Molecular genetic basis of sudden cardiac death

Mechanisms underlying electro-mechanical dysfunction in the Zucker diabetic fatty rat heart: a model of obesity and type 2 diabetes

Diabetes mellitus (DM) is a major and worsening global health problem, currently affecting over 450 million people and reducing their quality of life. Type 2 diabetes mellitus (T2DM) accounts for more than 90% of DM and the global epidemic of obesity, which largely explains the dramatic increase in the incidence and prevalence of T2DM in the past 20 years. Obesity is a major risk factor for DM which is a major cause of morbidity and mortality in diabetic patients. The electro-mechanical function of the heart is frequently compromised in diabetic patients. The aim of this review is to discuss the pathophysiology of electro-mechanical dysfunction in the diabetic heart and in particular, the Zucker diabetic fatty (ZDF) rat heart, a well-studied model of T2DM and obesity.

Significance of automated external defibrillator in identifying lethal ventricular arrhythmias

Automated electrical defibrillator (AED) is critical in saving children who develop unexpected cardiac arrest (CA), but its diagnostic capacity is not fully acknowledged. Retrospective cohort study of patients with aborted sudden cardiac death (SCD) was performed. Twenty-five patients (14 males) aged 1.3 to 17.5 years who presented with CA survived with prompt cardiopulmonary resuscitation. Eighteen patients had no prior cardiac diagnosis. Cardiac arrest occurred in 10 patients with more than moderate exercise, in 7 with light exercise, and in 8 at rest (including one during sleep). Twenty-two patients were resuscitated with AED, all of which were recognized as a shockable cardiac rhythm. Thorough investigations revealed 6 ion channelopathies (4 catecholaminergic polymorphic ventricular tachycardia, one long QT syndrome, and one Brugada syndrome), 5 congenital heart disease (including 2 with coronary artery obstruction), 6 cardiomyopathies, 2 myocarditis, and 2 miscellaneous. Four patients had no identifiable heart disease. In 5 patients, the downloaded AED-recorded rhythm strip delineated the underlying arrhythmias and their responses to electrical shocks. Four patients who presented with generalized seizure at rest were initially managed for seizure disorder until AED recording identified lethal ventricular arrhythmias.Conclusions: AED reliably identifies the underlying lethal ventricular arrhythmias in addition to aborting SCD. What is Known: • Although infrequent in children, sudden cardiac death (SCD) is often an unexpected and tragic event. The etiology is diverse and sometimes remains unknown despite extensive investigations. • Automated external defibrillator (AED) is both therapeutic in aborting SCD and diagnostic in identifying the underlying lethal ventricular arrhythmias. However, the diagnostic aspect of AED is under-acknowledged by most medical providers. What is New: • Four of 25 patients (16%) were initially managed for possible seizure disorders until AED recording identified lethal ventricular arrhythmia. • The AED recording of the lethal arrhythmia during cardiopulmonary resuscitation (CPR) should always be obtained as it plays a crucial role in the decision-making process before ICD implantation. All medical providers should become familiar with downloading cardiac rhythm strips from AED when requested.

Comparative Quantitative Studies on the Microvasculature of the Heart of a Highly Selected Meat-Type and a Wild-Type Turkey Line

In this study the macroscopic and microscopic structure of the heart of a fast growing, meat-type turkey line (British United turkeys BUT Big 6) and a wild-type turkey line (Canadian Wild turkey) were compared. At 8 and 16 weeks of age, 10 birds of each genotype and sex were sampled. The body mass and heart mass of the meat-type turkey both increased at a faster rate than those of the wild-type turkey. However in both turkey lines, the relative heart mass decreased slightly with age, the decrease was statistically significant only in the male turkeys. Furthermore meat-type turkeys had a significantly (p < 0.01) lower relative heart mass and relative thickness of the left ventricle compared to the wild-type turkeys of the same age. The wild-type turkeys showed no significant change in the size of cardiomyocytes (cross sectional area and diameter) from 8 weeks to 16 weeks. In contrast, the size of cardiomyocytes increased significantly (p < 0.001) with age in the meat-type turkeys. The number of capillaries in the left ventricular wall increased significantly (p < 0.001) in wild-type turkeys from 2351 per mm² at the age of 8 weeks to 2843 per mm² at 16 weeks. However, in the meat-type turkeys there were no significant changes, capillary numbers being 2989 per mm² at age 8 weeks and 2915 per mm² at age 16 weeks. Correspondingly the area occupied by capillaries in the myocardium increased in wild-type turkeys from 8.59% at the age of 8 weeks to 9.15% at 16 weeks, whereas in meat-type turkeys this area decreased from 10.4% at 8 weeks to 9.95% at 16 weeks. Our results indicate a mismatch in development between body mass and heart mass and a compromised cardiac capillary density and architecture in the meat-type turkeys in comparison to the wild-type turkeys.

Importance of genetic evaluation and testing in pediatric cardiomyopathy

Pediatric cardiomyopathies are clinically heterogeneous heart muscle disorders that are responsible for significant morbidity and mortality. Phenotypes include hypertrophic cardiomyopathy, dilated cardiomyopathy, restrictive cardiomyopathy, left ventricular noncompaction and arrhythmogenic right ventricular cardiomyopathy. There is substantial evidence for a genetic contribution to pediatric cardiomyopathy. To date, more than 100 genes have been implicated in cardiomyopathy, but comprehensive genetic diagnosis has been problematic because of the large number of genes, the private nature of mutations, and difficulties in interpreting novel rare variants. This review will focus on current knowledge on the genetic etiologies of pediatric cardiomyopathy and their diagnostic relevance in clinical settings. Recent developments in sequencing technologies are greatly impacting the pace of gene discovery and clinical diagnosis. Understanding the genetic basis for pediatric cardiomyopathy and establishing genotype-phenotype correlations may help delineate the molecular and cellular events necessary to identify potential novel therapeutic targets for heart muscle dysfunction in children.

Minimally invasive approach to the child with palpitations

Palpitations are a common reason for referral to a pediatric cardiologist. Although generally benign, palpitations are a significant cause for concern in the individual and their family. Similarly, palpitations may be the initial presentation of significant heart disease, resulting in heightened concern in the referring physician. Although emphasis is usually placed on excluding arrhythmia as the cause for palpitations, there are a variety of noncardiac causes for palpitations. The patient history and physical examination are the key components of the evaluation and guide subsequent investigations. In many cases, an immediate diagnosis cannot be made and additional testing may be required; this often includes further monitoring for episodes, cardiac imaging and ambulatory monitoring. Current technologies for ambulatory monitoring during symptoms include Holter monitoring and a variety of patient-activated event recorders, including implantable loop recorders. Each presents its own unique advantages and disadvantages to aid diagnosis in the management of a child with palpitations. The primary focus for the clinician is to determine whether the etiology is benign in nature or whether there is underlying heart disease that may carry a more serious prognosis.

Genetic screening of the canine connexin 40 gene in dogs with inherited cardiac conduction defects

Connexin 40 (Cx40) is a gap-junction protein expressed in the heart where it mediates the coordinated electrical activation of the atria and ventricular conduction tissues, facilitates cell-to-cell adhesion, and provides pathways for direct intercellular communication. Recent studies have shown that Cx40 null mice have cardiac conduction abnormalities with a very high incidence of cardiac malformations in heterozygous (18%) and homozygous (33%) animals, indicating that Cx40 plays a vital role in cardiomorphogenesis. Since several inherited cardiac conduction defects have also been found in dogs, we hypothesized that the clinical findings are genetically linked to a tissue-specific mutation or mutations in the canine Cx40 gene. We therefore screened the Cx40 gene in dogs with inherited cardiac conduction defects for mutations. In this study, we have identified three heterozygous base changes (C384G, C402T, C837T) in the dogs screened and determined them to be synonymous mutations. These mutations, however, have recently been found in an unrelated group of normal dogs.

Drosophila aging 2006/2007

Research on aging in Drosophila continues to provide new insights into this complex process. Drosophila is highly amenable to study aging because of its short generation time, comprehensive resources for genetic manipulation, and functionally conserved physiology. Importantly, many of these physiological processes such as heart function, sleep, and metabolism functionally senescence in older flies. As the evolutionarily conserved insulin and TOR pathways are critical regulators of aging, the influence of insulin and TOR signaling on these processes is an important area for future research. An important emerging theme is determining the age-dependent alterations that occur at the organ level and how this functional senescence is regulated by different tissues.

Genetic control of heart function and aging in Drosophila

The Drosophila heart has proven itself to be an excellent model for human cardiac development and recent investigations suggest that it may serve as a model for human heart function as well. Just as tinman-related genes underlie cardiac development in all organisms with a heart, the functional properties of mature hearts also appear to be conserved in the animal kingdom. Ion channels, such as those encoded by the potassium channel genes KCNQ and HERG, contribute to normal heart function in humans and flies, and when malfunctioning, cause cardiomyopathies or arrhythmias in remarkably similar ways in both species. Moreover, the KATP channel encoded by dSUR protects the heart against hypoxia/ischemia in flies and mammals, and this protection seems to be reduced with age. Indeed, aging appears to affect heart function and performance in flies in ways that are reminiscent of the decline in human heart function with age, and this likely includes a cardiac autonomous function for the insulin-signaling pathway. The potential for discovery of new genes, such as the two-pore ORK1 K+ channel that affects heart rate in flies, makes Drosophila an attractive heart model for genome-wide screens and for complex genetic manipulations needed to elucidate the mechanisms contributing to cardiac malfunction. Insights gained from the fly heart may prove to be instrumental in unraveling the mysteries of the human heart in health and disease.

Giα1-Mediated Cardiac Electrophysiological Remodeling and Arrhythmia in Hypertrophic Cardiomyopathy

BACKGROUND

Cardiac hypertrophy is a major risk factor for arrhythmias and sudden cardiac death. However, the underlying signaling mechanisms involved in the induction of arrhythmia and electrophysiological remodeling in cardiac hypertrophy are unclear.

METHODS AND RESULTS

Using an inducible gene-switch approach, we achieved tissue-specific and temporally regulated induction of a well-established hypertrophic pathway, the Ras-Raf-mitogen-activated protein kinases pathway, in adult mouse heart. On Ras activation, the transgenic animal developed ventricular hypertrophy and arrhythmias. The development of ventricular arrhythmias was temporally correlated with electrophysiological remodeling in isolated ventricular myocytes, including action potential prolongation, increased sodium-calcium exchanger activity, reduced outward potassium currents, sarcoplasmic reticulum Ca2+ defects, and loss of protein kinase A-dependent phospholamban phosphorylation. From genome-wide expression profiling, we discovered a selective induction of G alpha inhibiting subunit 1 (Gi alpha1) expression in the Ras transgenic heart. Treatment of transgenic animals with the Gi/o inhibitor pertussis toxin normalized the phospholamban phosphorylation by protein kinase A, reversed the action potential prolongation, and significantly reduced the frequency of cardiac arrhythmias in Ras transgenic animals.

CONCLUSIONS

These data suggest that selective induction of G alpha inhibiting subunit 1 expression and activity is a novel downstream event in hypertrophic signaling that may be a critical factor leading to cellular electrophysiological remodeling and cardiac arrhythmias in hypertrophic cardiomyopathy.

Brugada syndrome in childhood: a potential fatal arrhythmia not always recognised by paediatricians. A case report and review of the literature

We report on a youngster followed by his paediatrician from birth until 14 years of age for premature beats, most likely of ventricular origin. The sudden death of his sister provoked a re-assessment of his electrocardiograms (ECG), resulting in the diagnosis of Brugada syndrome and the subsequent implantation of a cardioverter defibrillator. This syndrome is a well known entity in adult cardiology, first described by Brugada and Brugada in 1992. It is considered to be the second most common cause of death in young adults after road traffic accidents. In children, however, the Brugada syndrome is not well known and we believe to be certainly underdiagnosed.

α1-Acid glycoprotein reverses cocaine-induced sodium channel blockade in cardiac myocytes

Alpha 1-acid glycoprotein (AAG) is an acute phase protein capable of binding basic drugs. This action explains its reversal of sodium channel blockade by drugs such as amitriptyline and quinidine. We report here the reversal of cocaine-induced sodium channel blockade by AAG. The sodium channel blocking property of cocaine is a major mechanism behind cocaine-induced sudden cardiac death, since sodium channels play a key role in the initiation and regulation of the heart beat. Voltage-gated sodium current (I(Na)) was recorded using whole-cell patch-clamp techniques. Guinea-pig cardiac ventricular myocytes were isolated and continuously perfused at room temperature with physiological solutions. At concentrations ranging from 5 to 320 microM cocaine showed a dose-dependent and reversible blockade of I(Na) with an IC50 of 45.9 microM. The addition of equimolar amounts of AAG to cocaine produced almost complete reversal of cocaine's effects, suggesting a single binding site for cocaine on the AAG molecule. With changes of peak I(Na) normalized against control as 1, cocaine at 20 and 40 microM reduced I(Na) to 0.62+/-0.042 (n = 6) and 0.57+/-0.052 (n = 9), respectively, and the addition of an equimolar concentration of AAG reversed I(Na) to 0.86+/-0.022 and 0.91+/-0.060, respectively.

IN CONCLUSION

AAG reverses cocaine-induced sodium channel blockade in a dose-dependent manner, indicating a therapeutic potential to reverse acute cocaine cardiac toxicity.

Gene Sequencing in Neonates and Infants with the Long QT Syndrome

The objective was to analyze the clinical and molecular findings in a cohort of neonates and infants with the autosomal dominant long QT syndrome (LQTS). Those affected face a high risk of ventricular arrhythmia resulting in syncope, seizure or sudden death. Blood samples submitted for molecular diagnostic studies on 7 infants were subject to DNA extraction and mutation analysis of 18 selected exons in 5 LQTS genes (KCNQ1, HERG, SCN5A, KCNE1, and KCNE2). We detected 11 mutations in these 7 patients. Four patients had 2 mutations in 1 gene (compound heterozygotes) or 2 different genes (digenic inheritance), while 3 patients had 1 mutation each. Except for 1 mutation in KCNE1, all other mutations were detected alone or in combination within HERG and the SCN5A genes. Four of the mutations we found are novel. The lethal nature of the LQTS demands careful attention to the family history and prompt and precise diagnosis and treatment with serious consideration of endocardial pacemaker implantation. While much larger studies are needed, our data suggest that compound heterozygotes or those with 2 mutations in different genes are likely to have a more severe LQTS including early manifestations in neonates and infants.

The Role of Genotyping in Diagnosing Cardiac Channelopathies

The role of genotyping for diagnosis of the cardiac ion channelopathies is a work in progress. No formal guidelines or other publications discussing current recommendations for genotyping exist, particularly for clinical/commercial genotyping. Further, the field is changing rapidly, opinions vary and, additionally, circumstances inside the US are different from outside. The following considerations are a current summary based on a review of the literature, discussions with experts in the field, and our own opinions and also include a brief discussion about genotyping for therapeutic decision making. Research-based genotyping is very important for continued understanding of the details of pathophysiology and the complex regulatory processes in these diseases. Clinical/commercial genotyping for diagnosis is important for identifying patients with reduced penetrance of the phenotype since effective therapies to prevent sudden death exist. Clinical genotyping for therapeutic advantage has limited application at present but will become much more important if and when genotype-/mutation-type specific therapies are shown to be effective. The recommendations will progressively change as new research findings and new genotyping technologies appear.