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Chand DH, Sun R, Diab KA, Kenny D, Tukov FF. Review of cardiac safety in onasemnogene abeparvovec gene replacement therapy: translation from preclinical to clinical findings. Gene Ther 2023; 30:685-697. [PMID: 37095320 PMCID: PMC10125853 DOI: 10.1038/s41434-023-00401-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 04/03/2023] [Accepted: 04/12/2023] [Indexed: 04/26/2023]
Abstract
Human gene replacement therapies such as onasemnogene abeparvovec (OA) use recombinant adeno-associated virus (rAAV) vectors to treat monogenic disorders. The heart and liver are known target organs of toxicity in animals; with cardiac and hepatic monitoring recommended in humans after OA dosing. This manuscript provides a comprehensive description of cardiac data from preclinical studies and clinical sources including clinical trials, managed access programs and the post-marketing setting following intravenous OA administration through 23 May 2022. Single dose mouse GLP-Toxicology studies revealed dose-dependent cardiac findings including thrombi, myocardial inflammation and degeneration/regeneration, which were associated with early mortality (4-7 weeks) in the high dose groups. No such findings were documented in non-human primates (NHP) after 6 weeks or 6 months post-dose. No electrocardiogram or echocardiogram abnormalities were noted in NHP or humans. After OA dosing, some patients developed isolated elevations in troponin without associated signs/symptoms; the reported cardiac adverse events in patients were considered of secondary etiology (e.g. respiratory dysfunction or sepsis leading to cardiac events). Clinical data indicate cardiac toxicity observed in mice does not translate to humans. Cardiac abnormalities have been associated with SMA. Healthcare professionals should use medical judgment when evaluating the etiology and assessment of cardiac events post OA dosing so as to consider all possibilities and manage the patient accordingly.
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Affiliation(s)
- Deepa H Chand
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA.
- Department of Pediatrics, University of Illinois College of Medicine and Children's Hospital of Illinois, Peoria, IL, USA.
| | - Rui Sun
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Karim A Diab
- Division of Cardiology, Department of Pediatrics, Inova Children's Hospital, Fairfax, VA, USA
| | - Damien Kenny
- Department of Paediatric Cardiology, CHI at Crumlin, Dublin, Ireland
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Maxwell GK, Szunyogova E, Shorrock HK, Gillingwater TH, Parson SH. Developmental and degenerative cardiac defects in the Taiwanese mouse model of severe spinal muscular atrophy. J Anat 2018; 232:965-978. [PMID: 29473159 PMCID: PMC5978979 DOI: 10.1111/joa.12793] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2018] [Indexed: 12/31/2022] Open
Abstract
Spinal muscular atrophy (SMA), an autosomal recessive disease caused by a decrease in levels of the survival motor neuron (SMN) protein, is the most common genetic cause of infant mortality. Although neuromuscular pathology is the most severe feature of SMA, other organs and tissues, including the heart, are also known to be affected in both patients and animal models. Here, we provide new insights into changes occurring in the heart, predominantly at pre- and early symptomatic ages, in the Taiwanese mouse model of severe SMA. Thinning of the interventricular septum and dilation of the ventricles occurred at pre- and early symptomatic ages. However, the left ventricular wall was significantly thinner in SMA mice from birth, occurring prior to any overt neuromuscular symptoms. Alterations in collagen IV protein from birth indicated changes to the basement membrane and contributed to the abnormal arrangement of cardiomyocytes in SMA hearts. This raises the possibility that developmental defects, occurring prenatally, may contribute to cardiac pathology in SMA. In addition, cardiomyocytes in SMA hearts exhibited oxidative stress at pre-symptomatic ages and increased apoptosis during early symptomatic stages of disease. Heart microvasculature was similarly decreased at an early symptomatic age, likely contributing to the oxidative stress and apoptosis phenotypes observed. Finally, an increased incidence of blood retention in SMA hearts post-fixation suggests the likelihood of functional defects, resulting in blood pooling. These pathologies mirror dilated cardiomyopathy, with clear consequences for heart function that would likely contribute to potential heart failure. Our findings add significant additional experimental evidence in support of the requirement to develop systemic therapies for SMA capable of treating non-neuromuscular pathologies.
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Affiliation(s)
| | - Eva Szunyogova
- Institute for Medical ScienceUniversity of AberdeenAberdeenUK
- Euan MacDonald Centre for Motor Neurone Disease ResearchUniversity of EdinburghEdinburghUK
| | - Hannah K. Shorrock
- Euan MacDonald Centre for Motor Neurone Disease ResearchUniversity of EdinburghEdinburghUK
- Edinburgh Medical School: Biomedical SciencesUniversity of EdinburghEdinburghUK
| | - Thomas H. Gillingwater
- Euan MacDonald Centre for Motor Neurone Disease ResearchUniversity of EdinburghEdinburghUK
- Edinburgh Medical School: Biomedical SciencesUniversity of EdinburghEdinburghUK
| | - Simon H. Parson
- Institute for Medical ScienceUniversity of AberdeenAberdeenUK
- Euan MacDonald Centre for Motor Neurone Disease ResearchUniversity of EdinburghEdinburghUK
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Sharawat IK, Sankhyan N. Tongue Fasciculations and Electrocardiographic Tremors in Spinal Muscular Atrophy. J Pediatr 2018; 197:314. [PMID: 29429566 DOI: 10.1016/j.jpeds.2018.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 12/29/2017] [Accepted: 01/04/2018] [Indexed: 10/18/2022]
Affiliation(s)
- Indar Kumar Sharawat
- Pediatric Neurology and Neurodevelopment Unit Department of Pediatrics Postgraduate Institute of Medical Education and Research Chandigarh, India
| | - Naveen Sankhyan
- Pediatric Neurology and Neurodevelopment Unit Department of Pediatrics Postgraduate Institute of Medical Education and Research Chandigarh, India
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Wijngaarde CA, Blank AC, Stam M, Wadman RI, van den Berg LH, van der Pol WL. Cardiac pathology in spinal muscular atrophy: a systematic review. Orphanet J Rare Dis 2017; 12:67. [PMID: 28399889 PMCID: PMC5387385 DOI: 10.1186/s13023-017-0613-5] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Accepted: 03/14/2017] [Indexed: 01/09/2023] Open
Abstract
Background Hereditary proximal spinal muscular atrophy (SMA) is a severe neuromuscular disease of childhood caused by homozygous loss of function of the survival motor neuron (SMN) 1 gene. The presence of a second, nearly identical SMN gene (SMN2) in the human genome ensures production of residual levels of the ubiquitously expressed SMN protein. Alpha-motor neurons in the ventral horns of the spinal cord are most vulnerable to reduced SMN concentrations but the development or function of other tissues may also be affected, and cardiovascular abnormalities have frequently been reported both in patients and SMA mouse models. Methods We systematically reviewed reported cardiac pathology in relation to SMN deficiency. To investigate the relevance of the possible association in more detail, we used clinical classification systems to characterize structural cardiac defects and arrhythmias. Conclusions Seventy-two studies with a total of 264 SMA patients with reported cardiac pathology were identified, along with 14 publications on SMA mouse models with abnormalities of the heart. Structural cardiac pathology, mainly septal defects and abnormalities of the cardiac outflow tract, was reported predominantly in the most severely affected patients (i.e. SMA type 1). Cardiac rhythm disorders were most frequently reported in patients with milder SMA types (e.g. SMA type 3). All included studies lacked control groups and a standardized approach for cardiac evaluation. The convergence to specific abnormalities of cardiac structure and function may indicate vulnerability of specific cell types or developmental processes relevant for cardiogenesis. Future studies would benefit from a controlled and standardized approach for cardiac evaluation in patients with SMA. Electronic supplementary material The online version of this article (doi:10.1186/s13023-017-0613-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- C A Wijngaarde
- Department of Neurology and Neurosurgery, F02.230, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands.
| | - A C Blank
- Department of Pediatric Cardiology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M Stam
- Department of Neurology and Neurosurgery, F02.230, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands
| | - R I Wadman
- Department of Neurology and Neurosurgery, F02.230, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands
| | - L H van den Berg
- Department of Neurology and Neurosurgery, F02.230, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands
| | - W L van der Pol
- Department of Neurology and Neurosurgery, F02.230, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands.
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Padmanabha H, Kadwa RA, Sahu JK, Singhi PD. Electrocardiographic Tremor as an Important Diagnostic Aid in Spinal Muscular Atrophy. Indian J Pediatr 2016; 83:1506-1507. [PMID: 27460488 DOI: 10.1007/s12098-016-2202-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 07/14/2016] [Indexed: 11/24/2022]
Affiliation(s)
- Hansashree Padmanabha
- Pediatric Neurology and Neurodevelopmental Unit, Department of Pediatrics, Advanced Pediatric Centre, Post Graduate Institute of Medical Education & Research, Chandigarh, 160012, India
| | - Razia Adam Kadwa
- Pediatric Neurology and Neurodevelopmental Unit, Department of Pediatrics, Advanced Pediatric Centre, Post Graduate Institute of Medical Education & Research, Chandigarh, 160012, India
| | - Jitendra Kumar Sahu
- Pediatric Neurology and Neurodevelopmental Unit, Department of Pediatrics, Advanced Pediatric Centre, Post Graduate Institute of Medical Education & Research, Chandigarh, 160012, India
| | - Pratibha D Singhi
- Pediatric Neurology and Neurodevelopmental Unit, Department of Pediatrics, Advanced Pediatric Centre, Post Graduate Institute of Medical Education & Research, Chandigarh, 160012, India.
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6
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Shababi M, Lorson CL, Rudnik-Schöneborn SS. Spinal muscular atrophy: a motor neuron disorder or a multi-organ disease? J Anat 2013; 224:15-28. [PMID: 23876144 DOI: 10.1111/joa.12083] [Citation(s) in RCA: 158] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2013] [Indexed: 12/13/2022] Open
Abstract
Spinal muscular atrophy (SMA) is an autosomal recessive disorder that is the leading genetic cause of infantile death. SMA is characterized by loss of motor neurons in the ventral horn of the spinal cord, leading to weakness and muscle atrophy. SMA occurs as a result of homozygous deletion or mutations in Survival Motor Neuron-1 (SMN1). Loss of SMN1 leads to a dramatic reduction in SMN protein, which is essential for motor neuron survival. SMA disease severity ranges from extremely severe to a relatively mild adult onset form of proximal muscle atrophy. Severe SMA patients typically die mostly within months or a few years as a consequence of respiratory insufficiency and bulbar paralysis. SMA is widely known as a motor neuron disease; however, there are numerous clinical reports indicating the involvement of additional peripheral organs contributing to the complete picture of the disease in severe cases. In this review, we have compiled clinical and experimental reports that demonstrate the association between the loss of SMN and peripheral organ deficiency and malfunction. Whether defective peripheral organs are a consequence of neuronal damage/muscle atrophy or a direct result of SMN loss will be discussed.
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Affiliation(s)
- Monir Shababi
- Department of Veterinary Pathobiology, Life Sciences Center, University of Missouri, Columbia, MO, USA; Department of Molecular Microbiology and Immunology, School of Medicine, University of Missouri, Columbia, MO, USA
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Alsaman AS, Alshaikh NM. Type III spinal muscular atrophy mimicking muscular dystrophies. Pediatr Neurol 2013; 48:363-6. [PMID: 23583053 DOI: 10.1016/j.pediatrneurol.2012.12.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Accepted: 12/31/2012] [Indexed: 11/28/2022]
Abstract
Types III and IV spinal muscular atrophy represent a diagnostic challenge due to the great variability in their presentation. We report a series of eight patients with type III spinal muscular atrophy who were followed for a long time for possible muscular dystrophy or myopathy, confirming its clinical heterogeneity and propensity to delayed diagnosis. Clinical examination revealed heterogeneous findings, where the diagnosis of type III spinal muscular atrophy was not immediately apparent in many patients as their clinical and laboratory abnormalities were consistent with muscular dystrophy or myopathy. The presence of dystrophic features such as hypertrophy of the calves, weakness of the limb girdle, high serum creatine kinase levels, and myopathic histopathology should not divert attention from the possibility of spinal muscular atrophy. It is strongly recommended to give variable presentations enough thought and to consider the autosomal recessive type III spinal muscular atrophy in the diagnostic evaluation.
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Affiliation(s)
- Abdulaziz S Alsaman
- Pediatric Neurology Department, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia.
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Somers E, Stencel Z, Wishart T, Gillingwater T, Parson S. Density, calibre and ramification of muscle capillaries are altered in a mouse model of severe spinal muscular atrophy. Neuromuscul Disord 2012; 22:435-42. [DOI: 10.1016/j.nmd.2011.10.021] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Revised: 10/13/2011] [Accepted: 10/30/2011] [Indexed: 11/29/2022]
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Han JJ, McDonald CM. Diagnosis and clinical management of spinal muscular atrophy. Phys Med Rehabil Clin N Am 2008; 19:661-80, xii. [PMID: 18625423 DOI: 10.1016/j.pmr.2008.02.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Spinal muscular atrophy (SMA) is an autosomal recessive neuromuscular disease characterized by degeneration of lower motor neurons, with resulting progressive muscle weakness. The clinical phenotype and disease severity can be varied and occupy a wide spectrum. Although many advances have been made regarding our understanding of SMA, no cure is yet available. The care of patients who have SMA can often be complex, with many medical issues to consider. When possible, a multidisciplinary team approach is effective. The current understanding of SMA, and the clinical management and rehabilitative care of patients who have SMA, are discussed in this article.
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Affiliation(s)
- Jay J Han
- Department of Physical Medicine and Rehabilitation, University of California-Davis, 4860 Y Street, Suite 3850, Sacramento, CA 95817, USA.
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Lewis WR, Yadlapalli S. Management of Cardiac Complications in Neuromuscular Disease. Phys Med Rehabil Clin N Am 1998. [DOI: 10.1016/s1047-9651(18)30284-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Posada Rodríguez IJ, Gutiérrez-Rivas E, Cabello A. [Cardiac involvement in neuromuscular diseases]. Rev Esp Cardiol 1997; 50:882-901. [PMID: 9470454 DOI: 10.1016/s0300-8932(97)74695-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Many neuromuscular disorders involve the heart, occasionally with overt clinical disease. Muscular dystrophies (dystrophinopathies, limb girdle muscular dystrophy, Emery-Dreifuss muscular dystrophy, Steinert's myotonic dystrophy), congenital myopathies, inflammatory myopathies and metabolic diseases (glycogenosis, periodic paralysis, mitochondrial diseases) may produce dilated or hypertrophic cardiomyopathy and heart rhythm or conduction disturbances. Furthermore the heart is commonly involved in some hereditary and degenerative diseases (Friedreich's ataxia and Kugelberg-Welander syndrome) and acquired (Guillain-Barré syndrome) or inherited (Refsum's disease and Charcot-Marie-Tooth syndrome) polyneuropathies. A cardiologist's high clinical suspicion and a simple but systematic skeletal muscle and peripheral nerve investigation, including muscle enzymes quantification, neurophysiological study and muscle biopsy, are necessary for an accurate diagnosis. In selected patients, more sophisticated biochemical and genetic analysis will be necessary. In most cases, endomyocardial biopsy is not essential for the diagnosis.
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MESH Headings
- Adolescent
- Adult
- Arrhythmias, Cardiac/diagnosis
- Arrhythmias, Cardiac/etiology
- Cardiomyopathy, Dilated/diagnosis
- Cardiomyopathy, Dilated/etiology
- Cardiomyopathy, Hypertrophic/diagnosis
- Cardiomyopathy, Hypertrophic/etiology
- Charcot-Marie-Tooth Disease/complications
- Child
- Child, Preschool
- Echocardiography
- Electrocardiography
- Glycogen Storage Disease/complications
- Glycogen Storage Disease/diagnosis
- Heart Diseases/diagnosis
- Heart Diseases/etiology
- Humans
- Infant
- Infant, Newborn
- Male
- Middle Aged
- Mitochondrial Myopathies/complications
- Mitochondrial Myopathies/diagnosis
- Muscular Atrophy/complications
- Muscular Atrophy/diagnosis
- Muscular Dystrophies/complications
- Muscular Dystrophies/diagnosis
- Myopathies, Nemaline/complications
- Myopathies, Nemaline/diagnosis
- Neuromuscular Diseases/complications
- Neuromuscular Diseases/diagnosis
- Neuromuscular Diseases/metabolism
- Paralyses, Familial Periodic/complications
- Paralyses, Familial Periodic/diagnosis
- Polyradiculoneuropathy/complications
- Polyradiculoneuropathy/diagnosis
- Refsum Disease/complications
- Refsum Disease/diagnosis
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