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Stutzman MJ, Gao X, Kim M, Ye D, Zhou W, Tester DJ, Giudicessi JR, Shannon K, Ackerman MJ. Functional characterization and identification of a therapeutic for a novel SCN5A-F1760C variant causing type 3 long QT syndrome refractory to all guideline-directed therapies. Heart Rhythm 2023; 20:709-717. [PMID: 36731785 DOI: 10.1016/j.hrthm.2023.01.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/23/2023] [Accepted: 01/24/2023] [Indexed: 02/01/2023]
Abstract
BACKGROUND Pathogenic variants in the SCN5A-encoded Nav1.5 sodium channel cause type 3 long QT syndrome (LQT3). We present the case of an infant with severe LQT3 who was refractory to multiple pharmacologic therapies as well as bilateral stellate ganglionectomy. The patient's novel variant, p.F1760C-SCN5A, involves a critical residue of the Nav1.5's local anesthetic binding domain. OBJECTIVE The purpose of this study was to characterize functionally the p.F1760C-SCN5A variant using TSA-201 and patient-specific induced pluripotent stem cell-derived cardiomyocytes (iPSC-CMs). METHODS Whole-cell patch clamp was used to assess p.F1760C-SCN5A associated sodium currents with/without lidocaine (Lido), flecainide, and phenytoin (PHT) in TSA-201 cells. p.F1760C-SCN5A and CRISPR-Cas9 variant-corrected isogenic control (IC) iPSC-CMs were generated. FluoVolt voltage dye was used to measure the action potential duration (APD) with/without mexiletine or PHT. RESULTS V1/2 of inactivation was right-shifted significantly in F1760C cells (-72.2 ± 0.7 mV) compared to wild-type (WT) cells (-86.3 ± 0.9 mV; P <.0001) resulting in a marked increase in window current. F1760C increased sodium late current 2-fold from 0.18% ± 0.04% of peak in WT to 0.49% ± 0.07% of peak in F1760C (P = .0005). Baseline APD to 90% repolarization (APD90) was increased markedly in F1760C iPSC-CMs (601 ± 4 ms) compared to IC iPSC-CMs (423 ± 15 ms; P <.0001). However, 4-hour treatment with 10 μM mexiletine failed to shorten APD90, and treatment with 5μM PHT significantly decreased APD90 of F1760C iPSC-CMs (453 ± 6 ms; P <.0001). CONCLUSION PHT rescued electrophysiological phenotype and APD of a novel p.F1760C-SCN5A variant. The antiepileptic drug PHT may be an effective alternative therapeutic for the treatment of LQT3, especially for variants that disrupt the Lido/mexiletine binding site.
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Affiliation(s)
- Marissa J Stutzman
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Windland Smith Rice Genetic Heart Rhythm Clinic, Mayo Clinic, Rochester, Minnesota; Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota; Department of Molecular Pharmacology & Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Xiaozhi Gao
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Windland Smith Rice Genetic Heart Rhythm Clinic, Mayo Clinic, Rochester, Minnesota; Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota; Department of Molecular Pharmacology & Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Maengjo Kim
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Windland Smith Rice Genetic Heart Rhythm Clinic, Mayo Clinic, Rochester, Minnesota; Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota; Department of Molecular Pharmacology & Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Dan Ye
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Windland Smith Rice Genetic Heart Rhythm Clinic, Mayo Clinic, Rochester, Minnesota; Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota; Department of Molecular Pharmacology & Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Wei Zhou
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Windland Smith Rice Genetic Heart Rhythm Clinic, Mayo Clinic, Rochester, Minnesota; Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota; Department of Molecular Pharmacology & Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, Minnesota
| | - David J Tester
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Windland Smith Rice Genetic Heart Rhythm Clinic, Mayo Clinic, Rochester, Minnesota; Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota; Department of Molecular Pharmacology & Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, Minnesota
| | - John R Giudicessi
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Windland Smith Rice Genetic Heart Rhythm Clinic, Mayo Clinic, Rochester, Minnesota; Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota; Department of Molecular Pharmacology & Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Kevin Shannon
- Department of Pediatrics, David Geffen UCLA School of Medicine, Los Angeles, California
| | - Michael J Ackerman
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Windland Smith Rice Genetic Heart Rhythm Clinic, Mayo Clinic, Rochester, Minnesota; Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota; Department of Molecular Pharmacology & Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, Minnesota.
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Espinosa Á, Ripollés-Melchor J, Brugada R, Campuzano Ó, Sarquella-Brugada G, Abad-Motos A, Zaballos-García M, Abad-Torrent A, Prieto-Gundin A, Brugada J. Brugada Syndrome: anesthetic considerations and management algorithm. Minerva Anestesiol 2018; 85:173-188. [PMID: 30394071 DOI: 10.23736/s0375-9393.18.13170-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Brugada Syndrome is characterized by arrhythmogenic risk that may be exacerbated by different metabolic and pharmacological factors. Since its first description, knowledge of this syndrome and its detection by physicians belonging to different specialties have gradually increased. The risk of arrhythmias is well known to increase in the postoperative period, and this risk is particularly accentuated in patients with Brugada Syndrome. The purpose of this review is to analyze the relationship between this syndrome and anesthesia; establish recommendations for the safe management of these patients in the surgical setting; and update the relevant concepts regarding the safety of drug administration in individuals with Brugada Syndrome.
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Affiliation(s)
- Ángel Espinosa
- Department of Cardiothoracic Anesthesia, Mohammed Bin Khalifa Bin Salman Al Khalifa Cardiac Center, Royal Medical Services, Awali, Bahrain.,Evidence Anesthesia Review Group (EAR), Department of Pharmacology, Faculty of Medicine of Complutense University of Madrid, Madrid, Spain
| | - Javier Ripollés-Melchor
- Evidence Anesthesia Review Group (EAR), Department of Pharmacology, Faculty of Medicine of Complutense University of Madrid, Madrid, Spain - .,Department of Anesthesiology and Critical Care, Infanta Leonor University Hospital, Madrid, Spain.,Madrid Complutense University, Madrid, Spain.,Spanish Perioperative Audit and Research Network (RedGERM), Zaragoza, Spain
| | - Ramón Brugada
- Cardiovascular Genetics Center, Girona Biomedical Research Institute (IDIBGI), University of Girona, Girona, Spain.,Department of Medical Sciences, School of Medicine, University of Girona, Girona, Spain.,Cardiovascular Diseases Network Biomedical Research Center (CIBERCV), Madrid, Spain.,Department of Cardiology, Josep Trueta Hospital, Girona, Spain
| | - Óscar Campuzano
- Cardiovascular Genetics Center, Girona Biomedical Research Institute (IDIBGI), University of Girona, Girona, Spain.,Department of Medical Sciences, School of Medicine, University of Girona, Girona, Spain.,Cardiovascular Diseases Network Biomedical Research Center (CIBERCV), Madrid, Spain
| | - Georgia Sarquella-Brugada
- Department of Medical Sciences, School of Medicine, University of Girona, Girona, Spain.,Unit of Pediatric Arrhythmia, Department of Cardiology, Sant Joan de Déu Hospital, Barcelona, Spain.,Section of Arrhythmia, Department of Cardiology, Clinic Hospital, University of Barcelona, Barcelona, Spain
| | - Ane Abad-Motos
- Department of Anesthesiology and Critical Care, Infanta Leonor University Hospital, Madrid, Spain.,Madrid Complutense University, Madrid, Spain.,Spanish Perioperative Audit and Research Network (RedGERM), Zaragoza, Spain
| | - Matilde Zaballos-García
- Department of Anesthesiology, Gregorio Marañón University General Hospital, Madrid, Spain.,Clinical Toxicology, Madrid Complutense University, Madrid, Spain
| | - Ana Abad-Torrent
- Department of Anesthesiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Alejandra Prieto-Gundin
- Department of Pediatric Anesthesiology, Sant Joan de Déu Hospital, Barcelona Children's Hospital, Barcelona, Spain
| | - Josep Brugada
- Unit of Pediatric Arrhythmia, Department of Cardiology, Sant Joan de Déu Hospital, Barcelona, Spain.,Section of Arrhythmia, Department of Cardiology, Clinic Hospital, University of Barcelona, Barcelona, Spain
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Oliván B, Arbeláez A, de Miguel M, Pelavski A. Diagnosis of Brugada's syndrome after subarachnoid injection of prilocaine. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2016; 63:483-486. [PMID: 26778671 DOI: 10.1016/j.redar.2015.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 10/22/2015] [Accepted: 11/20/2015] [Indexed: 06/05/2023]
Abstract
Brugada syndrome is an autosomal dominant genetic disease affecting sodium ion channels. It is characterised by right bundle branch block and ST elevation in the right precordial leads, and with no structural cardiac abnormalities. It is associated with sudden death. This disease may be unmasked by certain drugs and sudden changes in autonomic tone. Local anaesthetics may increase ECG changes due to a blockade of the sodium channels, mainly depending on the dose and the type of anaesthetic. Thus, there have been reported electrocardiographic changes consistent with Brugada syndrome, triggered after epidural or paravertebral infusion of bupivacaine and ropivacaine. The case is described of a 66 years old man, scheduled for inguinal herniorrhaphy as an outpatient. He had no history of syncope or arrhythmias. After spinal anaesthesia with 40mg of prilocaine the ECG showed ST elevation>2mm, and right bundle branch block in V1-V3.
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Affiliation(s)
- B Oliván
- Servicio de Anestesiología y Reanimación, Hospital Universitario Vall d'Hebron, Barcelona, España.
| | - A Arbeláez
- Servicio de Anestesiología y Reanimación, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - M de Miguel
- Servicio de Anestesiología y Reanimación, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - A Pelavski
- Servicio de Anestesiología y Reanimación, Hospital Universitario Vall d'Hebron, Barcelona, España
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Fuyuta M, Nakao S, Takai N, Shiba M, Tanaka Y, Iwamoto T, Kurita T. Sudden cardiac arrest during general anesthesia in an undiagnosed Brugada patient. J Cardiothorac Vasc Anesth 2012; 27:1334-6. [PMID: 23063101 DOI: 10.1053/j.jvca.2012.08.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Indexed: 11/11/2022]
Affiliation(s)
- Masaki Fuyuta
- Department of Anesthesiology, Kinki University, Osaka, Japan
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Anesthetic management of patients with Brugada syndrome: a case series and literature review. Can J Anaesth 2011; 58:824-36. [DOI: 10.1007/s12630-011-9546-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Accepted: 06/13/2011] [Indexed: 10/18/2022] Open
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Nakatome M, Yamamoto T, Isobe I, Matoba R. Diplotype analysis of the human cardiac sodium channel regulatory region in Japanese cases of sudden death by unknown causes. Leg Med (Tokyo) 2009; 11:298-301. [DOI: 10.1016/j.legalmed.2009.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Revised: 08/21/2009] [Accepted: 08/21/2009] [Indexed: 12/13/2022]
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Romero L, Pueyo E, Fink M, Rodríguez B. Impact of ionic current variability on human ventricular cellular electrophysiology. Am J Physiol Heart Circ Physiol 2009; 297:H1436-45. [PMID: 19648254 DOI: 10.1152/ajpheart.00263.2009] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Abnormalities in repolarization and its rate dependence are known to be related to increased proarrhythmic risk. A number of repolarization-related electrophysiological properties are commonly used as preclinical biomarkers of arrhythmic risk. However, the variability and complexity of repolarization mechanisms make the use of cellular biomarkers to predict arrhythmic risk preclinically challenging. Our goal is to investigate the role of ionic current properties and their variability in modulating cellular biomarkers of arrhythmic risk to improve risk stratification and identification in humans. A systematic investigation into the sensitivity of the main preclinical biomarkers of arrhythmic risk to changes in ionic current conductances and kinetics was performed using computer simulations. Four stimulation protocols were applied to the ten Tusscher and Panfilov human ventricular model to quantify the impact of +/-15 and +/-30% variations in key model parameters on action potential (AP) properties, Ca(2+) and Na(+) dynamics, and their rate dependence. Simulations show that, in humans, AP duration is moderately sensitive to changes in all repolarization current conductances and in L-type Ca(2+) current (I(CaL)) and slow component of the delayed rectifier current (I(Ks)) inactivation kinetics. AP triangulation, however, is strongly dependent only on inward rectifier K(+) current (I(K1)) and delayed rectifier current (I(Kr)) conductances. Furthermore, AP rate dependence (i.e., AP duration rate adaptation and restitution properties) and intracellular Ca(2+) and Na(+) levels are highly sensitive to both I(CaL) and Na(+)/K(+) pump current (I(NaK)) properties. This study provides quantitative insights into the sensitivity of preclinical biomarkers of arrhythmic risk to variations in ionic current properties in humans. The results show the importance of sensitivity analysis as a powerful method for the in-depth validation of mathematical models in cardiac electrophysiology.
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Affiliation(s)
- Lucía Romero
- Instituto de Investigación Interuniversitario en Bioingeniería y Tecnología Orientada al Ser Humano, Universidad Politécnica de Valencia, Valencia, Spain.
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Patanè S, Marte F. Revelation of Brugada electrocardiographic pattern during a febrile state associated with acute myocardial infarction. Int J Cardiol 2009; 144:e1-4. [PMID: 19155074 DOI: 10.1016/j.ijcard.2008.12.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2008] [Accepted: 12/05/2008] [Indexed: 11/28/2022]
Abstract
The prevalence of the Brugada-type ECG and its natural history are still unclear. The Brugada syndrome is usually identified by a characteristic Brugada-type ECG that consists of ST elevation of a coved type in the precordial leads V1 to V3 and ventricular fibrillation that can lead to sudden cardiac death, although affected individuals may have a normal ECG. Mutations in the cardiac sodium channel gene SCN5A, which encodes the alpha-subunit of the human cardiac voltage-dependent Na+ channel (Na(v)1.5), are identified in 15-30% of patients with Brugada syndrome. Most SCN5A mutations lead to a 'loss-of-function' phenotype, reducing the Na+ current during the early phases of the action potential. Several nongenetic factors have been mentioned in the literature as possible inductors of the ECG pattern resembling Brugada syndrome. As such, a Brugada-type ECG may appear in some patients during febrile states and in those who are under the influence of cocaine and pharmaceutical drugs that have a sodium channel-blocking effect. It has been also reported chest pain and ST elevation Brugada pattern during febrile states. We present a case of revelation of Brugada pattern in a 69-year-old Italian man during a febrile state associated with acute myocardial infarction. Also this report confirms that Brugada pattern should be considered as one of differential diagnoses when we examine the patients during a febrile state.
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Patanè S, Marte F, La Rosa FC, Albanese A, La Rocca R, Villari SA. Revelation of Brugada electrocardiographic pattern during a febrile state. Int J Cardiol 2008; 140:e19-21. [PMID: 19117622 DOI: 10.1016/j.ijcard.2008.11.069] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2008] [Accepted: 11/15/2008] [Indexed: 11/19/2022]
Abstract
The prevalence of the Brugada-type ECG and its natural history are still unclear. The Brugada syndrome is usually identified by a characteristic Brugada-type ECG that consists of ST elevation of a coved type in the precordial leads V1 to V3 and ventricular fibrillation that can lead to sudden cardiac death, although affected individuals may have a normal ECG. Mutations in the cardiac sodium channel gene SCN5A, which encodes the alpha-subunit of the human cardiac voltage-dependent Na+ channel (Na(v)1.5), are identified in 15-30% of patients with Brugada syndrome. Most SCN5A mutations lead to a 'loss-of-function' phenotype, reducing the Na+ current during the early phases of the action potential. Several nongenetic factors have been mentioned in the literature as possible inductors of the ECG pattern resembling Brugada syndrome. As such, a Brugada-type ECG may appear in some patients during febrile states and in those who are under the influence of cocaine and pharmaceutical drugs that have a sodium channel-blocking effect. It has been also reported that chest pain and ST elevation Brugada pattern occur during febrile states. We present a case of revelation of Brugada pattern in a 61-year-old Italian man complaining of pain in the left hipocondrium during a febrile state. Also this report confirms that Brugada pattern should be considered as one of differential diagnoses when we examine the patients during a febrile state.
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