Samples

This study was approved by the University of Utah and Primary Children’s Medical Center Institutional Review Boards (IRB#00028740). Written informed consent for participation in the study was obtained from the participants or their parents.

Emulsion PCR enrichment

A primer library (RainDance Technologies, Boston, MA) was custom-designed to amplify 194 exons and exon/intron boundaries for nine aortopathy genes listed in Table 1 (~0.1 Mb). Primers were designed using RainDance’s design parameters and Primer3 (http://primer3.sourceforge.net/). The 350 PCR amplicons ranged in size from 201–919 bp and had a guanine cytosine (GC) content of 24-80%. Genomic DNA (1.5-3 μg) was sheared to 2–4 kb fragments using a Covaris S2 instrument (Covaris, Woburn, MA) and added to a mixture that included all the components of the PCR reaction excluding the primers. This mixture and the primer library were loaded separately onto the RDT1000 instrument, and PCR droplets containing one primer pair per droplet were generated. After amplification, emulsion PCR droplets were broken releasing the amplicons which were then purified and concatenated according to the manufacturer’s instructions. Concatenated samples were sheared to 300 bp fragments, and Illumina adapters were added using the SPRI-TE instrument (Beckman-Coulter, Danvers, MA). Barcode indexes were added using PCR, and sample quality and quantity was assessed using a Bioanalyzer (Agilent Technologies, Santa Clara, CA).

Solution-based hybridization capture enrichment

Custom RNA baits were designed to specifically target the exons and exon/intron boundaries of the nine aortopathy genes from Table 1 (~0.1 Mb). RNA baits were tiled at 5 × spacing and were in replicates of 10 to increase hybridization efficiency. Genomic DNA (3 μg) was sheared to 180 bp fragments. Illumina adapters were added using SureSelect XT kit reagents (Agilent Technologies, Santa Clara, CA). Adapter ligated DNA underwent hybridization with the biotinylated RNA baits for 24 hours at 65°C. Hybridized DNA targets of interest were captured using streptavidin-coated magnetic beads. DNA targets of interest were eluted and barcode/indexed after a series of washes to remove the non-targeted, unbound genome. DNA quality and quantity was assessed (Bioanalyzer).

NGS sequencing and data analysis

Concentrations of indexed samples from the enrichments were determined by quantitative-PCR (KAPA Biosystems, Woburn, MA). Samples were pooled and sequenced on a HiSeq2000 instrument (Illumina, San Diego, CA) using 2 × 100 paired-end sequencing. Sequences were aligned to the human genome reference (hg19) sequence using the Burrows-Wheeler Alignment tool (BWA 0.5.9) [21] with default parameters. PCR duplicates were removed using the Samtools package [22], and base quality score recalibration, local realignment, and variant calling were performed with the Genome Analysis Toolkit (GaTK v1.3) [23]. Variants with coverage less than 6, with 'quality-by-depth' scores of less than two, with variant allele frequencies of less than 0.15, or with overall quality scores of less than 10 were discarded.

Sanger sequencing

Select variants were Sanger sequenced. Primers sequences are available upon request. Amplicons were bi-directly sequenced using the Big Dye® Terminator v3.1 cycle sequencing kit and an ABI 3730 DNA Analyzer (Life Technologies, Carlsbad, CA). Sequences were compared to reference sequences using Mutation Surveyor (SoftGenetics, State College, PA).

Exome sequencing

In addition to the custom targeted enrichments, we also examined depth of coverage for the targeted regions obtained through exome sequencing. Briefly, ten samples from individuals without known aortopathies were sequenced on the Illumina HiSeq2000 platform after undergoing exome capture enrichment (SureSelect 50Mb exome kit, Agilent Technologies, Santa Clara, CA). Exome samples were indexed and pooled, two per lane, using a one-to-one ratio, and were sequenced using 2x100-base pair paired end reads.

Sample enrichment

Six of eight samples underwent successful enrichment using both RainDance emulsion PCR and SureSelect hybridization capture (Table 2). Sample 7 (from Coriell) failed during the RDT1000 merge when the DNA droplets failed to merge properly with the primer library droplets. Hybridization capture of this sample was also poor and analysis was not completed due to sub-optimal DNA quality (A₂₆₀/A₂₈₀ was not between 1.8 and 2.0). Sample 8 failed during hybridization capture due to a pipetting error. Herein, the accuracy of the two enrichment methods, depth of coverage, and variant calling were compared among the six samples enriched using both techniques.

Accuracy

Pathogenic mutations from four positive control samples were detected using both enrichment methods (Table 2, samples 1–4). For example, a heterozygous FBN1 c.1585C > T, p.R529X mutation was detected in sample 1 using both enrichment methods and was confirmed using Sanger sequencing (Additional file 1: Figure S1).

Depth of coverage

Omitting failed samples, both methods generated very high coverage in the targeted regions. Pooling data from all samples and examining coverage on a gene-by-gene basis, the SureSelect enriched material yielded slightly higher, but also more variable, coverage (per-gene average 471.7, range 189.9-592.0) compared to the emulsion PCR technique (per-gene average 414.8, range 303.4-554.4). Both methods yielded significantly higher average coverage per gene than whole-exome sequencing (Figure 1A) and had substantially fewer exons with less than tenfold coverage (Figure 1B). SureSelect results were influenced by particularly low coverage for the NOTCH1 gene (mean 189x), a feature not observed with the sequences generated by emulsion PCR. Low coverage may be related to the GC content of the NOTCH1 gene, in which 17 of 34 exons are > 65% GC.

Examining exons individuals, the SureSelect enrichment yielded fewer total exons with coverage below 10 when compared to both RainDance and the whole exome capture (Figure 1B). Some 98.5% of all exons had mean depth greater than 50 for SureSelect, as compared to 85.5% for RainDance and 70% for whole exome.

Despite relatively high read depths across most exons, several exons consistently had little or no coverage among the samples. Within the SureSelect-enchriched sequences, much of the variation appears to be related to the GC content of the surrounding sequence (Figure 2). For exons containing greater than 75% GC (for instance, exon 1 in the NOTCH1 and TGFβR1 genes) no coverage was observed.

In contrast to the strong correlation of GC content with read depth for the hybridization capture enrichment, exon coverage varied in an unpredictable manner for the emulsion PCR enrichment method (Figure 3). To assess the degree of coverage variability across samples, we computed the standard deviation in coverage for each exon across samples for both custom-designed panel enrichment techniques. The mean of these deviations across exons reflects the overall degree of coverage variability across all samples, with zero indicating that each exon was covered by the same number of reads in every sample. Between sample variability was significantly higher for the emulsion PCR enrichment, with a mean of 330.4, compared to 215.8 for the hybridization enrichment panel (paired t-test, p < 2.2 × 10^-16, Figure 4).

Variants analysis

In addition to the number of reads mapping to targeted locations, we also assessed the quantity and character of the variants identified by both enrichment methods. Because both methods targeted overlapping, but partially distinct regions, we considered only those variants in the intersection of the two capture regions. The intersection of the two capture regions was 60.58 Kb in size, comprising 64% of the bases targeted by SureSelect and 99% of bases in the RainDance capture.

In total, 252 unique variants were identified across all samples, 195 of which were identified by both methods (Additional file 1: Table S1). The sequences generated by the RainDance enrichment contained several more variants, 221 in total, including 26 not identified in the SureSelect-enriched sequences. In contrast, the SureSelect protocol yielded 214 total variants, of which 19 were not found using the emulsion PCR technique. Among the variants common to both methods, 55 (28.2%) were in dbSNP (v. 132), while 2 of the 17 variants (12%) unique to SureSelect were in dbSNP, and 3 of the 23 variants (13%) unique to emulsion PCR were in dbSNP. Assuming variants found in dbSNP are not false positives in our samples, this suggests that even the relatively high coverage obtained by both enrichment methods did not guarantee accurate variant detection, as both the custom targeted enrichment methods identified several variants not recognized by the other method. Similarly discordant results have been found in other recent studies [13].

Examination of the discordant variants suggested several sources for the disagreement. First, discordant variants appeared in the intronic and untranslated areas at the periphery of individual capture regions. Ten SureSelect and fifteen RainDance discordant variants were located in non-exonic regions. Examination of read depth in these areas suggested that coverage was relatively low compared to the mean for the whole exon, implicating variation in read depth as a potential source of discordant or false positive calls.

A second source of discordant variation was the NOTCH1 gene. A relatively high fraction of the discordant variants appeared in the exons of NOTCH1 (15 of 45, or 33%), and these appeared with similar frequencies in both the RainDance and SureSelect samples (8 from RainDance, 7 from SureSelect). NOTCH1 is likely to be problematic for two reasons. First, the high GC content of NOTCH1 reduces the read depths obtained with the SureSelect enrichment procedure. Second, NOTCH1 bears substantial sequence homology to other NOTCH genes, potentially confounding alignment algorithms and generating spurious variant calls.

Clinical utility of the aortopathy panel

Two clinically affected individuals who had previously tested negative for a FBN1, TGFBR1, and TGFBR2 mutation by Sanger sequencing and MLPA [20] were evaluated using the aortopathy panel. Sample 5 was from a 19-year-old female with borderline aortic dilatation, mild tricuspid valve prolapse and mild mitral valve insufficiency, height of 178 cm (5’10”) (99^th percentile), arm span of 176 cm (5’9”) severe pectus carinatum, scoliosis, arachnodactyly, joint mobility, positive wrist and thumb signs, and skin striae. Analysis of the coding region variants and splice site variants from both enrichment methods revealed two nonsynonymous heterozygous variants in SLC2A10 (c.616G > A, p.Ala206Thr and c.1154C > G, p. Ala385Gly) and a NOTCH1 potential splice site variant (IVS16-4C > T). These variants were present in dbSNP and are likely not disease causing.

Sample 6 was from a 34-year-old female with mild aortic dilatation in the setting of past aortic dissection and unknown family history. Two heterozygous nonsynonymous variants, one in COL3A1 (c.2092G > A, p.Ala698Thr) and the other in FBN2 (c.2893G > A, p.Val965Ile) were both present in dbSNP, rs1800255 and rs154001 at 19.8% and 72.4% frequencies in 1000 genomes (November 2010 release, 1000genomes.org), respectively. A novel heterozygous COL3A1 variant (IVS9-7T > C) not found in dbSNP or the COL3A1 locus specific mutation database was also identified. Splice site prediction programs were run to determine if the change altered splicing [24], but they predicted that no change in splicing would occur. It is likely that this variant is also not disease causing.

No synonymous splice site variants were identified in either patient. It is possible that these two patients have a large deletion or duplication of one of the nine aortopathy genes, but this has yet to be evaluated. Currently, detection of structural variation cannot be reliably detected from NGS data alone. Patient samples that test negative from the NGS assay should be run on an exonic level comparative genomic hybridization (CGH) array assay used to evaluate large copy number changes in the same gene set. Until NGS data analysis programs improve in their ability and accuracy to detect structural variation, CGH array assays are the suggested approach for detecting such large deletions or duplications in multi-gene panels. Alternatively, another gene not included in the aortopathy panel may be responsible for the disorder in these patients.

Enrichment performance

All targeted enrichment methods evaluated yielded very high read depths in the aortopathies targeted regions, with all genes except for NOTCH1 from the exome capture obtaining a mean depth of coverage of over 50 × (Figure 1). Overall, the custom-designed hybridization capture enrichment yielded lower coverage in regions of high GC content (Figure 2), but consistently high coverage in regions of low GC bias. The emulsion PCR method, in contrast, yielded exons with very low coverage that had no obvious correlate (Figure 2). Although influenced by GC content, the hybridization capture nonetheless yielded fewer total exons with low coverage than did the emulsion PCR technique (Figure 1B). Overall, emulsion PCR yielded significantly higher between-sample variability in coverage. In a clinical setting, a high degree of between sample consistency is desirable. Low coverage exons will likely require follow-up Sanger sequencing. Knowing which exons will require such treatment beforehand may ameliorate the cost and additional time resulting from designing new primer sets on an as-needed basis.

Despite satisfactory coverage, the methods yielded only partially overlapping sets of variants, with some 10% of variants identified by one method but not by the other (Additional file 1: Table S1). These inconsistencies may be related to variability in read depth as well as alignment ambiguity related to sequence homology. Similarly high discordancy rates were found in a recent study comparing the RainDance and Fluidigm enrichment platforms [13], in which only 42% of variants identified were common to both methods, and 67% of the discordant variants were found in regions of less than 20-fold coverage. Until procedures are devised that substantially decrease the number of regions with low coverage, Sanger confirmation of suspected variants will likely be necessary prior to clinical action.

A high sample failure rate of 25% (2 of 8 samples) was observed due to sample quality (sample 7, RainDance and SureSelect) and a pipetting error (sample 8, SureSelect) (Table 2). Based on our results, only DNA samples of high quality (A_260/280 is between 1.8 and 2.0) should be evaluated using NGS enrichment. If a sample falls below this initial quality measurement, DNA should be extracted again and/or the sample should be purified until an acceptable quality is obtained. For complex enrichment protocols such as the SureSelect method, pipetting errors can be avoided by incorporating automation into sample preparation (discussed further below). This is especially important as the number of clinical samples increase.

NGS enrichment in the clinical laboratory

When compared to emulsion PCR, the solution-based hybridization technique yielded higher coverage as well as greater predictability in performance. These attributes, when combined with lower cost, strongly favor the hybridization capture for enrichment of the aortopathy panel in the clinical setting. Emulsion PCR enrichment is significantly more expensive and requires the use of a costly instrument. Exome sequencing is also more costly because the cost to sequence the exome at a high enough depth of coverage to accurately call variants is much higher than for the targeted panel. Samples can also be indexed and pooled prior to hybridization capture [25], reducing the overall cost per sample even further.

Despite the lower cost, the hybridization capture protocol is more time consuming, complex, and labor intensive when compared to the emulsion PCR technique. However, the ability to automate this process in the clinical laboratory alleviates these challenges and yields more consistent, reliable results [26]. Currently, the emulsion PCR instrument processes one sample/hour, limiting the total number of samples processed in a day to approximately twenty-four. With the increasing interest in exome sequencing, automation of hybridization capture enrichment protocols have become readily available [26], and up to 96 different custom-designed NGS panels and exome hybridizations can take place at the same time during the same run. Solution-based hybridization libraries can be ordered in larger volumes, aliquoted for up to two-three freeze/thaw cycles, and stored for up to one year. RainDance primer libraries have to be switched out after the eighth sample with the RDT1000 instrument design, and if there are not eight samples to run using the same primer library, the rest will be wasted.