactive in situ hybridization
For histological analysis, embryos and adult hearts were fixed in
4% paraformaldehyde and paraffin embedded. Hematoxylin and
eosin (H and E) staining was carried out on heart sections using
previously  using35S-labeled antisense probes synthesized with
T3, T7, or SP6 RNA polymerase (Maxiscript; Ambion Inc., Austin,
TX) from mouse Hand1, Hand2 and Tbx5 cDNA.
Proliferation and apoptosis assays
For the immunostaining studies, histologic sections were
deparafinnized in xylene and rehydrated in phosphate buffered
Mouse Model of Human GATA4 Mutation
PLoS Genetics | www.plosgenetics.org10May 2012 | Volume 8 | Issue 5 | e1002690
saline (PBS). Proliferation assays were performed using the
phosphohistone H3 (PH3) antibody (Upstate Cell Signaling
Solutions, Temecula, CA). The sections were permeabilized in
0.3% Triton X-100 in PBS. Sections were then blocked by 3.5%
donkey serum in PBS followed by incubation with 1% rabbit anti-
phosphohistone H3 antibody overnight at 4uC. Sections were then
washed in PBS and Cy3 (1%) secondary antibodies (Vector
Laboratories, Burlingame, CA) for 30 min. For cell proliferation
studies, contiguous sections were stained for monoclonal mouse
anti-human desmin using Cy3-conjugated antibody (Dako,
Carpinteria, CA) to label the cardiomyocytes. The percentage of
PH3-stained ventricular cardiomyocytes/total number of ventric-
ular cardiomyocytes was calculated by analyzing a minimum of
three embryos for each genotype. A minimum of four sections per
embryo were analyzed, and the means and standard deviations are
shown. Apoptosis (TUNEL) assays were performed using the In
Situ Cell Death Detection Kit, Fluorescein (Roche) according to
manufacturer instructions. Labeled ventricular cardiomyocytes
were counted on a minimum of six sections of control and mutant
embryonic hearts. Statistical analysis was performed using
Gene expression analysis
RNA was purified from embryonic hearts (E8.5–E10.5) from
mutant embryos and their respective wildtype littermates using
Trizol (Invitrogen). Real-time quantitative reverse transcription-
polymerase chain reaction (qRT-PCR) was performed using the
Taqman Universal PCR Master Mix kit (Applied Biosystems,
Foster City, CA). 100 ng of total RNA was used for reverse
transcription and amplification in each real-time PCR reaction
using Applied Biosystems 7500 real-time PCR machine. Com-
mercially available SYBR Green (Applied Biosystems) PCR mix
was utilized for the following genes: ANF, a-MHC, cTnC, Myl3,
CyclinD2, Nkx2-5, Tbx5, Mef2C, b-MHC, HNF4, Hex1, alpha-
fetoprotein and Sox17. The sequences for primers are in Table S2.
Mean relative gene expression was calculated from wildtype and
mutant hearts after normalization to 18S ribosomal RNA,
minimum of n=3 per group. Statistical analysis was performed
using Student’s t-test, and a p value of less than 0.05 was
HeLa cells were transfected using Fugene 6 (Roche) according
to manufacturer’s instructions with 200 ng of Gata4 wildtype and
Gata4 G295S myc-tagged expression vectors , 200 ng of Cyclin
D2 pAUG-b-gal reporter vector . Immunoblots were used to
verify appropriate expression. Cells were cultured for 48 h after
transfection, harvested and cellular extracts were prepared by
sonication and normalized as described previously . Chemi-
luminescence b-galactosidase (b-Gal) assays were performed using
the luminescent b-Gal detection system (Clontech) according to
the manufacturer’s recommendations, and relative light units were
detected using a Tropix TR717 microplate luminometer (PE
Embryonic heart samples for fluorescence-activated cell sorting
(FACS) were prepared in the following manner: 15–20 embryonic
hearts of each genotype were dissected, dissociated to a single cell
solution, digested with collagenase type II (Worthington) solution,
washed, spun down and resuspended in cardiomyocyte staining
buffer. Cells were fixed with BD Cytofix/CytopermTM solution,
permeabilized and incubated with monoclonal mouse anti-
troponin T (Abcam, Cambridge, MA) and Ki67 (Abcam, Cam-
bridge, MA ). Experiments were performed in triplicate and cells
were analysed on a LSRII with DiVa software (BD Biosciences,
San Jose, CA, USA).
wildtype and Gata4 G295Swt/kimice. (A) Scatter plot showing
fractional shortening in wildtype and Gata4 G295Ski/wtmice at 8
and 16 weeks of age. Scatter plots show (B) left ventricular internal
diameter (LVID) at end-diastole, (C) left ventricular internal
diameter during systole, (D) left ventricular anterolateral wall
(LVAW) thickness at end-diastole, (E) left ventricular anterolateral
wall thickness during systole, (F) left ventricular posterior wall
(LVPW) thickness at end-diastole, and (G) scatter plot showing left
ventricular posterior wall thickness during systole.
Summary of M-mode echocardiographic analysis of
pulmonary valve stenosis in Gata4 G295Swt/kimurine hearts by
histologic section. Interatrial communication in the form of patent
foramen ovale (arrowhead in B, D) is found in Gata4 G295Swt/ki
mice (B, D) as compared to wildtype littermate (A, C). (C, D)
represent high magnification image of boxed area in (A, B),
respectively. Thickening of aortic valve leaflets is found in Gata4
G295Swt/kimouse (F) that had aortic valve stenosis by echocardio-
gram as compared to wildtype (E). Thickened pulmonary valve
leaflets in Gata4 G295Swt/kimouse are shown (H) as compared to
normal leaflets in wildtype littermate (G). RA, right atrium; LA,
left atrium; RV, right ventricle; LV, left ventricle; AO, aorta; PA,
pulmonary artery. Scale bars indicate 200 mm.
Patent foramen ovale, aortic valve stenosis and
during development. (A) Normal cardiac looping in wildtype
E10.5 embryo as compared to incomplete looping in Gata4
G295Ski/kiin E10.5 embryo (B). Red arrow, heart. Scale bars
indicate 200 mm.
Variable cardiac looping of Gata4 G295Ski/kiembryos
G295Ski/kiembryonic hearts. Quantitative RT-PCR demonstrates
no significant change in expression levels of Gata5 and Gata6. in
E9.5 Gata4 G295Ski/ki
hearts when compared to wildtype
Expression of Gata5 and Gata6 is unchanged in Gata4
in Gata4 G295Ski/kiembryos. Coronal sections through E9.5 hearts
of Gata4 G295Swt/ki(A–D) and Gata4 G295Ski/kiembryos (E–H).
Radioactive section in situ hybridization demonstrates mRNA
expression of Hand1 (B,F), Tbx5 (C,G), and Hand2 (D,H) in Gata4
G295Ski/kiembryos is similar to Gata4 G295Swt/kilittermates.
Bright-field images are shown in (A) and (E). A, atria; V, ventricle;
OFT, outflow tract.
Expression of Hand1, Tbx5 and Hand2 is unchanged
Gata4 G295Ski/kiembryos hearts. Expression of the Gata4 target
endoderm genes, (A) alpha-fetoprotein and (B) Sox17 along with
expression of (C) Hex1 and (D) HNF4, genes that are not Gata4
targets, is shown in E8.5 (red), E9.5 (green) and E10.5 (black)
embryos. Solid bars, wildtype embryos; striped bars, Gata4
Expression of endoderm genes is not decreased in
Cre+, Gata4 G295Ski/flox; Tie2-Cre+, Gata4 G295Ski/flox; a-MHC-Cre+
Expression of Gata4 in Gata4 G295Ski/flox; Nkx2-5-
Mouse Model of Human GATA4 Mutation
PLoS Genetics | www.plosgenetics.org11May 2012 | Volume 8 | Issue 5 | e1002690
E10.5 embryos. Immunohistochemistry for Gata4 on histologic
sections of E10.5 embryos shows decreased myocardial expression
(*) and unchanged endocardial expression (arrowhead) in Gata4
G295Ski/flox; Nkx2-5-Cre+embryo (B) as compared to wildtype
littermate (A). Gata4 expression is decreased in the endocardium
(arrowhead) of E10.5 Gata4 G295Ski/flox; Tie2-Cre+embryo (D)
compared to wildtype littermate (C). Areas of decreased
myocardial expression of Gata4 (arrowhead) in Gata4 G295Ski/
flox; a-MHC-Cre+E10.5 embryos (F) as compared to wildtype
littermate (E). Arrowheads, endocardium;V, ventricle; scale bars
indicate 200 mm.
for the following mouse crosses.
Distribution of surviving progeny at postnatal day 10
We thank members of the University of Texas Southwestern Transgenic
Mouse Core Facility for assistance with gene targeting, members of the
Histology Core at the Research Institute at Nationwide Children’s Hospital
and Molecular Pathology Core at University of Texas Southwestern
Medical Center for histology and radioactive in situ hybridization,
Nianyuan Huang for technical assistance, Dave Dunaway in the Flow
Cytometry Core at The Research Institute at Nationwide Children’s
Hospital for assistance with cell analysis, B. L. Black for providing us with
cyclin D2 reporter plasmid, M. Yanagisawa for the Tie2-Cre mice, M.D.
Schneider for the a-MHC-Cre mice, and E. N. Olson for the Nkx2-5-Cre
Conceived and designed the experiments: CM NS DS VG. Performed the
experiments: CM NS CRM SNK HAN AG. Analyzed the data: CM NS
CRM AG VG. Contributed reagents/materials/analysis tools: PAL WTP.
Wrote the paper: CM VG.
1. Hoffman JI, Kaplan S (2002) The incidence of congenital heart disease. J Am
Coll Cardiol 39: 1890–1900.
Botto LD, Correa A, Erickson JD (2001) Racial and temporal variations in the
prevalence of heart defects. Pediatrics 107: E32.
Pierpont ME, Basson CT, Benson DW, Jr., Gelb BD, Giglia TM, et al. (2007)
Genetic basis for congenital heart defects: current knowledge: a scientific
statement from the American Heart Association Congenital Cardiac Defects
Committee, Council on Cardiovascular Disease in the Young: endorsed by the
American Academy of Pediatrics. Circulation 115: 3015–3038.
Jenkins KJ, Correa A, Feinstein JA, Botto L, Britt AE, et al. (2007) Noninherited
risk factors and congenital cardiovascular defects: current knowledge: a scientific
statement from the American Heart Association Council on Cardiovascular
Disease in the Young: endorsed by the American Academy of Pediatrics.
Circulation 115: 2995–3014.
Srivastava D (2006) Making or breaking the heart: from lineage determination to
morphogenesis. Cell 126: 1037–1048.
Garg V (2006) Insights into the genetic basis of congenital heart disease. Cell
Mol Life Sci 63: 1141–1148.
Basson CT, Bachinsky DR, Lin RC, Levi T, Elkins JA, et al. (1997) Mutations in
human TBX5 cause limb and cardiac malformation in Holt-Oram syndrome.
Nat Genet 15: 30–35.
Bruneau BG, Nemer G, Schmitt JP, Charron F, Robitaille L, et al. (2001) A
murine model of Holt-Oram syndrome defines roles of the T-box transcription
factor Tbx5 in cardiogenesis and disease. Cell 106: 709–721.
Schott JJ, Benson DW, Basson CT, Pease W, Silberbach GM, et al. (1998)
Congenital heart disease caused by mutations in the transcription factor NKX2-
5. Science 281: 108–111.
10. Lyons I, Parsons LM, Hartley L, Li R, Andrews JE, et al. (1995) Myogenic and
morphogenetic defects in the heart tubes of murine embryos lacking the homeo
box gene Nkx2-5. Genes Dev 9: 1654–1666.
11. Biben C, Weber R, Kesteven S, Stanley E, McDonald L, et al. (2000) Cardiac
septal and valvular dysmorphogenesis in mice heterozygous for mutations in the
homeobox gene Nkx2-5. Circulation research 87: 888–895.
12. Garg V, Kathiriya IS, Barnes R, Schluterman MK, King IN, et al. (2003)
GATA4 mutations cause human congenital heart defects and reveal an
interaction with TBX5. Nature 424: 443–447.
13. Rajagopal SK, Ma Q, Obler D, Shen J, Manichaikul A, et al. (2007) Spectrum
of heart disease associated with murine and human GATA4 mutation. J Mol
Cell Cardiol 43: 677–685.
14. Tomita-Mitchell A, Maslen CL, Morris CD, Garg V, Goldmuntz E (2007)
GATA4 sequence variants in patients with congenital heart disease. J Med
Genet 44: 779–783.
15. Zhang W, Li X, Shen A, Jiao W, Guan X, et al. (2008) GATA4 mutations in
486 Chinese patients with congenital heart disease. Eur J Med Genet 51:
16. Butler TL, Esposito G, Blue GM, Cole AD, Costa MW, et al. (2010) GATA4
mutations in 357 unrelated patients with congenital heart malformation. Genet
Test Mol Biomarkers 14: 797–802.
17. Molkentin JD, Lin Q, Duncan SA, Olson EN (1997) Requirement of the
transcription factor GATA4 for heart tube formation and ventral morphogen-
esis. Genes Dev 11: 1061–1072.
18. Kuo CT, Morrisey EE, Anandappa R, Sigrist K, Lu MM, et al. (1997) GATA4
transcription factor is required for ventral morphogenesis and heart tube
formation. Genes Dev 11: 1048–1060.
19. Hiroi Y, Kudoh S, Monzen K, Ikeda Y, Yazaki Y, et al. (2001) Tbx5 associates
with Nkx2-5 and synergistically promotes cardiomyocyte differentiation. Nat
Genet 28: 276–280.
20. Moskowitz IP, Kim JB, Moore ML, Wolf CM, Peterson MA, et al. (2007) A
molecular pathway including Id2, Tbx5, and Nkx2-5 required for cardiac
conduction system development. Cell 129: 1365–1376.
21. Maitra M, Schluterman MK, Nichols HA, Richardson JA, Lo CW, et al. (2009)
Interaction of Gata4 and Gata6 with Tbx5 is critical for normal cardiac
development. Dev Biol 326: 368–377.
22. Sarkozy A, Conti E, Neri C, D’Agostino R, Digilio MC, et al. (2005) Spectrum
of atrial septal defects associated with mutations of NKX2.5 and GATA4
transcription factors. J Med Genet 42: e16.
23. Pu WT, Ishiwata T, Juraszek AL, Ma Q, Izumo S (2004) GATA4 is a dosage-
sensitive regulator of cardiac morphogenesis. Dev Biol 275: 235–244.
24. Watt AJ, Battle MA, Li J, Duncan SA (2004) GATA4 is essential for formation
of the proepicardium and regulates cardiogenesis. Proc Natl Acad Sci U S A
25. Zeisberg EM, Ma Q, Juraszek AL, Moses K, Schwartz RJ, et al. (2005)
Morphogenesis of the right ventricle requires myocardial expression of Gata4.
J Clin Invest 115: 1522–1531.
26. Rivera-Feliciano J, Lee KH, Kong SW, Rajagopal S, Ma Q, et al. (2006)
Development of heart valves requires Gata4 expression in endothelial-derived
cells. Development 133: 3607–3618.
27. Crispino JD, Lodish MB, Thurberg BL, Litovsky SH, Collins T, et al. (2001)
Proper coronary vascular development and heart morphogenesis depend on
interaction of GATA-4 with FOG cofactors. Genes Dev 15: 839–844.
28. Chang YF, Imam JS, Wilkinson MF (2007) The nonsense-mediated decay RNA
surveillance pathway. Annu Rev Biochem 76: 51–74.
29. Molkentin JD (2000) The zinc finger-containing transcription factors GATA-4, -
5, and -6. Ubiquitously expressed regulators of tissue-specific gene expression.
J Biol Chem 275: 38949–38952.
30. Brown CO, 3rd, Chi X, Garcia-Gras E, Shirai M, Feng XH, Schwartz RJ (2004)
The cardiac determination factor, Nkx2-5, is activated by mutual co-factors
GATA-4 and Smad1/4 via a novel upstream enhancer. J Biol Chem 279:
31. Dodou E, Verzi MP, Anderson JP, Xu SM, Black BL (2004) Mef2c is a direct
transcriptional target of ISL1 and GATA factors in the anterior heart field
during mouse embryonic development. Development 131: 3931–3942.
32. Rojas A, Schachterle W, Xu SM, Martin F, Black BL (2010) Direct
transcriptional regulation of Gata4 during early endoderm specification is
controlled by FoxA2 binding to an intronic enhancer. Dev Biol 346: 346–355.
33. Holtzinger A, Rosenfeld GE, Evans T (2010) Gata4 directs development of
cardiac-inducing endoderm from ES cells. Dev Biol 337: 63–73.
34. Duncan SA, Nagy A, Chan W (1997) Murine gastrulation requires HNF-4
regulated gene expression in the visceral endoderm: tetraploid rescue of Hnf-
4(2/2) embryos. Development 124: 279–287.
35. Artus J, Piliszek A, Hadjantonakis AK (2011) The primitive endoderm lineage of
the mouse blastocyst: sequential transcription factor activation and regulation of
differentiation by Sox17. Dev Biol 350: 393–404.
36. Soudais C, Bielinska M, Heikinheimo M, MacArthur CA, Narita N, et al. (1995)
Targeted mutagenesis of the transcription factor GATA-4 gene in mouse
embryonic stem cells disrupts visceral endoderm differentiation in vitro.
Development 121: 3877–3888.
37. Rojas A, Kong SW, Agarwal P, Gilliss B, Pu WT, et al. (2008) GATA4 is a direct
transcriptional activator of cyclin D2 and Cdk4 and is required for
cardiomyocyte proliferation in anterior heart field-derived myocardium. Mol
Cell Biol 28: 5420–5431.
38. Walsh S, Ponten A, Fleischmann BK, Jovinge S (2010) Cardiomyocyte cell cycle
control and growth estimation in vivo–an analysis based on cardiomyocyte
nuclei. Cardiovasc Res 86: 365–373.
Mouse Model of Human GATA4 Mutation
PLoS Genetics | www.plosgenetics.org12May 2012 | Volume 8 | Issue 5 | e1002690
39. Kisanuki YY, Hammer RE, Miyazaki J, Williams SC, Richardson JA, et al. Download full-text
(2001) Tie2-Cre transgenic mice: a new model for endothelial cell-lineage
analysis in vivo. Dev Biol 230: 230–242.
40. Gaussin V, Van de Putte T, Mishina Y, Hanks MC, Zwijsen A, et al. (2002)
Endocardial cushion and myocardial defects after cardiac myocyte-specific
conditional deletion of the bone morphogenetic protein receptor ALK3. Proc
Natl Acad Sci U S A 99: 2878–2883.
41. McFadden DG, Barbosa AC, Richardson JA, Schneider MD, Srivastava D, et
al. (2005) The Hand1 and Hand2 transcription factors regulate expansion of the
embryonic cardiac ventricles in a gene dosage-dependent manner. Development
42. Nadeau M, Georges RO, Laforest B, Yamak A, Lefebvre C, et al. (2010) An
endocardial pathway involving Tbx5, Gata4, and Nos3 required for atrial
septum formation. Proc Natl Acad Sci U S A 107: 19356–19361.
43. LaForest B, Andelfinger G, Nemer M (2011) Loss of Gata5 in mice leads to
bicuspid aortic valve. J Clin Invest 131: 2876–2887.
44. LaForest B, Nemer M (2011) GATA5 interacts with GATA4 and GATA6 in
outflow tract development. Dev Biol 358: 368–378.
45. Pehlivan T, Pober BR, Brueckner M, Garrett S, Slaugh R, et al. (1999) GATA4
haploinsufficiency in patients with interstitial deletion of chromosome region
8p23.1 and congenital heart disease. Am J Med Genet 83: 201–206.
46. Sherr CJ, Roberts JM (2004) Living with or without cyclins and cyclin-
dependent kinases. Genes Dev 18: 2699–2711.
47. Kozar K, Ciemerych MA, Rebel VI, Shigematsu H, Zagozdzon A, et al. (2004)
Mouse development and cell proliferation in the absence of D-cyclins. Cell 118:
48. Garg V, Yamagishi C, Hu T, Kathiriya IS, Yamagishi H, et al. (2001) Tbx1, a
DiGeorge syndrome candidate gene, is regulated by sonic hedgehog during
pharyngeal arch development. Dev Biol 235: 62–73.
49. Schluterman MK, Krysiak AE, Kathiriya IS, Abate N, Chandalia M, et al.
(2007) Screening and biochemical analysis of GATA4 sequence variations
identified in patients with congenital heart disease. Am J Med Genet Part A
Mouse Model of Human GATA4 Mutation
PLoS Genetics | www.plosgenetics.org 13May 2012 | Volume 8 | Issue 5 | e1002690