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Here we explore for the first time the genetic aetiology of MMS using whole-exome sequencing (WES) in undiagnosed patients from the Greek-Cypriot population after prior extensive diagnostics workup including karyotype and array-CGH. A total of 100 individuals (37 affected), from 32 families were recruited and family-based WES was applied to detect causative single-nucleotide variants (SNVs) and indels. A genetic diagnosis was reported for 16 MMS patients (43.2%), with 10\/17 (58.8%) of the findings being novel. All autosomal dominant findings occurred <jats:italic>de novo<\/jats:italic>. Functional studies were also performed to elucidate the molecular mechanism relevant to the abnormal phenotypes, in cases where the clinical significance of the findings was unclear. The 17 variants identified in our cohort were located in 14 genes (<jats:italic>PCNT<\/jats:italic>, <jats:italic>UBE3A<\/jats:italic>, <jats:italic>KAT6A<\/jats:italic>, <jats:italic>SPR<\/jats:italic>, <jats:italic>POMGNT1<\/jats:italic>, <jats:italic>PIEZO2<\/jats:italic>, <jats:italic>PXDN<\/jats:italic>, <jats:italic>KDM6A<\/jats:italic>, <jats:italic>PHIP<\/jats:italic>, <jats:italic>HECW2<\/jats:italic>, <jats:italic>TFAP2A<\/jats:italic>, <jats:italic>CNOT3<\/jats:italic>, <jats:italic>AGTPBP1<\/jats:italic> and <jats:italic>GAMT<\/jats:italic>). This study has highlighted the efficacy of WES through the high detection rate (43.2%) achieved for a challenging category of undiagnosed patients with MMS compared to other conventional diagnostic testing methods (10\u201320% for array-CGH and ~3% for G-banding karyotype analysis). As a result, family-based WES could potentially be considered as a first-tier cost effective diagnostic test for patients with MMS that facilitates better patient management, prognosis and offer accurate recurrence risks to the families.<\/jats:p>","DOI":"10.1371\/journal.pone.0253562","type":"journal-article","created":{"date-parts":[[2021,7,29]],"date-time":"2021-07-29T18:26:35Z","timestamp":1627583195000},"page":"e0253562","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":13,"title":["Unravelling the genetic causes of multiple malformation syndromes: A whole exome sequencing study of the Cypriot 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