The NM_001114753.3: c.447G>C variant in ENG is a missense variant predicted to cause substitution of tryptophan by cysteine at amino acid 149 (p.Trp149Cys). This variant is absent from gnomAD v2.1.1 (PM2_Supporting). This variant has been reported in >4 probands with a phenotype consistent with HHT (PS4; PMID: 9554745, 22022569, 22991266, 32300199, Internal lab contributors). At least one patient's phenotype meets Curacao Criteria for HHT, and sequencing and large deletion/duplication analysis was performed for ENG and ACVRL1, which is highly specific for HHT (PP4_Moderate; Internal lab contributors). The variant has been reported to segregate with HHT in 3 affected individuals of a family (4 generations) (PP1; PMID: 10545596). The computational predictor REVEL gives a score of 0.762, which is above the threshold of ≥0.644, evidence that correlates with impact to ENG function (PP3). Additionally, expression studies in endoglin-deficient mice, human umbilical vein endothelial cells (HUVECs) and peripheral blood activated monocytes showed reduced expression of fully processed normal endoglin indicating that this variant impacts protein function (PS3_Supporting; PMID: 10545596, 11343967, 10749981). In summary, this variant meets the criteria to be classified as pathogenic for autosomal dominant hereditary hemorrhagic telangiectasia based on the ACMG/AMP criteria applied, as specified by the ClinGen Hereditary Hemorrhagic Telangiectasia Variant Curation Expert Panel: PM2_Supporting, PP3, PP4_Moderate, PS4, PS3_Supporting, PP1 (specification version 1.0.0; 1/4/2024).