1
|
Kotta M, Torchio M, Bayliss P, Cohen MC, Quarrell O, Wheeldon N, Marton T, Gentilini D, Crotti L, Coombs RC, Schwartz PJ. Cardiac Genetic Investigation of Sudden Infant and Early Childhood Death: A Study From Victims to Families. J Am Heart Assoc 2023; 12:e029100. [PMID: 37589201 PMCID: PMC10547337 DOI: 10.1161/jaha.122.029100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/27/2023] [Indexed: 08/18/2023]
Abstract
Background Sudden infant death syndrome (SIDS) is the leading cause of death up to age 1. Sudden unexplained death in childhood (SUDC) is similar but affects mostly toddlers aged 1 to 4. SUDC is rarer than SIDS, and although cardiogenetic testing (molecular autopsy) identifies an underlying cause in a fraction of SIDS, less is known about SUDC. Methods and Results Seventy-seven SIDS and 16 SUDC cases underwent molecular autopsy with 25 definitive-evidence arrhythmia-associated genes. In 18 cases, another 76 genes with varying degrees of evidence were analyzed. Parents were offered cascade screening. Double-blind review of clinical-genetic data established genotype-phenotype correlations. The yield of likely pathogenic variants in the 25 genes was higher in SUDC than in SIDS (18.8% [3/16] versus 2.6% [2/77], respectively; P=0.03), whereas novel/ultra-rare variants of uncertain significance were comparably represented. Rare variants of uncertain significance and likely benign variants were found only in SIDS. In cases with expanded analyses, likely pathogenic/likely benign variants stemmed only from definitive-evidence genes, whereas all other genes contributed only variants of uncertain significance. Among 24 parents screened, variant status and phenotype largely agreed, and 3 cases positively correlated for cardiac channelopathies. Genotype-phenotype correlations significantly aided variant adjudication. Conclusions Genetic yield is higher in SUDC than in SIDS although, in both, it is contributed only by definitive-evidence genes. SIDS/SUDC cascade family screening facilitates establishment or dismissal of a diagnosis through definitive variant adjudication indicating that anonymity is no longer justifiable. Channelopathies may underlie a relevant fraction of SUDC. Binary classifications of genetic causality (pathogenic versus benign) could not always be adequate.
Collapse
Affiliation(s)
- Maria‐Christina Kotta
- Center for Cardiac Arrhythmias of Genetic Origin and Laboratory of Cardiovascular GeneticsIRCCS Istituto Auxologico ItalianoMilanItaly
| | - Margherita Torchio
- Center for Cardiac Arrhythmias of Genetic Origin and Laboratory of Cardiovascular GeneticsIRCCS Istituto Auxologico ItalianoMilanItaly
| | - Pauline Bayliss
- Department of Clinical GeneticsSheffield Children’s NHS Foundation TrustSheffieldUnited Kingdom
| | - Marta C. Cohen
- Department of HistopathologySheffield Children’s NHS Foundation TrustSheffieldUnited Kingdom
| | - Oliver Quarrell
- Sheffield Children’s Hospital NHS Foundation TrustSheffieldUnited Kingdom
- Department of NeurosciencesUniversity of SheffieldSheffieldUnited Kingdom
| | - Nigel Wheeldon
- Cardiothoracic CentreNorthern General Hospital, Sheffield Teaching Hospitals NHS TrustSheffieldUnited Kingdom
| | - Tamás Marton
- Cellular Pathology DepartmentBirmingham Women’s and Children’s HospitalBirminghamUnited Kingdom
| | - Davide Gentilini
- Bioinformatics and Statistical Genetics UnitIRCCS Istituto Auxologico ItalianoMilanItaly
| | - Lia Crotti
- Center for Cardiac Arrhythmias of Genetic Origin and Laboratory of Cardiovascular GeneticsIRCCS Istituto Auxologico ItalianoMilanItaly
- Department of Medicine and SurgeryUniversity of Milano‐BicoccaMilanItaly
| | - Robert C. Coombs
- Department of NeonatologySheffield Teaching Hospitals. NHS TrustSheffieldUnited Kingdom
| | - Peter J. Schwartz
- Center for Cardiac Arrhythmias of Genetic Origin and Laboratory of Cardiovascular GeneticsIRCCS Istituto Auxologico ItalianoMilanItaly
| |
Collapse
|
2
|
Immadisetty K, Fang X, Ramon GS, Hartle CM, McCoy TP, Center RG, Mirshahi T, Delisle BP, Kekenes-Huskey PM. Prediction of Kv11.1 potassium channel PAS-domain variants trafficking via machine learning. J Mol Cell Cardiol 2023; 180:69-83. [PMID: 37187232 DOI: 10.1016/j.yjmcc.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 04/28/2023] [Accepted: 05/09/2023] [Indexed: 05/17/2023]
Abstract
Congenital long QT syndrome (LQTS) is characterized by a prolonged QT-interval on an electrocardiogram (ECG). An abnormal prolongation in the QT-interval increases the risk for fatal arrhythmias. Genetic variants in several different cardiac ion channel genes, including KCNH2, are known to cause LQTS. Here, we evaluated whether structure-based molecular dynamics (MD) simulations and machine learning (ML) could improve the identification of missense variants in LQTS-linked genes. To do this, we investigated KCNH2 missense variants in the Kv11.1 channel protein shown to have wild type (WT) like or class II (trafficking-deficient) phenotypes in vitro. We focused on KCNH2 missense variants that disrupt normal Kv11.1 channel protein trafficking, as it is the most common phenotype for LQTS-associated variants. Specifically, we used computational techniques to correlate structural and dynamic changes in the Kv11.1 channel protein PAS domain (PASD) with Kv11.1 channel protein trafficking phenotypes. These simulations unveiled several molecular features, including the numbers of hydrating waters and hydrogen bonding pairs, as well as folding free energy scores, that are predictive of trafficking. We then used statistical and machine learning (ML) (Decision tree (DT), Random forest (RF), and Support vector machine (SVM)) techniques to classify variants using these simulation-derived features. Together with bioinformatics data, such as sequence conservation and folding energies, we were able to predict with reasonable accuracy (≈75%) which KCNH2 variants do not traffic normally. We conclude that structure-based simulations of KCNH2 variants localized to the Kv11.1 channel PASD led to an improvement in classification accuracy. Therefore, this approach should be considered to complement the classification of variant of unknown significance (VUS) in the Kv11.1 channel PASD.
Collapse
Affiliation(s)
| | - Xuan Fang
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
| | | | | | | | | | | | | | | |
Collapse
|
3
|
Zheng Z, Song Y, Tan X. Deciphering hERG Mutation in Long QT Syndrome Type 2 Using Antisense Oligonucleotide-Mediated Techniques: Lessons from Cystic Fibrosis. Heart Rhythm 2023:S1547-5271(23)02180-X. [PMID: 37121422 DOI: 10.1016/j.hrthm.2023.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/18/2023] [Accepted: 04/25/2023] [Indexed: 05/02/2023]
Abstract
Long QT syndrome type 2 (LQT2) is a genetic disorder caused by mutations in the KCNH2 gene, also known as the human ether-a-go-go-related gene (hERG). Over 30% of hERG mutations result in a premature termination codon (PTC) that triggers a process called nonsense-mediated mRNA decay (NMD), where the mRNA transcript is degraded. NMD is a quality control mechanism that removes faulty mRNA to prevent the translation of truncated proteins. Recent advances in antisense oligonucleotide (ASO) technology in the field of cystic fibrosis (CF) have yielded significant progress, including the ASO-mediated comprehensive characterization of key NMD factors and exon-skipping therapy. These advances have contributed to our understanding of the role of PTC-containing mutations in disease phenotypes and have also led to the development of potentially useful therapeutic strategies. Historically, studies of CF have provided valuable insights for the research on LQT2, particularly concerning increasing the expression of hERG. In this article, we outline the current state of knowledge regarding ASO, NMD, and hERG and discuss the introduction of ASO technology in the CF to elucidate the pathogenic mechanisms through targeting NMD. We also discuss the potential clinical therapeutic benefits and limitations of ASO for the management of LQT2. By drawing on lessons learned from CF research, we explore the potential translational values of these advances into LQT2 studies.
Collapse
Affiliation(s)
- Zequn Zheng
- Department of Cardiology, Shantou University Medical College, Shantou, China; Department of Cardiology, First Affiliated Hospital of Shantou University Medical College, Shantou, China; Clinical Research Center, First Affiliated Hospital of Shantou University Medical College, Shantou, China.
| | - Yongfei Song
- Ningbo Institute for Medicine &Biomedical Engineering Combined Innovation, Ningbo, China
| | - Xuerui Tan
- Department of Cardiology, First Affiliated Hospital of Shantou University Medical College, Shantou, China; Clinical Research Center, First Affiliated Hospital of Shantou University Medical College, Shantou, China.
| |
Collapse
|
4
|
Zhang Y, Grimwood AL, Hancox JC, Harmer SC, Dempsey CE. Evolutionary coupling analysis guides identification of mistrafficking-sensitive variants in cardiac K + channels: Validation with hERG. Front Pharmacol 2022; 13:1010119. [PMID: 36339618 PMCID: PMC9632996 DOI: 10.3389/fphar.2022.1010119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 09/30/2022] [Indexed: 09/27/2023] Open
Abstract
Loss of function (LOF) mutations of voltage sensitive K+ channel proteins hERG (Kv11.1) and KCNQ1 (Kv7.1) account for the majority of instances of congenital Long QT Syndrome (cLQTS) with the dominant molecular phenotype being a mistrafficking one resulting from protein misfolding. We explored the use of Evolutionary Coupling (EC) analysis, which identifies evolutionarily conserved pairwise amino acid interactions that may contribute to protein structural stability, to identify regions of the channels susceptible to misfolding mutations. Comparison with published experimental trafficking data for hERG and KCNQ1 showed that the method strongly predicts "scaffolding" regions of the channel membrane domains and has useful predictive power for trafficking phenotypes of individual variants. We identified a region in and around the cytoplasmic S2-S3 loop of the hERG Voltage Sensor Domain (VSD) as susceptible to destabilising mutation, and this was confirmed using a quantitative LI-COR ® based trafficking assay that showed severely attenuated trafficking in eight out of 10 natural hERG VSD variants selected using EC analysis. Our analysis highlights an equivalence in the scaffolding structures of the hERG and KCNQ1 membrane domains. Pathogenic variants of ion channels with an underlying mistrafficking phenotype are likely to be located within similar scaffolding structures that are identifiable by EC analysis.
Collapse
Affiliation(s)
- Yihong Zhang
- School of Physiology, Pharmacology and Neuroscience, Biomedical Sciences Building, University Walk, Bristol, United Kingdom
| | - Amy L. Grimwood
- School of Biological Sciences, Life Sciences Building, Bristol, United Kingdom
| | - Jules C. Hancox
- School of Physiology, Pharmacology and Neuroscience, Biomedical Sciences Building, University Walk, Bristol, United Kingdom
| | - Stephen C. Harmer
- School of Physiology, Pharmacology and Neuroscience, Biomedical Sciences Building, University Walk, Bristol, United Kingdom
| | - Christopher E. Dempsey
- School of Biochemistry, Biomedical Sciences Building, University Walk, Bristol, United Kingdom
| |
Collapse
|
5
|
Ng CA, Ullah R, Farr J, Hill AP, Kozek KA, Vanags LR, Mitchell DW, Kroncke BM, Vandenberg JI. A massively parallel assay accurately discriminates between functionally normal and abnormal variants in a hotspot domain of KCNH2. Am J Hum Genet 2022; 109:1208-1216. [PMID: 35688148 PMCID: PMC9300756 DOI: 10.1016/j.ajhg.2022.05.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 05/03/2022] [Indexed: 01/09/2023] Open
Abstract
Many genes, including KCNH2, contain "hotspot" domains associated with a high density of variants associated with disease. This has led to the suggestion that variant location can be used as evidence supporting classification of clinical variants. However, it is not known what proportion of all potential variants in hotspot domains cause loss of function. Here, we have used a massively parallel trafficking assay to characterize all single-nucleotide variants in exon 2 of KCNH2, a known hotspot for variants that cause long QT syndrome type 2 and an increased risk of sudden cardiac death. Forty-two percent of KCNH2 exon 2 variants caused at least 50% reduction in protein trafficking, and 65% of these trafficking-defective variants exerted a dominant-negative effect when co-expressed with a WT KCNH2 allele as assessed using a calibrated patch-clamp electrophysiology assay. The massively parallel trafficking assay was more accurate (AUC of 0.94) than bioinformatic prediction tools (REVEL and CardioBoost, AUC of 0.81) in discriminating between functionally normal and abnormal variants. Interestingly, over half of variants in exon 2 were found to be functionally normal, suggesting a nuanced interpretation of variants in this "hotspot" domain is necessary. Our massively parallel trafficking assay can provide this information prospectively.
Collapse
Affiliation(s)
- Chai-Ann Ng
- Mark Cowley Lidwill Research Program in Cardiac Electrophysiology, Victor Chang Cardiac Research Institute, Darlinghurst, NSW 2010, Australia; School of Clinical Medicine, UNSW Sydney, Darlinghurst, NSW, Australia
| | - Rizwan Ullah
- Vanderbilt Center for Arrhythmia Research and Therapeutics, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Jessica Farr
- Mark Cowley Lidwill Research Program in Cardiac Electrophysiology, Victor Chang Cardiac Research Institute, Darlinghurst, NSW 2010, Australia; School of Computer Science and Engineering, UNSW Sydney, Kensington, NSW, Australia
| | - Adam P Hill
- Mark Cowley Lidwill Research Program in Cardiac Electrophysiology, Victor Chang Cardiac Research Institute, Darlinghurst, NSW 2010, Australia; School of Clinical Medicine, UNSW Sydney, Darlinghurst, NSW, Australia
| | - Krystian A Kozek
- Vanderbilt Center for Arrhythmia Research and Therapeutics, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Loren R Vanags
- Vanderbilt Center for Arrhythmia Research and Therapeutics, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Devyn W Mitchell
- Vanderbilt Center for Arrhythmia Research and Therapeutics, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Brett M Kroncke
- Vanderbilt Center for Arrhythmia Research and Therapeutics, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
| | - Jamie I Vandenberg
- Mark Cowley Lidwill Research Program in Cardiac Electrophysiology, Victor Chang Cardiac Research Institute, Darlinghurst, NSW 2010, Australia; School of Clinical Medicine, UNSW Sydney, Darlinghurst, NSW, Australia.
| |
Collapse
|
6
|
Egly CL, Blackwell DJ, Schmeckpeper J, Delisle BP, Weaver CD, Knollmann BC. A High-Throughput Screening Assay to Identify Drugs that Can Treat Long QT Syndrome Caused by Trafficking-Deficient K V11.1 (hERG) Variants. Mol Pharmacol 2022; 101:236-245. [PMID: 35125346 PMCID: PMC9638947 DOI: 10.1124/molpharm.121.000421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 01/01/2022] [Indexed: 11/22/2022] Open
Abstract
Loss-of-function (LOF) variants in the KV11.1 potassium channel cause long QT syndrome (LQTS). Most variants disrupt intracellular channel transport (trafficking) to the cell membrane. Since some channel inhibitors improve trafficking of KV11.1 variants, a high-throughput screening (HTS) assay to detect trafficking enhancement would be valuable to the identification of drug candidates. The thallium (Tl+) flux assay technique, widely used for drug screening, was optimized using human embryonic kidney (HEK-293) cells expressing a trafficking-deficient KV11.1 variant in 384-well plates. Assay quality was assessed using Z prime (Z') scores comparing vehicle to E-4031, a drug that increases KV11.1 membrane trafficking. The optimized assay was validated by immunoblot, electrophysiology experiments, and a pilot drug screen. The combination of: 1) truncating the trafficking-deficient variant KV11.1-G601S (KV11.1-G601S-G965*X) with the addition of 2) KV11.1 channel activator (VU0405601) and 3) cesium (Cs+) to the Tl+ flux assay buffer resulted in an outstanding Z' of 0.83. To validate the optimized trafficking assay, we carried out a pilot screen that identified three drugs (ibutilide, azaperone, and azelastine) that increase KV11.1 trafficking. The new assay exhibited 100% sensitivity and specificity. Immunoblot and voltage-clamp experiments confirmed that all three drugs identified by the new assay improved membrane trafficking of two additional LQTS KV11.1 variants. We report two new ways to increase target-specific activity in trafficking assays-genetic modification and channel activation-that yielded a novel HTS assay for identifying drugs that improve membrane expression of pathogenic KV11.1 variants. SIGNIFICANCE STATEMENT: This manuscript reports the development of a high-throughput assay (thallium flux) to identify drugs that can increase function in KV11.1 variants that are trafficking-deficient. Two key aspects that improved the resolving power of the assay and could be transferable to other ion channel trafficking-related assays include genetic modification and channel activation.
Collapse
Affiliation(s)
- Christian L Egly
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (C.L.E., D.J.B., J.S., B.C.K.); Department of Physiology, University of Kentucky, Lexington, Kentucky (B.P.D.); and Department of Pharmacology, Vanderbilt University, Nashville, Tennessee (C.D.W.)
| | - Daniel J Blackwell
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (C.L.E., D.J.B., J.S., B.C.K.); Department of Physiology, University of Kentucky, Lexington, Kentucky (B.P.D.); and Department of Pharmacology, Vanderbilt University, Nashville, Tennessee (C.D.W.)
| | - Jeffrey Schmeckpeper
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (C.L.E., D.J.B., J.S., B.C.K.); Department of Physiology, University of Kentucky, Lexington, Kentucky (B.P.D.); and Department of Pharmacology, Vanderbilt University, Nashville, Tennessee (C.D.W.)
| | - Brian P Delisle
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (C.L.E., D.J.B., J.S., B.C.K.); Department of Physiology, University of Kentucky, Lexington, Kentucky (B.P.D.); and Department of Pharmacology, Vanderbilt University, Nashville, Tennessee (C.D.W.)
| | - C David Weaver
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (C.L.E., D.J.B., J.S., B.C.K.); Department of Physiology, University of Kentucky, Lexington, Kentucky (B.P.D.); and Department of Pharmacology, Vanderbilt University, Nashville, Tennessee (C.D.W.)
| | - Björn C Knollmann
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (C.L.E., D.J.B., J.S., B.C.K.); Department of Physiology, University of Kentucky, Lexington, Kentucky (B.P.D.); and Department of Pharmacology, Vanderbilt University, Nashville, Tennessee (C.D.W.)
| |
Collapse
|
7
|
Isogenic Sets of hiPSC-CMs Harboring Distinct KCNH2 Mutations Differ Functionally and in Susceptibility to Drug-Induced Arrhythmias. Stem Cell Reports 2021; 15:1127-1139. [PMID: 33176122 PMCID: PMC7664051 DOI: 10.1016/j.stemcr.2020.10.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 10/12/2020] [Accepted: 10/13/2020] [Indexed: 12/26/2022] Open
Abstract
Mutations in KCNH2 can lead to long QT syndrome type 2. Variable disease manifestation observed with this channelopathy is associated with the location and type of mutation within the protein, complicating efforts to predict patient risk. Here, we demonstrated phenotypic differences in cardiomyocytes derived from isogenic human induced pluripotent stem cells (hiPSC-CMs) genetically edited to harbor mutations either within the pore or tail region of the ion channel. Electrophysiological analysis confirmed that the mutations prolonged repolarization of the hiPSC-CMs, with differences between the mutations evident in monolayer cultures. Blocking the hERG channel revealed that the pore-loop mutation conferred greater susceptibility to arrhythmic events. These findings showed that subtle phenotypic differences related to KCNH2 mutations could be captured by hiPSC-CMs under genetically matched conditions. Moreover, the results support hiPSC-CMs as strong candidates for evaluating the underlying severity of individual KCNH2 mutations in humans, which could facilitate patient risk stratification. Mutation-specific differences detected in hiPSC-CMs with same genetic background APD and FPD in the hERG pore variant hiPSC-CMs more prolonged than the tail variant The pore variant was also more susceptible to drug-induced arrhythmic events Potential strategy to determine KCNH2 mutation-specific arrhythmic risk
Collapse
|
8
|
Li JV, Ng CA, Cheng D, Zhou Z, Yao M, Guo Y, Yu ZY, Ramaswamy Y, Ju LA, Kuchel PW, Feneley MP, Fatkin D, Cox CD. Modified N-linked glycosylation status predicts trafficking defective human Piezo1 channel mutations. Commun Biol 2021; 4:1038. [PMID: 34489534 PMCID: PMC8421374 DOI: 10.1038/s42003-021-02528-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 08/05/2021] [Indexed: 02/06/2023] Open
Abstract
Mechanosensitive channels are integral membrane proteins that sense mechanical stimuli. Like most plasma membrane ion channel proteins they must pass through biosynthetic quality control in the endoplasmic reticulum that results in them reaching their destination at the plasma membrane. Here we show that N-linked glycosylation of two highly conserved asparagine residues in the 'cap' region of mechanosensitive Piezo1 channels are necessary for the mature protein to reach the plasma membrane. Both mutation of these asparagines (N2294Q/N2331Q) and treatment with an enzyme that hydrolyses N-linked oligosaccharides (PNGaseF) eliminates the fully glycosylated mature Piezo1 protein. The N-glycans in the cap are a pre-requisite for N-glycosylation in the 'propeller' regions, which are present in loops that are essential for mechanotransduction. Importantly, trafficking-defective Piezo1 variants linked to generalized lymphatic dysplasia and bicuspid aortic valve display reduced fully N-glycosylated Piezo1 protein. Thus the N-linked glycosylation status in vitro correlates with efficient membrane trafficking and will aid in determining the functional impact of Piezo1 variants of unknown significance.
Collapse
Affiliation(s)
- Jinyuan Vero Li
- Molecular Cardiology and Biophysics Division, Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Chai-Ann Ng
- Molecular Cardiology and Biophysics Division, Victor Chang Cardiac Research Institute, Sydney, Australia
- St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Delfine Cheng
- Molecular Cardiology and Biophysics Division, Victor Chang Cardiac Research Institute, Sydney, Australia
- St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Zijing Zhou
- Molecular Cardiology and Biophysics Division, Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Mingxi Yao
- Mechanobiology Institute, National University of Singapore, Singapore, Singapore
| | - Yang Guo
- Molecular Cardiology and Biophysics Division, Victor Chang Cardiac Research Institute, Sydney, Australia
- St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Ze-Yan Yu
- Molecular Cardiology and Biophysics Division, Victor Chang Cardiac Research Institute, Sydney, Australia
- St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Yogambha Ramaswamy
- School of Biomedical Engineering, Faculty of Engineering, The University of Sydney, Camperdown, NSW, Australia
| | - Lining Arnold Ju
- School of Biomedical Engineering, Faculty of Engineering, The University of Sydney, Camperdown, NSW, Australia
| | - Philip W Kuchel
- School of Life and Environmental Sciences, University of Sydney, Sydney, NSW, Australia
| | - Michael P Feneley
- Molecular Cardiology and Biophysics Division, Victor Chang Cardiac Research Institute, Sydney, Australia
- St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia
- Department of Cardiology, St Vincent's Hospital, Sydney, Australia
| | - Diane Fatkin
- Molecular Cardiology and Biophysics Division, Victor Chang Cardiac Research Institute, Sydney, Australia
- St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Charles D Cox
- Molecular Cardiology and Biophysics Division, Victor Chang Cardiac Research Institute, Sydney, Australia.
- St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia.
| |
Collapse
|
9
|
Kemp JM, Whittaker DG, Venkateshappa R, Pang Z, Johal R, Sergeev V, Tibbits GF, Mirams GR, Claydon TW. Electrophysiological characterization of the hERG R56Q LQTS variant and targeted rescue by the activator RPR260243. J Gen Physiol 2021; 153:212555. [PMID: 34398210 PMCID: PMC8493834 DOI: 10.1085/jgp.202112923] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/11/2021] [Accepted: 07/21/2021] [Indexed: 11/20/2022] Open
Abstract
Human Ether-à-go-go (hERG) channels contribute to cardiac repolarization, and inherited variants or drug block are associated with long QT syndrome type 2 (LQTS2) and arrhythmia. Therefore, hERG activator compounds present a therapeutic opportunity for targeted treatment of LQTS. However, a limiting concern is over-activation of hERG resurgent current during the action potential and abbreviated repolarization. Activators that slow deactivation gating (type I), such as RPR260243, may enhance repolarizing hERG current during the refractory period, thus ameliorating arrhythmogenicity with reduced early repolarization risk. Here, we show that, at physiological temperature, RPR260243 enhances hERG channel repolarizing currents conducted in the refractory period in response to premature depolarizations. This occurs with little effect on the resurgent hERG current during the action potential. The effects of RPR260243 were particularly evident in LQTS2-associated R56Q mutant channels, whereby RPR260243 restored WT-like repolarizing drive in the early refractory period and diastolic interval, combating attenuated protective currents. In silico kinetic modeling of channel gating predicted little effect of the R56Q mutation on hERG current conducted during the action potential and a reduced repolarizing protection against afterdepolarizations in the refractory period and diastolic interval, particularly at higher pacing rates. These simulations predicted partial rescue from the arrhythmic effects of R56Q by RPR260243 without risk of early repolarization. Our findings demonstrate that the pathogenicity of some hERG variants may result from reduced repolarizing protection during the refractory period and diastolic interval with limited effect on action potential duration, and that the hERG channel activator RPR260243 may provide targeted antiarrhythmic potential in these cases.
Collapse
Affiliation(s)
- Jacob M Kemp
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, Canada
| | - Dominic G Whittaker
- Centre for Mathematical Medicine & Biology, School of Mathematical Sciences, University of Nottingham, Nottingham, UK
| | | | - ZhaoKai Pang
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, Canada
| | - Raj Johal
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, Canada
| | - Valentine Sergeev
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, Canada
| | - Glen F Tibbits
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, Canada
| | - Gary R Mirams
- Centre for Mathematical Medicine & Biology, School of Mathematical Sciences, University of Nottingham, Nottingham, UK
| | - Thomas W Claydon
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, Canada
| |
Collapse
|
10
|
Ng CA, Farr J, Young P, Windley MJ, Perry MD, Hill AP, Vandenberg JI. Heterozygous KCNH2 variant phenotyping using Flp-In HEK293 and high-throughput automated patch clamp electrophysiology. Biol Methods Protoc 2021; 6:bpab003. [PMID: 33884304 PMCID: PMC8046900 DOI: 10.1093/biomethods/bpab003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/10/2021] [Accepted: 03/16/2021] [Indexed: 11/13/2022] Open
Abstract
KCNH2 is one of the 59 medically actionable genes recommended by the American College of Medical Genetics for reporting of incidental findings from clinical genomic sequencing. However, half of the reported KCNH2 variants in the ClinVar database are classified as variants of uncertain significance. In the absence of strong clinical phenotypes, there is a need for functional phenotyping to help decipher the significance of variants identified incidentally. Here, we report detailed methods for assessing the molecular phenotype of any KCNH2 missense variant. The key components of the assay include quick and cost-effective generation of a bi-cistronic vector to co-express Wild-type (WT) and any KCNH2 variant allele, generation of stable Flp-In HEK293 cell lines and high-throughput automated patch clamp electrophysiology analysis of channel function. Stable cell lines take 3–4 weeks to produce and can be generated in bulk, which will then allow up to 30 variants to be phenotyped per week after 48 h of channel expression. This high-throughput functional genomics assay will enable a much more rapid assessment of the extent of loss of function of any KCNH2 variant.
Collapse
Affiliation(s)
- Chai-Ann Ng
- Victor Chang Cardiac Research Institute, 405 Liverpool Street, Darlinghurst, New South Wales 2010, Australia.,St Vincent's Clinical School, UNSW Sydney, Darlinghurst, New South Wales 2010, Australia
| | - Jessica Farr
- Victor Chang Cardiac Research Institute, 405 Liverpool Street, Darlinghurst, New South Wales 2010, Australia.,School of Computer Science and Engineering, UNSW Sydney, Kensington, New South Wales 2052, Australia
| | - Paul Young
- Victor Chang Cardiac Research Institute, 405 Liverpool Street, Darlinghurst, New South Wales 2010, Australia
| | - Monique J Windley
- Victor Chang Cardiac Research Institute, 405 Liverpool Street, Darlinghurst, New South Wales 2010, Australia
| | - Matthew D Perry
- Victor Chang Cardiac Research Institute, 405 Liverpool Street, Darlinghurst, New South Wales 2010, Australia.,St Vincent's Clinical School, UNSW Sydney, Darlinghurst, New South Wales 2010, Australia
| | - Adam P Hill
- Victor Chang Cardiac Research Institute, 405 Liverpool Street, Darlinghurst, New South Wales 2010, Australia.,St Vincent's Clinical School, UNSW Sydney, Darlinghurst, New South Wales 2010, Australia
| | - Jamie I Vandenberg
- Victor Chang Cardiac Research Institute, 405 Liverpool Street, Darlinghurst, New South Wales 2010, Australia.,St Vincent's Clinical School, UNSW Sydney, Darlinghurst, New South Wales 2010, Australia
| |
Collapse
|
11
|
Perry MD, Ng CA, Mangala MM, Ng TYM, Hines AD, Liang W, Xu MJO, Hill AP, Vandenberg JI. Pharmacological activation of IKr in models of long QT Type 2 risks overcorrection of repolarization. Cardiovasc Res 2021; 116:1434-1445. [PMID: 31628797 DOI: 10.1093/cvr/cvz247] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 08/21/2019] [Accepted: 10/09/2019] [Indexed: 12/11/2022] Open
Abstract
AIMS Current treatment for congenital long QT syndrome Type 2 (cLQTS2), an electrical disorder that increases the risk of life-threatening cardiac arrhythmias, is aimed at reducing the incidence of arrhythmia triggers (beta-blockers) or terminating the arrhythmia after onset (implantable cardioverter-defibrillator). An alternative strategy is to target the underlying disease mechanism, which is reduced rapid delayed rectifier current (IKr) passed by Kv11.1 channels. Small molecule activators of Kv11.1 have been identified but the extent to which these can restore normal cardiac signalling in cLQTS2 backgrounds remains unclear. Here, we examined the ability of ICA-105574, an activator of Kv11.1 that impairs transition to the inactivated state, to restore function to heterozygous Kv11.1 channels containing either inactivation enhanced (T618S, N633S) or expression deficient (A422T) mutations. METHODS AND RESULTS ICA-105574 effectively restored Kv11.1 current from heterozygous inactivation enhanced or expression defective mutant channels in heterologous expression systems. In a human-induced pluripotent stem cell-derived cardiomyocyte (hiPSC-CM) model of cLQTS2 containing the expression defective Kv11.1 mutant A422T, cardiac repolarization, estimated from the duration of calcium transients in isolated cells and the rate corrected field potential duration (FPDc) in culture monolayers of cells, was significantly prolonged. The Kv11.1 activator ICA-105574 was able to reverse the prolonged repolarization in a concentration-dependent manner. However, at higher doses, ICA-105574 produced a shortening of the FPDc compared to controls. In vitro and in silico analysis suggests that this overcorrection occurs as a result of a temporal redistribution of the peak IKr to much earlier in the plateau phase of the action potential, which results in early repolarization. CONCLUSION Kv11.1 activators, which target the primary disease mechanism, provide a possible treatment option for cLQTS2, with the caveat that there may be a risk of overcorrection that could itself be pro-arrhythmic.
Collapse
Affiliation(s)
- Matthew D Perry
- Victor Chang Cardiac Research Institute, 405 Liverpool Street, Darlinghurst, New South Wales 2010, Australia.,St Vincent's Clinical School, UNSW Sydney, New South Wales, Australia
| | - Chai-Ann Ng
- Victor Chang Cardiac Research Institute, 405 Liverpool Street, Darlinghurst, New South Wales 2010, Australia.,St Vincent's Clinical School, UNSW Sydney, New South Wales, Australia
| | - Melissa M Mangala
- Victor Chang Cardiac Research Institute, 405 Liverpool Street, Darlinghurst, New South Wales 2010, Australia
| | - Timothy Y M Ng
- Victor Chang Cardiac Research Institute, 405 Liverpool Street, Darlinghurst, New South Wales 2010, Australia.,St Vincent's Clinical School, UNSW Sydney, New South Wales, Australia
| | - Adam D Hines
- Victor Chang Cardiac Research Institute, 405 Liverpool Street, Darlinghurst, New South Wales 2010, Australia.,Queensland Brain Institute, The University of Queensland, St. Lucia 4072, Queensland, Australia
| | - Whitney Liang
- Victor Chang Cardiac Research Institute, 405 Liverpool Street, Darlinghurst, New South Wales 2010, Australia
| | - Michelle J O Xu
- Victor Chang Cardiac Research Institute, 405 Liverpool Street, Darlinghurst, New South Wales 2010, Australia.,St Vincent's Clinical School, UNSW Sydney, New South Wales, Australia
| | - Adam P Hill
- Victor Chang Cardiac Research Institute, 405 Liverpool Street, Darlinghurst, New South Wales 2010, Australia.,St Vincent's Clinical School, UNSW Sydney, New South Wales, Australia
| | - Jamie I Vandenberg
- Victor Chang Cardiac Research Institute, 405 Liverpool Street, Darlinghurst, New South Wales 2010, Australia.,St Vincent's Clinical School, UNSW Sydney, New South Wales, Australia
| |
Collapse
|
12
|
Kompella SN, Brette F, Hancox JC, Shiels HA. Phenanthrene impacts zebrafish cardiomyocyte excitability by inhibiting IKr and shortening action potential duration. J Gen Physiol 2021; 153:e202012733. [PMID: 33475719 PMCID: PMC7829948 DOI: 10.1085/jgp.202012733] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 12/18/2020] [Indexed: 01/14/2023] Open
Abstract
Air pollution is an environmental hazard that is associated with cardiovascular dysfunction. Phenanthrene is a three-ringed polyaromatic hydrocarbon that is a significant component of air pollution and crude oil and has been shown to cause cardiac dysfunction in marine fishes. We investigated the cardiotoxic effects of phenanthrene in zebrafish (Danio rerio), an animal model relevant to human cardiac electrophysiology, using whole-cell patch-clamp of ventricular cardiomyocytes. First, we show that phenanthrene significantly shortened action potential duration without altering resting membrane potential or upstroke velocity (dV/dt). L-type Ca2+ current was significantly decreased by phenanthrene, consistent with the decrease in action potential duration. Phenanthrene blocked the hERG orthologue (zfERG) native current, IKr, and accelerated IKr deactivation kinetics in a dose-dependent manner. Furthermore, we show that phenanthrene significantly inhibits the protective IKr current envelope, elicited by a paired ventricular AP-like command waveform protocol. Phenanthrene had no effect on other IK. These findings demonstrate that exposure to phenanthrene shortens action potential duration, which may reduce refractoriness and increase susceptibility to certain arrhythmia triggers, such as premature ventricular contractions. These data also reveal a previously unrecognized mechanism of polyaromatic hydrocarbon cardiotoxicity on zfERG by accelerating deactivation and decreasing IKr protective current.
Collapse
Affiliation(s)
- Shiva N. Kompella
- Division of Cardiovascular Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - Fabien Brette
- Institut National de la Santé et de la Recherche Médicale, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
- Université de Bordeaux, Centre de Recherche Cardio-Thoracique, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France
| | - Jules C. Hancox
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, UK
| | - Holly A. Shiels
- Division of Cardiovascular Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| |
Collapse
|
13
|
O'Hare BJ, John Kim CS, Hamrick SK, Ye D, Tester DJ, Ackerman MJ. Promise and Potential Peril With Lumacaftor for the Trafficking Defective Type 2 Long-QT Syndrome-Causative Variants, p.G604S, p.N633S, and p.R685P, Using Patient-Specific Re-Engineered Cardiomyocytes. CIRCULATION-GENOMIC AND PRECISION MEDICINE 2020; 13:466-475. [PMID: 32940533 DOI: 10.1161/circgen.120.002950] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND The KCNH2-encoded Kv11.1 hERG (human ether-a-go-go related gene) potassium channel is a critical regulator of cardiomyocyte action potential duration (APD). The majority of type 2 long-QT syndrome (LQT2) stems from trafficking defective KCNH2 mutations. Recently, Food and Drug Administration-approved cystic fibrosis protein trafficking chaperone, lumacaftor, has been proposed as novel therapy for LQT2. Here, we test the efficacy of lumacaftor treatment in patient-specific induced pluripotent stem cell-cardiomyocytes (iPSC-CMs) derived from 2 patients with known LQT2 trafficking defective mutations and a patient with novel KCNH2 variant, p.R685P. METHODS Patient-specific iPSC-CM models of KCNH2-G604S, KCNH2-N633S, and KCNH2-R685P were generated from 3 unrelated patients diagnosed with severe LQT2 (rate-corrected QT>500 ms). Lumacaftor efficacy was also tested by ANEPPS, FluoVolt, and ArcLight voltage dye-based APD90 measurements. RESULTS All 3 mutations were hERG trafficking defective in iPSC-CMs. While lumacaftor treatment failed to rescue the hERG trafficking defect in TSA201 cells, lumacaftor rescued channel trafficking for all mutations in the iPSC-CM model. All 3 mutations conferred a prolonged APD90 compared with control. While lumacaftor treatment rescued the phenotype of KCNH2-N633S and KCNH2-R685P, lumacaftor paradoxically prolonged the APD90 in KCNH2-G604S iPSC-CMs. Lumacaftor-mediated APD90 rescue was affected by rapidly activating delayed rectifier K+ current blocker consistent with the increase of rapidly activating delayed rectifier K+ current by lumacaftor is the underlying mechanism of the LQT2 rescue. CONCLUSIONS While lumacaftor is an effective hERG channel trafficking chaperone and may be therapeutic for LQT2, we urge caution. Without understanding the functionality of the mutant channel to be rescued, lumacaftor therapy could be harmful.
Collapse
Affiliation(s)
- Bailey J O'Hare
- Department of Molecular Pharmacology and Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory (B.J.O., C.S.J.K., S.K.H., D.Y., D.J.T., M.J.A.), Mayo Clinic, Rochester, MN
| | - C S John Kim
- Department of Molecular Pharmacology and Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory (B.J.O., C.S.J.K., S.K.H., D.Y., D.J.T., M.J.A.), Mayo Clinic, Rochester, MN
| | - Samantha K Hamrick
- Department of Molecular Pharmacology and Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory (B.J.O., C.S.J.K., S.K.H., D.Y., D.J.T., M.J.A.), Mayo Clinic, Rochester, MN
| | - Dan Ye
- Department of Molecular Pharmacology and Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory (B.J.O., C.S.J.K., S.K.H., D.Y., D.J.T., M.J.A.), Mayo Clinic, Rochester, MN
| | - David J Tester
- Department of Molecular Pharmacology and Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory (B.J.O., C.S.J.K., S.K.H., D.Y., D.J.T., M.J.A.), Mayo Clinic, Rochester, MN
| | - Michael J Ackerman
- Department of Molecular Pharmacology and Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory (B.J.O., C.S.J.K., S.K.H., D.Y., D.J.T., M.J.A.), Mayo Clinic, Rochester, MN.,Division of Heart Rhythm Services, Department of Cardiovascular Medicine, Windland Smith Rice Genetic Heart Rhythm Clinic (M.J.A.), Mayo Clinic, Rochester, MN.,Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine (M.J.A.), Mayo Clinic, Rochester, MN
| |
Collapse
|
14
|
Shi YP, Pang Z, Venkateshappa R, Gunawan M, Kemp J, Truong E, Chang C, Lin E, Shafaattalab S, Faizi S, Rayani K, Tibbits GF, Claydon VE, Claydon TW. The hERG channel activator, RPR260243, enhances protective IKr current early in the refractory period reducing arrhythmogenicity in zebrafish hearts. Am J Physiol Heart Circ Physiol 2020; 319:H251-H261. [PMID: 32559136 DOI: 10.1152/ajpheart.00038.2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Human ether-à-go-go related gene (hERG) K+ channels are important in cardiac repolarization, and their dysfunction causes prolongation of the ventricular action potential, long QT syndrome, and arrhythmia. As such, approaches to augment hERG channel function, such as activator compounds, have been of significant interest due to their marked therapeutic potential. Activator compounds that hinder channel inactivation abbreviate action potential duration (APD) but carry risk of overcorrection leading to short QT syndrome. Enhanced risk by overcorrection of the APD may be tempered by activator-induced increased refractoriness; however, investigation of the cumulative effect of hERG activator compounds on the balance of these effects in whole organ systems is lacking. Here, we have investigated the antiarrhythmic capability of a hERG activator, RPR260243, which primarily augments channel function by slowing deactivation kinetics in ex vivo zebrafish whole hearts. We show that RPR260243 abbreviates the ventricular APD, reduces triangulation, and steepens the slope of the electrical restitution curve. In addition, RPR260243 increases the post-repolarization refractory period. We provide evidence that this latter effect arises from RPR260243-induced enhancement of hERG channel-protective currents flowing early in the refractory period. Finally, the cumulative effect of RPR260243 on arrhythmogenicity in whole organ zebrafish hearts is demonstrated by the restoration of normal rhythm in hearts presenting dofetilide-induced arrhythmia. These findings in a whole organ model demonstrate the antiarrhythmic benefit of hERG activator compounds that modify both APD and refractoriness. Furthermore, our results demonstrate that targeted slowing of hERG channel deactivation and enhancement of protective currents may provide an effective antiarrhythmic approach.NEW & NOTEWORTHY hERG channel dysfunction causes long QT syndrome and arrhythmia. Activator compounds have been of significant interest due to their therapeutic potential. We used the whole organ zebrafish heart model to demonstrate the antiarrhythmic benefit of the hERG activator, RPR260243. The activator abbreviated APD and increased refractoriness, the combined effect of which rescued induced ventricular arrhythmia. Our findings show that the targeted slowing of hERG channel deactivation and enhancement of protective currents caused by the RPR260243 activator may provide an effective antiarrhythmic approach.
Collapse
Affiliation(s)
- Yu Patrick Shi
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, British Columbia, Canada
| | - ZhaoKai Pang
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, British Columbia, Canada
| | - Ravichandra Venkateshappa
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, British Columbia, Canada
| | - Marvin Gunawan
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, British Columbia, Canada
| | - Jacob Kemp
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, British Columbia, Canada
| | - Elson Truong
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, British Columbia, Canada
| | - Cherlene Chang
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, British Columbia, Canada
| | - Eric Lin
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, British Columbia, Canada
| | - Sanam Shafaattalab
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, British Columbia, Canada
| | - Shoaib Faizi
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, British Columbia, Canada
| | - Kaveh Rayani
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, British Columbia, Canada
| | - Glen F Tibbits
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, British Columbia, Canada
| | - Victoria E Claydon
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, British Columbia, Canada
| | - Thomas W Claydon
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, British Columbia, Canada
| |
Collapse
|
15
|
Larsson JE, Larsson HP, Liin SI. KCNE1 tunes the sensitivity of K V7.1 to polyunsaturated fatty acids by moving turret residues close to the binding site. eLife 2018; 7:37257. [PMID: 30014849 PMCID: PMC6080945 DOI: 10.7554/elife.37257] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 07/15/2018] [Indexed: 12/23/2022] Open
Abstract
The voltage-gated potassium channel KV7.1 and the auxiliary subunit KCNE1 together form the cardiac IKs channel, which is a proposed target for future anti-arrhythmic drugs. We previously showed that polyunsaturated fatty acids (PUFAs) activate KV7.1 via an electrostatic mechanism. The activating effect was abolished when KV7.1 was co-expressed with KCNE1, as KCNE1 renders PUFAs ineffective by promoting PUFA protonation. PUFA protonation reduces the potential of PUFAs as anti-arrhythmic compounds. It is unknown how KCNE1 promotes PUFA protonation. Here, we found that neutralization of negatively charged residues in the S5-P-helix loop of KV7.1 restored PUFA effects on KV7.1 co-expressed with KCNE1 in Xenopus oocytes. We propose that KCNE1 moves the S5-P-helix loop of KV7.1 towards the PUFA-binding site, which indirectly causes PUFA protonation, thereby reducing the effect of PUFAs on KV7.1. This mechanistic understanding of how KCNE1 alters KV7.1 pharmacology is essential for development of drugs targeting the IKs channel.
Collapse
Affiliation(s)
- Johan E Larsson
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - H Peter Larsson
- Department of Physiology and Biophysics, University of Miami, Miami, United States
| | - Sara I Liin
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| |
Collapse
|
16
|
Kanner SA, Jain A, Colecraft HM. Development of a High-Throughput Flow Cytometry Assay to Monitor Defective Trafficking and Rescue of Long QT2 Mutant hERG Channels. Front Physiol 2018; 9:397. [PMID: 29725305 PMCID: PMC5917007 DOI: 10.3389/fphys.2018.00397] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 04/04/2018] [Indexed: 11/24/2022] Open
Abstract
Long QT Syndrome (LQTS) is an acquired or inherited disorder characterized by prolonged QT interval, exertion-triggered arrhythmias, and sudden cardiac death. One of the most prevalent hereditary LQTS subtypes, LQT2, results from loss-of-function mutations in the hERG channel, which conducts IKr, the rapid component of the delayed rectifier K+ current, critical for cardiac repolarization. The majority of LQT2 mutations result in Class 2 deficits characterized by impaired maturation and trafficking of hERG channels. Here, we have developed a high-throughput flow cytometric assay to analyze the surface and total expression of wild-type (WT) and mutant hERG channels with single-cell resolution. To test our method, we focused on 16 LQT2 mutations in the hERG Per-Arnt-Sim (PAS) domain that were previously studied via a widely used biochemical approach that compares levels of 135-kDa immature and 155-kDa fully glycosylated hERG protein to infer surface expression. We confirmed that LQT2 mutants expressed in HEK293 cells displayed a decreased surface density compared to WT hERG, and were differentially rescued by low temperature. However, we also uncovered some notable differences from the findings obtained via the biochemical approach. In particular, three mutations (N33T, R56Q, and A57P) with apparent WT-like hERG glycosylation patterns displayed up to 50% decreased surface expression. Furthermore, despite WT-like levels of complex glycosylation, these mutants have impaired forward trafficking, and exhibit varying half-lives at the cell surface. The results highlight utility of the surface labeling/flow cytometry approach to quantitatively assess trafficking deficiencies associated with LQT2 mutations, to discern underlying mechanisms, and to report on interventions that rescue deficits in hERG surface expression.
Collapse
Affiliation(s)
- Scott A Kanner
- Doctoral Program in Neurobiology and Behavior, Columbia University College of Physicians and Surgeons, New York, NY, United States
| | - Ananya Jain
- Department of Physiology and Cellular Biophysics, Columbia University College of Physicians and Surgeons, New York, NY, United States
| | - Henry M Colecraft
- Doctoral Program in Neurobiology and Behavior, Columbia University College of Physicians and Surgeons, New York, NY, United States.,Department of Physiology and Cellular Biophysics, Columbia University College of Physicians and Surgeons, New York, NY, United States.,Department of Pharmacology, Columbia University College of Physicians and Surgeons, New York, NY, United States
| |
Collapse
|
17
|
Sergeev V, Perry F, Roston TM, Sanatani S, Tibbits GF, Claydon TW. Functional characterization of a novel hERG variant in a family with recurrent sudden infant death syndrome: Retracting a genetic diagnosis. Forensic Sci Int 2018; 284:39-45. [PMID: 29331839 DOI: 10.1016/j.forsciint.2017.12.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 12/05/2017] [Accepted: 12/07/2017] [Indexed: 01/25/2023]
Abstract
Long QT syndrome (LQTS) is the most common cardiac ion channelopathy and has been found to be responsible for approximately 10% of sudden infant death syndrome (SIDS) cases. Despite increasing use of broad panels and now whole exome sequencing (WES) in the investigation of SIDS, the probability of identifying a pathogenic mutation in a SIDS victim is low. We report a family-based study who are afflicted by recurrent SIDS in which several members harbor a variant, p.Pro963Thr, in the C-terminal region of the human-ether-a-go-go (hERG) gene, published to be responsible for cases of LQTS type 2. Functional characterization was undertaken due to the variable phenotype in carriers, the discrepancy with published cases, and the importance of identifying a cause for recurrent deaths in a single family. Studies of the mutated ion channel in in vitro heterologous expression systems revealed that the mutation has no detectable impact on membrane surface expression, biophysical gating properties such as activation, deactivation and inactivation, or the amplitude of the protective current conducted by hERG channels during early repolarization. These observations suggest that the p.Pro963Thr mutation is not a monogenic disease-causing LQTS mutation despite evidence of co-segregation in two siblings affected by SIDS. Our findings demonstrate some of the potential pitfalls in post-mortem molecular testing and the importance of functional testing of gene variants in determining disease-causation, especially where the impacts of cascade screening can affect multiple generations.
Collapse
Affiliation(s)
- Valentine Sergeev
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada
| | - Frances Perry
- Division of Cardiology, Department of Pediatrics, BC Children's Hospital & University of British Columbia, Vancouver, BC, Canada
| | - Thomas M Roston
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada; Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Shubhayan Sanatani
- Division of Cardiology, Department of Pediatrics, BC Children's Hospital & University of British Columbia, Vancouver, BC, Canada
| | - Glen F Tibbits
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada
| | - Thomas W Claydon
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada.
| |
Collapse
|
18
|
Abstract
Pharmacological chaperones (PCs) are small molecules that bind to nascent protein targets to facilitate their biogenesis. The ability of PCs to assist in the folding and subsequent forward trafficking of disease-causative protein misfolding mutants has opened new avenues for the treatment of conformational diseases such as cystic fibrosis and lysosomal storage disorders. In this chapter, an overview of the use of PCs for the treatment of conformational disorders is provided. Beyond the therapeutic application of PCs for the treatment of these disorders, pharmacological chaperoning of wild-type integral membrane proteins is discussed. Central to this discussion is the notion that the endoplasmic reticulum is a reservoir of viable but inefficiently processed wild-type protein folding intermediates whose biogenesis can be facilitated by PCs to increase functional pools. To date, the potential therapeutic use of PCs to enhance the biogenesis of wild-type proteins has received little attention. Here the rationale for the development of PCs that target WT proteins is discussed. Also considered is the likelihood that some commonly used therapeutic agents may exert unrecognized pharmacological chaperoning activity on wild-type targets in patient populations.
Collapse
Affiliation(s)
- Nancy J Leidenheimer
- Department of Biochemistry and Molecular Biology, Louisiana State University Health Sciences Center - Shreveport, Shreveport, LA, USA.
| |
Collapse
|
19
|
Vandenberg JI, Perry MD, Hill AP. Recent advances in understanding and prevention of sudden cardiac death. F1000Res 2017; 6:1614. [PMID: 29026525 PMCID: PMC5583740 DOI: 10.12688/f1000research.11855.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/01/2017] [Indexed: 01/01/2023] Open
Abstract
There have been tremendous advances in the diagnosis and treatment of heart disease over the last 50 years. Nevertheless, it remains the number one cause of death. About half of heart-related deaths occur suddenly, and in about half of these cases the person was unaware that they had underlying heart disease. Genetic heart disease accounts for only approximately 2% of sudden cardiac deaths, but as it typically occurs in younger people it has been a particular focus of activity in our quest to not only understand the underlying mechanisms of cardiac arrhythmogenesis but also develop better strategies for earlier detection and prevention. In this brief review, we will highlight trends in the recent literature focused on sudden cardiac death in genetic heart diseases and how these studies are contributing to a broader understanding of sudden death in the community.
Collapse
Affiliation(s)
- Jamie I Vandenberg
- St Vincent's Clinical School, University of New South Wales, Darlinghurst, Australia.,Victor Chang Cardiac Research Institute, Darlinghurst, Australia
| | - Matthew D Perry
- St Vincent's Clinical School, University of New South Wales, Darlinghurst, Australia.,Victor Chang Cardiac Research Institute, Darlinghurst, Australia
| | - Adam P Hill
- St Vincent's Clinical School, University of New South Wales, Darlinghurst, Australia.,Victor Chang Cardiac Research Institute, Darlinghurst, Australia
| |
Collapse
|
20
|
Phan K, Ng CA, David E, Shishmarev D, Kuchel PW, Vandenberg JI, Perry MD. The S1 helix critically regulates the finely tuned gating of Kv11.1 channels. J Biol Chem 2017; 292:7688-7705. [PMID: 28280240 DOI: 10.1074/jbc.m117.779298] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 02/26/2017] [Indexed: 11/06/2022] Open
Abstract
Congenital mutations in the cardiac Kv11.1 channel can cause long QT syndrome type 2 (LQTS2), a heart rhythm disorder associated with sudden cardiac death. Mutations act either by reducing protein expression at the membrane and/or by perturbing the intricate gating properties of Kv11.1 channels. A number of clinical LQTS2-associated mutations have been reported in the first transmembrane segment (S1) of Kv11.1 channels, but the role of this region of the channel is largely unexplored. In part, this is due to problems defining the extent of the S1 helix, as a consequence of its low sequence homology with other Kv family members. Here, we used NMR spectroscopy and electrophysiological characterization to show that the S1 of Kv11.1 channels extends seven helical turns, from Pro-405 to Phe-431, and is flanked by unstructured loops. Functional analysis suggests that pre-S1 loop residues His-402 and Tyr-403 play an important role in regulating the kinetics and voltage dependence of channel activation and deactivation. Multiple residues within the S1 helix also play an important role in fine-tuning the voltage dependence of activation, regulating slow deactivation, and modulating C-type inactivation of Kv11.1 channels. Analyses of LQTS2-associated mutations in the pre-S1 loop or S1 helix of Kv11.1 channels demonstrate perturbations to both protein expression and most gating transitions. Thus, S1 region mutations would reduce both the action potential repolarizing current passed by Kv11.1 channels in cardiac myocytes, as well as the current passed in response to premature depolarizations that normally helps protect against the formation of ectopic beats.
Collapse
Affiliation(s)
- Kevin Phan
- From the Victor Chang Cardiac Research Institute, 405 Liverpool Street, Darlinghurst, New South Wales 2010.,the St. Vincent's Clinical School, University of New South Wales, New South Wales 2052, and
| | - Chai Ann Ng
- From the Victor Chang Cardiac Research Institute, 405 Liverpool Street, Darlinghurst, New South Wales 2010.,the St. Vincent's Clinical School, University of New South Wales, New South Wales 2052, and
| | - Erikka David
- From the Victor Chang Cardiac Research Institute, 405 Liverpool Street, Darlinghurst, New South Wales 2010
| | - Dmitry Shishmarev
- the School of Life and Environmental Sciences, The University of Sydney, Sydney, New South Wales 2006, Australia
| | - Philip W Kuchel
- the School of Life and Environmental Sciences, The University of Sydney, Sydney, New South Wales 2006, Australia
| | - Jamie I Vandenberg
- From the Victor Chang Cardiac Research Institute, 405 Liverpool Street, Darlinghurst, New South Wales 2010.,the St. Vincent's Clinical School, University of New South Wales, New South Wales 2052, and
| | - Matthew D Perry
- From the Victor Chang Cardiac Research Institute, 405 Liverpool Street, Darlinghurst, New South Wales 2010, .,the St. Vincent's Clinical School, University of New South Wales, New South Wales 2052, and
| |
Collapse
|
21
|
Abstract
Cardiac arrhythmias can follow disruption of the normal cellular electrophysiological processes underlying excitable activity and their tissue propagation as coherent wavefronts from the primary sinoatrial node pacemaker, through the atria, conducting structures and ventricular myocardium. These physiological events are driven by interacting, voltage-dependent, processes of activation, inactivation, and recovery in the ion channels present in cardiomyocyte membranes. Generation and conduction of these events are further modulated by intracellular Ca2+ homeostasis, and metabolic and structural change. This review describes experimental studies on murine models for known clinical arrhythmic conditions in which these mechanisms were modified by genetic, physiological, or pharmacological manipulation. These exemplars yielded molecular, physiological, and structural phenotypes often directly translatable to their corresponding clinical conditions, which could be investigated at the molecular, cellular, tissue, organ, and whole animal levels. Arrhythmogenesis could be explored during normal pacing activity, regular stimulation, following imposed extra-stimuli, or during progressively incremented steady pacing frequencies. Arrhythmic substrate was identified with temporal and spatial functional heterogeneities predisposing to reentrant excitation phenomena. These could arise from abnormalities in cardiac pacing function, tissue electrical connectivity, and cellular excitation and recovery. Triggering events during or following recovery from action potential excitation could thereby lead to sustained arrhythmia. These surface membrane processes were modified by alterations in cellular Ca2+ homeostasis and energetics, as well as cellular and tissue structural change. Study of murine systems thus offers major insights into both our understanding of normal cardiac activity and its propagation, and their relationship to mechanisms generating clinical arrhythmias.
Collapse
Affiliation(s)
- Christopher L-H Huang
- Physiological Laboratory and the Department of Biochemistry, University of Cambridge, Cambridge, United Kingdom
| |
Collapse
|
22
|
Liin SI, Larsson JE, Barro-Soria R, Bentzen BH, Larsson HP. Fatty acid analogue N-arachidonoyl taurine restores function of I Ks channels with diverse long QT mutations. eLife 2016; 5. [PMID: 27690226 PMCID: PMC5081249 DOI: 10.7554/elife.20272] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 09/28/2016] [Indexed: 01/08/2023] Open
Abstract
About 300 loss-of-function mutations in the IKs channel have been identified in patients with Long QT syndrome and cardiac arrhythmia. How specific mutations cause arrhythmia is largely unknown and there are no approved IKs channel activators for treatment of these arrhythmias. We find that several Long QT syndrome-associated IKs channel mutations shift channel voltage dependence and accelerate channel closing. Voltage-clamp fluorometry experiments and kinetic modeling suggest that similar mutation-induced alterations in IKs channel currents may be caused by different molecular mechanisms. Finally, we find that the fatty acid analogue N-arachidonoyl taurine restores channel gating of many different mutant channels, even though the mutations are in different domains of the IKs channel and affect the channel by different molecular mechanisms. N-arachidonoyl taurine is therefore an interesting prototype compound that may inspire development of future IKs channel activators to treat Long QT syndrome caused by diverse IKs channel mutations. DOI:http://dx.doi.org/10.7554/eLife.20272.001 Every heartbeat relies on an electric wave that travels through the heart. This wave must reach different parts of the heart in a specific sequence to ensure that the heart muscle cells contract in a coordinated manner. Such coordinated contractions enable the heart to pump enough blood around the body. By allowing specific ions to flow into or out of the heart muscle cell, proteins called ion channels in the cell membrane generate the electric wave, keep it going and stop it. One such protein called the IKs channel controls the flow of potassium ions, and in doing so stops the electric wave in heart muscle cells. About 300 different mutations in the IKs channel have been shown to cause abnormal heart rhythms in individuals with a disorder called long QT syndrome. People with this condition may suddenly black out because their heart develops prolonged electric waves that prevent blood from being pumped properly. To investigate how mutations in the IKs channel produce heart rhythm abnormalities, Liin et al. genetically engineered the egg cells of African clawed frogs to have one of eight mutant forms of the human IKs channel. Studying these channels revealed that the mutations reduce how well the channels work in a wide variety of ways. However, treating the cells with a particular fatty acid helped to normalize how each of the mutant channels worked. Therefore, variants of the fatty acid could potentially form a useful treatment for people with heart rhythm problems caused by mutations in the IKs channel. More studies are needed to confirm whether the fatty acid is as effective at combating the effects of the mutations in whole hearts and animals. As ion channels related to the IKs channel are found in many types of cells, it is also important to investigate whether treatment with the fatty acid could cause any side effects that affect other organs. DOI:http://dx.doi.org/10.7554/eLife.20272.002
Collapse
Affiliation(s)
- Sara I Liin
- Department of Physiology and Biophysics, University of Miami, Miami, United States.,Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Johan E Larsson
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Rene Barro-Soria
- Department of Physiology and Biophysics, University of Miami, Miami, United States
| | - Bo Hjorth Bentzen
- The Danish Arrhythmia Research Centre, University of Copenhagen, Copenhagen, Denmark.,Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - H Peter Larsson
- Department of Physiology and Biophysics, University of Miami, Miami, United States
| |
Collapse
|
23
|
Ng CA, Gravel AE, Perry MD, Arnold AA, Marcotte I, Vandenberg JI. Tyrosine Residues from the S4-S5 Linker of Kv11.1 Channels Are Critical for Slow Deactivation. J Biol Chem 2016; 291:17293-302. [PMID: 27317659 DOI: 10.1074/jbc.m116.729392] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Indexed: 01/24/2023] Open
Abstract
Slow deactivation of Kv11.1 channels is critical for its function in the heart. The S4-S5 linker, which joins the voltage sensor and pore domains, plays a critical role in this slow deactivation gating. Here, we use NMR spectroscopy to identify the membrane-bound surface of the S4S5 linker, and we show that two highly conserved tyrosine residues within the KCNH subfamily of channels are membrane-associated. Site-directed mutagenesis and electrophysiological analysis indicates that Tyr-542 interacts with both the pore domain and voltage sensor residues to stabilize activated conformations of the channel, whereas Tyr-545 contributes to the slow kinetics of deactivation by primarily stabilizing the transition state between the activated and closed states. Thus, the two tyrosine residues in the Kv11.1 S4S5 linker play critical but distinct roles in the slow deactivation phenotype, which is a hallmark of Kv11.1 channels.
Collapse
Affiliation(s)
- Chai-Ann Ng
- From the Victor Chang Cardiac Research Institute, 405 Liverpool Street, Darlinghurst and the St. Vincent's Clinical School, University of New South Wales, Victoria Street, Darlinghurst, New South Wales 2010, Australia and
| | - Andrée E Gravel
- the Department of Chemistry, Université du Québec à Montréal, Montreal H3C 3P8, Québec, Canada
| | - Matthew D Perry
- From the Victor Chang Cardiac Research Institute, 405 Liverpool Street, Darlinghurst and the St. Vincent's Clinical School, University of New South Wales, Victoria Street, Darlinghurst, New South Wales 2010, Australia and
| | - Alexandre A Arnold
- the Department of Chemistry, Université du Québec à Montréal, Montreal H3C 3P8, Québec, Canada
| | - Isabelle Marcotte
- the Department of Chemistry, Université du Québec à Montréal, Montreal H3C 3P8, Québec, Canada
| | - Jamie I Vandenberg
- From the Victor Chang Cardiac Research Institute, 405 Liverpool Street, Darlinghurst and the St. Vincent's Clinical School, University of New South Wales, Victoria Street, Darlinghurst, New South Wales 2010, Australia and
| |
Collapse
|
24
|
Fedida D, Macdonald L. hERG long QT syndrome type 2 mutants need more than a chaperone to dance. J Physiol 2016; 594:4095-4096. [PMID: 27477605 PMCID: PMC4967728 DOI: 10.1113/jp272417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024] Open
Affiliation(s)
- David Fedida
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, 2350 Health Sciences Mall, Vancouver, British Columbia, Canada, V6T 1Z3.
| | - Logan Macdonald
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, 2350 Health Sciences Mall, Vancouver, British Columbia, Canada, V6T 1Z3
| |
Collapse
|