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Mundisugih J, Kumar S, Kizana E. Adeno-associated virus-mediated gene therapy for cardiac tachyarrhythmia: A systematic review and meta-analysis. Heart Rhythm 2024; 21:939-949. [PMID: 38336191 DOI: 10.1016/j.hrthm.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 02/01/2024] [Accepted: 02/01/2024] [Indexed: 02/12/2024]
Abstract
Cardiac tachyarrhythmia presents a significant health care challenge, causing notable morbidity and mortality. Conventional treatments have limitations and potential risks, resulting in an elevated disease burden. Adeno-associated virus (AAV)-mediated gene therapy holds promise as a potential future treatment option. Therefore, we aimed to provide a measured overview of the latest developments in this rapidly growing field. PubMed and Embase databases were searched up to January 2024. Studies that employed AAV as a vector for delivery of therapeutic agents to treat cardiac tachyarrhythmia were included. Of the 26 studies included, 20 published in the last 5 years. There were 22 novel molecular targets identified. More than 80% of the included studies employed small-animal models or used AAV9. In atrial fibrillation preclinical studies, AAV-mediated gene therapy reduced atrial fibrillation inducibility by 81% (odds ratio, 0.19 [0.08-0.45]; P < .01). Similarly, for acquired and inherited ventricular arrhythmia, animal models receiving gene therapy had less inducible ventricular arrhythmia (odds ratio, 0.06 [0.03-0.11]; P < .01). This review highlights the rapid progress of AAV-mediated gene therapy for cardiac tachyarrhythmia. Although these investigations are currently in the early stages of clinical application, they present promising prospects for gene therapy. (PROSPERO registry: CRD42023479448).
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Affiliation(s)
- Juan Mundisugih
- Centre for Heart Research, Westmead Institute for Medical Research, New South Wales, Australia; Department of Cardiology, Westmead Hospital, New South Wales, Australia; Sydney Medical School, The University of Sydney, New South Wales, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, New South Wales, Australia; Sydney Medical School, The University of Sydney, New South Wales, Australia
| | - Eddy Kizana
- Centre for Heart Research, Westmead Institute for Medical Research, New South Wales, Australia; Department of Cardiology, Westmead Hospital, New South Wales, Australia; Sydney Medical School, The University of Sydney, New South Wales, Australia.
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2
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Zhang ZH, Barajas-Martinez H, Jiang H, Huang CX, Antzelevitch C, Xia H, Hu D. Gene and stem cell therapy for inherited cardiac arrhythmias. Pharmacol Ther 2024; 256:108596. [PMID: 38301770 DOI: 10.1016/j.pharmthera.2024.108596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 12/11/2023] [Accepted: 01/13/2024] [Indexed: 02/03/2024]
Abstract
Inherited cardiac arrhythmias are a group of genetic diseases predisposing to sudden cardiac arrest, mainly resulting from variants in genes encoding cardiac ion channels or proteins involved in their regulation. Currently available therapeutic options (pharmacotherapy, ablative therapy and device-based therapy) can not preclude the occurrence of arrhythmia events and/or provide complete protection. With growing understanding of the genetic background and molecular mechanisms of inherited cardiac arrhythmias, advancing insight of stem cell technology, and development of vectors and delivery strategies, gene therapy and stem cell therapy may be promising approaches for treatment of inherited cardiac arrhythmias. Recent years have witnessed impressive progress in the basic science aspects and there is a clear and urgent need to be translated into the clinical management of arrhythmic events. In this review, we present a succinct overview of gene and cell therapy strategies, and summarize the current status of gene and cell therapy. Finally, we discuss future directions for implementation of gene and cell therapy in the therapy of inherited cardiac arrhythmias.
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Affiliation(s)
- Zhong-He Zhang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, PR China; Cardiovascular Research Institute, Wuhan University, Wuhan, 430060, PR China; Hubei Key Laboratory of Cardiology, Wuhan, 430060, PR China
| | - Hector Barajas-Martinez
- Lankenau Institute for Medical Research, Lankenau Heart Institute, Wynnwood, PA, 19096, USA; Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - Hong Jiang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, PR China; Cardiovascular Research Institute, Wuhan University, Wuhan, 430060, PR China; Hubei Key Laboratory of Cardiology, Wuhan, 430060, PR China
| | - Cong-Xin Huang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, PR China; Cardiovascular Research Institute, Wuhan University, Wuhan, 430060, PR China; Hubei Key Laboratory of Cardiology, Wuhan, 430060, PR China
| | - Charles Antzelevitch
- Lankenau Institute for Medical Research, Lankenau Heart Institute, Wynnwood, PA, 19096, USA; Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - Hao Xia
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, PR China; Cardiovascular Research Institute, Wuhan University, Wuhan, 430060, PR China; Hubei Key Laboratory of Cardiology, Wuhan, 430060, PR China.
| | - Dan Hu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, PR China; Cardiovascular Research Institute, Wuhan University, Wuhan, 430060, PR China; Hubei Key Laboratory of Cardiology, Wuhan, 430060, PR China.
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3
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Bains S, Giudicessi JR, Odening KE, Ackerman MJ. State of Gene Therapy for Monogenic Cardiovascular Diseases. Mayo Clin Proc 2024; 99:610-629. [PMID: 38569811 DOI: 10.1016/j.mayocp.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 10/22/2023] [Accepted: 11/03/2023] [Indexed: 04/05/2024]
Abstract
Over the past 2 decades, significant efforts have been made to advance gene therapy into clinical practice. Although successful examples exist in other fields, gene therapy for the treatment of monogenic cardiovascular diseases lags behind. In this review, we (1) highlight a brief history of gene therapy, (2) distinguish between gene silencing, gene replacement, and gene editing technologies, (3) discuss vector modalities used in the field with a special focus on adeno-associated viruses, (4) provide examples of gene therapy approaches in cardiomyopathies, channelopathies, and familial hypercholesterolemia, and (5) present current challenges and limitations in the gene therapy field.
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Affiliation(s)
- Sahej Bains
- Mayo Clinic Medical Scientist Training Program, Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, MN; Department of Molecular Pharmacology and Experimental Therapeutics (Windland Smith Rice Sudden Death Genomics Laboratory), Mayo Clinic, Rochester, MN
| | - John R Giudicessi
- Department of Molecular Pharmacology and Experimental Therapeutics (Windland Smith Rice Sudden Death Genomics Laboratory), Mayo Clinic, Rochester, MN; Department of Cardiovascular Medicine (Division of Heart Rhythm Services and Circulatory Failure and the Windland Smith Rice Genetic Heart Rhythm Clinic), Mayo Clinic, Rochester, MN
| | - Katja E Odening
- Translational Cardiology, Department of Cardiology and Department of Physiology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Michael J Ackerman
- Department of Molecular Pharmacology and Experimental Therapeutics (Windland Smith Rice Sudden Death Genomics Laboratory), Mayo Clinic, Rochester, MN; Department of Cardiovascular Medicine (Division of Heart Rhythm Services and Circulatory Failure and the Windland Smith Rice Genetic Heart Rhythm Clinic), Mayo Clinic, Rochester, MN; Department of Pediatric and Adolescent Medicine (Division of Pediatric Cardiology), Mayo Clinic, Rochester, MN.
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4
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Priori SG. Restoring PKP2 in arrhythmogenic cardiomyopathy. NATURE CARDIOVASCULAR RESEARCH 2023; 2:1115-1116. [PMID: 39196151 DOI: 10.1038/s44161-023-00382-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/29/2024]
Affiliation(s)
- Silvia G Priori
- Molecular Cardiology, IRCCS Istituti Clinici Scientifici Maugeri, Pavia, Italy.
- Department of Molecular Medicine, University of Pavia, Pavia, Italy.
- Molecular Cardiology, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.
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5
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Siu A, Tandanu E, Ma B, Osas EE, Liu H, Liu T, Chou OHI, Huang H, Tse G. Precision medicine in catecholaminergic polymorphic ventricular tachycardia: Recent advances toward personalized care. Ann Pediatr Cardiol 2023; 16:431-446. [PMID: 38817258 PMCID: PMC11135882 DOI: 10.4103/apc.apc_96_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 12/12/2023] [Accepted: 01/14/2024] [Indexed: 06/01/2024] Open
Abstract
Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a rare inherited cardiac ion channelopathy where the initial disease presentation is during childhood or adolescent stages, leading to increased risks of sudden cardiac death. Despite advances in medical science and technology, several gaps remain in the understanding of the molecular mechanisms, risk prediction, and therapeutic management of patients with CPVT. Recent studies have identified and validated seven sets of genes responsible for various CPVT phenotypes, including RyR2, CASQ-2, TRDN, CALM1, 2, and 3, and TECRL, providing novel insights into the molecular mechanisms. However, more data on atypical CPVT genotypes are required to investigate the underlying mechanisms further. The complexities of the underlying genetics contribute to challenges in risk stratification as well as the uncertainty surrounding nongenetic modifiers. Therapeutically, although medical management involving beta-blockers and flecainide, or insertion of an implantable cardioverter defibrillator remains the mainstay of treatment, animal and stem cell studies on gene therapy for CPVT have shown promising results. However, its clinical applicability remains unclear. Current gene therapy studies have primarily focused on the RyR2 and CASQ-2 variants, which constitute 75% of all CPVT cases. Alternative approaches that target a broader population, such as CaMKII inhibition, could be more feasible for clinical implementation. Together, this review provides an update on recent research on CPVT, highlighting the need for further investigation of the molecular mechanisms, risk stratification, and therapeutic management of this potentially lethal condition.
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Affiliation(s)
- Anthony Siu
- Cardiac Electrophysiology Unit, Cardiovascular Analytics Group, Powerhealth Research Institute, Hong Kong, China
- GKT School of Medical Education, King’s College London, London, United Kingdom
| | - Edelyne Tandanu
- GKT School of Medical Education, King’s College London, London, United Kingdom
| | - Brian Ma
- Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | | | - Haipeng Liu
- Research Centre for Intelligent Healthcare, Coventry University, Coventry, United Kingdom
| | - Tong Liu
- Department of Cardiology, Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Oscar Hou In Chou
- Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Helen Huang
- University of Medicine and Health Science, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Gary Tse
- Department of Cardiology, Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
- Kent and Medway Medical School, University of Kent, Canterbury, United Kingdom
- School of Nursing and Health Studies, Hong Kong Metropolitan University, Hong Kong, China
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6
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Ryan T, Roberts JD. Emerging Targeted Therapies for Inherited Cardiomyopathies and Arrhythmias. Card Electrophysiol Clin 2023; 15:261-271. [PMID: 37558297 DOI: 10.1016/j.ccep.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
Inherited cardiomyopathy and arrhythmia syndromes are associated with significant morbidity and mortality, particularly in young people. Medical management of these conditions has primarily been limited to agents previously developed for more common forms of heart disease and not tailored to their distinct pathophysiology. As our understanding of their underlying genetics and disease mechanisms has improved, an era of targeted therapies for these rare conditions has begun to emerge. In recent years, several novel agents have been developed and tested in preclinical models and, in some cases, have advanced to both the clinical trial and clinical approval stages with exciting results. These new treatments are derived from multiple classes of therapeutics, including small molecules, antisense oligonucleotides, small interfering RNAs, adeno-associated virus-mediated gene therapies, and in vivo gene editing. Collectively, they carry the promise of revolutionizing management of affected patients and their families.
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Affiliation(s)
- Tammy Ryan
- McMaster University, Hamilton, Ontario, Canada; Department of Medicine, Division of Cardiology, DBCVSRI, Hamilton General Hospital, Room C3-121, 237 Barton Street East, Hamilton, Ontario L8L2X2, Canada
| | - Jason D Roberts
- McMaster University, Hamilton, Ontario, Canada; DBCVSRI, Room C3-111, 237 Barton Street East, Hamilton, Ontario L8L2X2, Canada; Population Health Research Institute and Hamilton Health Sciences, Hamilton, Ontario, Canada.
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7
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Crotti L, Brugada P, Calkins H, Chevalier P, Conte G, Finocchiaro G, Postema PG, Probst V, Schwartz PJ, Behr ER. From gene-discovery to gene-tailored clinical management: 25 years of research in channelopathies and cardiomyopathies. Europace 2023; 25:euad180. [PMID: 37622577 PMCID: PMC10450790 DOI: 10.1093/europace/euad180] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 06/03/2023] [Indexed: 08/26/2023] Open
Abstract
In the early nineties, few years before the birth of Europace, the clinical and scientific world of familial arrhythmogenic conditions was revolutionized by the identification of the first disease-causing genes. The explosion of genetic studies over a 15-year period led to the discovery of major disease-causing genes in practically all channelopathies and cardiomyopathies, bringing insight into the pathophysiological mechanisms of these conditions. The birth of next generation sequencing allowed a further step forward and other significant genes, as CALM1-3 in channelopathies and FLN C and TTN in cardiomyopathies were identified. Genotype-phenotype studies allowed the implementation of the genetic results in diagnosis, risk stratification, and therapeutic management with a different level of evidence in different arrhythmogenic conditions. The influence of common genetic variants, i.e. SNPs, on disease manifestation was proved in mid-twenties, and in the last 10 years with the advent of genome-wide association studies performed in familial arrhythmogenic diseases, the concept of polygenic risk score has been consolidated. Now, we are at the start of another amazing phase, i.e. the initiation of first gene therapy clinical trials.
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Affiliation(s)
- Lia Crotti
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Piazza dell'Ateneo Nuovo, 1 - 20126, Italy
- IRCCS Istituto Auxologico Italiano, Department of Cardiology, Cardiomyopathy Unit, Center for Cardiac Arrhythmias of Genetic Origin and Laboratory of Cardiovascular Genetics, Piazzale Brescia, 20, 20149 Milan, Italy
| | - Pedro Brugada
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Laarbeeklaan 101, Brussels 1090, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Philippe Chevalier
- Neuromyogene Institute, Claude Bernard University, Lyon 1, Lyon, France
- Service de Rythmologie, Hospices Civils de Lyon, Lyon, France
| | - Giulio Conte
- Division of Cardiology, Istituto Cardiocentro Ticino, Ente Cantonale Ospedaliero, Lugano, Switzerland
| | - Gherardo Finocchiaro
- Cardiovascular Sciences Research Centre, St. George’s, University of London, London, UK
| | - Pieter G Postema
- Department of Cardiology, Amsterdam University Medical Centers, location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam, the Netherlands
| | - Vincent Probst
- Centre Hospitalier Universitaire Nantes, Nantes Université, CNRS, INSERM, l'institut du thorax, Nantes, France
| | - Peter J Schwartz
- IRCCS Istituto Auxologico Italiano, Center for Cardiac Arrhythmias of Genetic Origin, Milan, Italy
| | - Elijah R Behr
- Cardiology Section, Institute of Molecular and Clinical Sciences, St. George's, University of London, London SW17 0RE, UK
- Department of Cardiology, Mayo Clinic Healthcare, 15 Portland Pl, London W1B 1PT, UK
- Department of Cardiology, St. George's University Hospitals NHS Foundation Trust, London SW17 0QT
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8
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Przybylski R, Abrams DJ. Current management of inherited arrhythmia syndromes associated with the cardiac ryanodine receptor. Curr Opin Cardiol 2023; 38:390-395. [PMID: 37016946 DOI: 10.1097/hco.0000000000001051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
PURPOSE OF REVIEW Gain-of-function variants in the gene encoding the cardiac ryanodine receptor ( RYR2 ) are associated with catecholaminergic polymorphic ventricular tachycardia (CPVT). The exercise stress test (EST) has long been fundamental in diagnosis and management, but recent work has further explored its role. A new entity termed calcium release deficiency syndrome (CRDS) has been associated with loss-of-function RYR2 variants and a different arrhythmic phenotype. RECENT FINDINGS Standard EST is not perfectly reproducible with regards to provocation of arrhythmia in CPVT. A newly described burst EST protocol may be more sensitive in this regard. Nadolol is the most effective beta blocker in CPVT, though arrhythmic events remain frequent and dual therapy with flecainide and/or left cardiac sympathetic denervation may add protection. A recent report renews debate regarding the use of implantable defibrillator therapy in CPVT. CRDS is characterized by later age of presentation, normal/near normal EST, and ventricular arrhythmia induced by a novel ventricular stimulation protocol. SUMMARY Burst EST may aid in the diagnosis and management of CPVT. Nadolol is the preferred beta blocker in CPVT, and consideration should be given to early dual therapy. CRDS should be suspected in patients with arrhythmic events, rare RYR2 variants, and a phenotype inconsistent with CPVT.
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Affiliation(s)
- Robert Przybylski
- Department of Cardiology, Center for Cardiovascular Genetics, Boston Children's Hospital, Boston, Massachusetts, USA
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9
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Pérez PR, Hylind RJ, Roston TM, Bezzerides VJ, Abrams DJ. Gene Therapy for Catecholaminergic Polymorphic Ventricular Tachycardia. Heart Lung Circ 2023; 32:790-797. [PMID: 37032191 DOI: 10.1016/j.hlc.2023.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 10/13/2022] [Accepted: 01/04/2023] [Indexed: 04/11/2023]
Abstract
Over the last three decades, the genetic basis of various inherited arrhythmia syndromes has been elucidated, providing key insights into cardiomyocyte biology and various regulatory pathways associated with cellular excitation, contraction, and repolarisation. As varying techniques to manipulate genetic sequence, gene expression, and different cellular pathways have become increasingly defined and understood, the potential to apply various gene-based therapies to inherited arrhythmia has been explored. The promise of gene therapy has generated significant interest in the medical and lay press, providing hope for sufferers of seemingly incurable disorders to imagine a future without repeated medical intervention, and, in the case of various cardiac disorders, without the risk of sudden death. In this review, we focus on catecholaminergic polymorphic ventricular tachycardia (CPVT), discussing the clinical manifestations, genetic basis, and molecular biology, together with current avenues of research related to gene therapy.
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Affiliation(s)
- Paloma Remior Pérez
- Center for Cardiovascular Genetics, Boston Children's Hospital, Harvard Medical School, Boston MA, USA; Department of Cardiology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Robyn J Hylind
- Center for Cardiovascular Genetics, Boston Children's Hospital, Harvard Medical School, Boston MA, USA
| | - Thomas M Roston
- Center for Cardiovascular Genetics, Boston Children's Hospital, Harvard Medical School, Boston MA, USA; Clinician Investigator Program, The University of British Columbia, Vancouver, Canada
| | - Vassilios J Bezzerides
- Center for Cardiovascular Genetics, Boston Children's Hospital, Harvard Medical School, Boston MA, USA.
| | - Dominic J Abrams
- Center for Cardiovascular Genetics, Boston Children's Hospital, Harvard Medical School, Boston MA, USA.
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10
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Deb A, Tow BD, Qing Y, Walker M, Hodges ER, Stewart JA, Knollmann BC, Zheng Y, Wang Y, Liu B. Genetic Inhibition of Mitochondrial Permeability Transition Pore Exacerbates Ryanodine Receptor 2 Dysfunction in Arrhythmic Disease. Cells 2023; 12:204. [PMID: 36672139 PMCID: PMC9856515 DOI: 10.3390/cells12020204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 12/12/2022] [Accepted: 12/21/2022] [Indexed: 01/06/2023] Open
Abstract
The brief opening mode of the mitochondrial permeability transition pore (mPTP) serves as a calcium (Ca2+) release valve to prevent mitochondrial Ca2+ (mCa2+) overload. Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a stress-induced arrhythmic syndrome due to mutations in the Ca2+ release channel complex of ryanodine receptor 2 (RyR2). We hypothesize that inhibiting the mPTP opening in CPVT exacerbates the disease phenotype. By crossbreeding a CPVT model of CASQ2 knockout (KO) with a mouse missing CypD, an activator of mPTP, a double KO model (DKO) was generated. Echocardiography, cardiac histology, and live-cell imaging were employed to assess the severity of cardiac pathology. Western blot and RNAseq were performed to evaluate the contribution of various signaling pathways. Although exacerbated arrhythmias were reported, the DKO model did not exhibit pathological remodeling. Myocyte Ca2+ handling was similar to that of the CASQ2 KO mouse at a low pacing frequency. However, increased ROS production, activation of the CaMKII pathway, and hyperphosphorylation of RyR2 were detected in DKO. Transcriptome analysis identified altered gene expression profiles associated with electrical instability in DKO. Our study provides evidence that genetic inhibition of mPTP exacerbates RyR2 dysfunction in CPVT by increasing activation of the CaMKII pathway and subsequent hyperphosphorylation of RyR2.
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Affiliation(s)
- Arpita Deb
- Department of Biological Sciences, Mississippi State University, Starkville, MS 39762, USA
| | - Brian D. Tow
- Department of Biological Sciences, Mississippi State University, Starkville, MS 39762, USA
| | - You Qing
- Beijing Key Laboratory for Agricultural Application and New Technique, College of Plant Science and Technology, Bioinformatics Center, Beijing University of Agriculture, Beijing 102206, China
| | - Madelyn Walker
- Department of Biological Sciences, Mississippi State University, Starkville, MS 39762, USA
| | - Emmanuel R. Hodges
- School of Pharmacy, Division of BioMolecular Sciences, University of Mississippi, Oxford, MS 38677, USA
| | - James A. Stewart
- School of Pharmacy, Division of BioMolecular Sciences, University of Mississippi, Oxford, MS 38677, USA
| | - Björn C. Knollmann
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN 37232, USA
| | - Yi Zheng
- Beijing Key Laboratory for Agricultural Application and New Technique, College of Plant Science and Technology, Bioinformatics Center, Beijing University of Agriculture, Beijing 102206, China
| | - Ying Wang
- Department of Biological Sciences, Mississippi State University, Starkville, MS 39762, USA
| | - Bin Liu
- Department of Biological Sciences, Mississippi State University, Starkville, MS 39762, USA
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11
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Qu Z, Liu MB, Olcese R, Karagueuzian H, Garfinkel A, Chen PS, Weiss JN. R-on-T and the initiation of reentry revisited: Integrating old and new concepts. Heart Rhythm 2022; 19:1369-1383. [PMID: 35364332 PMCID: PMC11334931 DOI: 10.1016/j.hrthm.2022.03.1224] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/11/2022] [Accepted: 03/23/2022] [Indexed: 12/29/2022]
Abstract
Initiation of reentry requires 2 factors: (1) a triggering event, most commonly focal excitations such as premature ventricular complexes (PVCs); and (2) a vulnerable substrate with regional dispersion of refractoriness and/or excitability, such as occurs during the T wave of the electrocardiogram when some areas of the ventricle have repolarized and recovered excitability but others have not. When the R wave of a PVC coincides in time with the T wave of the previous beat, this timing can lead to unidirectional block and initiation of reentry, known as the R-on-T phenomenon. Classically, the PVC triggering reentry has been viewed as arising focally from 1 region and propagating into another region whose recovery is delayed, resulting in unidirectional conduction block and reentry initiation. However, more recent evidence indicates that PVCs also can arise from the T wave itself. In the latter case, the PVC initiating reentry is not a separate event from the T wave but rather is causally generated from the repolarization gradient that manifests as the T wave. We call the former an "R-to-T" mechanism and the latter an "R-from-T" mechanism, which are initiation mechanisms distinct from each other. Both are important components of the R-on-T phenomenon and need to be taken into account when designing antiarrhythmic strategies. Strategies targeting suppression of triggers alone or vulnerable substrate alone may be appropriate in some instances but not in others. Preventing R-from-T arrhythmias requires suppressing the underlying dynamic tissue instabilities responsible for producing both triggers and substrate vulnerability simultaneously. The same principles are likely to apply to supraventricular arrhythmias.
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Affiliation(s)
- Zhilin Qu
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California; Department of Computational Medicine, David Geffen School of Medicine, University of California, Los Angeles, California.
| | - Michael B Liu
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Riccardo Olcese
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, California; Department of Physiology, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Hrayr Karagueuzian
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Alan Garfinkel
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California; Department of Integrative Biology and Physiology, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Peng-Sheng Chen
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - James N Weiss
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California; Department of Physiology, David Geffen School of Medicine, University of California, Los Angeles, California
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12
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Huang J, Luo R, Zheng C, Cao X, Zhu Y, He T, Liu M, Yang Z, Wu X, Li X. Integrative Analyses Identify Potential Key Genes and Calcium-Signaling Pathway in Familial Atrioventricular Nodal Reentrant Tachycardia Using Whole-Exome Sequencing. Front Cardiovasc Med 2022; 9:910826. [PMID: 35924220 PMCID: PMC9339905 DOI: 10.3389/fcvm.2022.910826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/20/2022] [Indexed: 12/20/2022] Open
Abstract
Background Atrioventricular nodal reentrant tachycardia (AVNRT) is a common arrhythmia. Growing evidence suggests that family aggregation and genetic factors are involved in AVNRT. However, in families with a history of AVNRT, disease-causing genes have not been reported. Objective To investigate the genetic contribution of familial AVNRT using a whole-exome sequencing (WES) approach. Methods Blood samples were collected from 20 patients from nine families with a history of AVNRT and 100 control participants, and we systematically analyzed mutation profiles using WES. Gene-based burden analysis, integration of previous sporadic AVNRT data, pedigree-based co-segregation, protein-protein interaction network analysis, single-cell RNA sequencing, and confirmation of animal phenotype were performed. Results Among 95 related reference genes, seven candidate pathogenic genes have been identified both in sporadic and familial AVNRT, including CASQ2, AGXT, ANK2, SYNE2, ZFHX3, GJD3, and SCN4A. Among the 37 reference genes from sporadic AVNRT, five candidate pathogenic genes were identified in patients with both familial and sporadic AVNRT: LAMC1, ryanodine receptor 2 (RYR2), COL4A3, NOS1, and ATP2C2. To identify the common pathogenic mechanisms in all AVNRT cases, five pathogenic genes were identified in patients with both familial and sporadic AVNRT: LAMC1, RYR2, COL4A3, NOS1, and ATP2C2. Considering the unique internal candidate pathogenic gene within pedigrees, three genes, TRDN, CASQ2, and WNK1, were likely to be the pathogenic genes in familial AVNRT. Notably, the core calcium-signaling pathway may be closely associated with the occurrence of AVNRT, including CASQ2, RYR2, TRDN, NOS1, ANK2, and ATP2C2. Conclusion Our pedigree-based studies demonstrate that RYR2 and related calcium signaling pathway play a critical role in the pathogenesis of familial AVNRT using the WES approach.
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Affiliation(s)
- Jichang Huang
- Institute of Geriatric Cardiovascular Disease, Chengdu Medical College, Chengdu, China
| | - Rong Luo
- Institute of Geriatric Cardiovascular Disease, Chengdu Medical College, Chengdu, China
| | - Chenqing Zheng
- State Key Laboratory of Biocontrol, School of Life Sciences, Sun Yat-sen University, Guangzhou, China
| | - Xin Cao
- School of Acupuncture-Moxibustion and Tuina, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yuncai Zhu
- Department of Cardiology, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Tao He
- Department of Cardiology, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Mingjiang Liu
- Department of Cardiology, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Zhenglin Yang
- The Sichuan Provincial Key Laboratory of Human Disease Study, Institute of Laboratory Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiushan Wu
- The Center for Heart Development, Hunan Normal University, Changsha, China
- Guangdong Provincial Key Laboratory of Pathogenesis, Targeted Prevention and Treatment of Heart Disease, Guangzhou, China
| | - Xiaoping Li
- Department of Cardiology, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
- *Correspondence: Xiaoping Li,
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13
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Yu G, Chakrabarti S, Tischenko M, Chen AL, Wang Z, Cho H, French BA, Naga Prasad SV, Chen Q, Wang QK. Gene therapy targeting protein trafficking regulator MOG1 in mouse models of Brugada syndrome, arrhythmias, and mild cardiomyopathy. Sci Transl Med 2022; 14:eabf3136. [PMID: 35675436 DOI: 10.1126/scitranslmed.abf3136] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Brugada syndrome (BrS) is a fatal arrhythmia that causes an estimated 4% of all sudden death in high-incidence areas. SCN5A encodes cardiac sodium channel NaV1.5 and causes 25 to 30% of BrS cases. Here, we report generation of a knock-in (KI) mouse model of BrS (Scn5aG1746R/+). Heterozygous KI mice recapitulated some of the clinical features of BrS, including an ST segment abnormality (a prominent J wave) on electrocardiograms and development of spontaneous ventricular tachyarrhythmias (VTs), seizures, and sudden death. VTs were caused by shortened cardiac action potential duration and late phase 3 early afterdepolarizations associated with reduced sodium current density (INa) and increased Kcnd3 and Cacna1c expression. We developed a gene therapy using adeno-associated virus serotype 9 (AAV9) vector-mediated MOG1 delivery for up-regulation of MOG1, a chaperone that binds to NaV1.5 and traffics it to the cell surface. MOG1 was chosen for gene therapy because the large size of the SCN5A coding sequence (6048 base pairs) exceeds the packaging capacity of AAV vectors. AAV9-MOG1 gene therapy increased cell surface expression of NaV1.5 and ventricular INa, reversed up-regulation of Kcnd3 and Cacna1c expression, normalized cardiac action potential abnormalities, abolished J waves, and blocked VT in Scn5aG1746R/+ mice. Gene therapy also rescued the phenotypes of cardiac arrhythmias and contractile dysfunction in heterozygous humanized KI mice with SCN5A mutation p.D1275N. Using a small chaperone protein may have broad implications for targeting disease-causing genes exceeding the size capacity of AAV vectors.
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Affiliation(s)
- Gang Yu
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA.,Key Laboratory of Molecular Biophysics of the Ministry of Education, College of Life Science and Technology, and Center for Human Genome Research, Huazhong University of Science and Technology, Wuhan 430074, P. R. China.,Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH 44195, USA
| | - Susmita Chakrabarti
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA.,Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH 44195, USA
| | - Miroslava Tischenko
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA.,Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH 44195, USA
| | - Ai-Lan Chen
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA.,Department of Cardiology, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 511436, P. R. China
| | - Zhijie Wang
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA.,Key Laboratory of Molecular Biophysics of the Ministry of Education, College of Life Science and Technology, and Center for Human Genome Research, Huazhong University of Science and Technology, Wuhan 430074, P. R. China.,Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH 44195, USA
| | - Hyosuk Cho
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA.,Department of Genetics and Genome Sciences, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
| | - Brent A French
- Department of Biomedical Engineering, University of Virginia Health System, Charlottesville, VA 22903, USA
| | - Sathyamangla V Naga Prasad
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA.,Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH 44195, USA
| | - Qiuyun Chen
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA.,Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH 44195, USA
| | - Qing K Wang
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA.,Key Laboratory of Molecular Biophysics of the Ministry of Education, College of Life Science and Technology, and Center for Human Genome Research, Huazhong University of Science and Technology, Wuhan 430074, P. R. China.,Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH 44195, USA.,Department of Genetics and Genome Sciences, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
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14
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Sarcoplasmic Reticulum Ca2+ Dysregulation in the Pathophysiology of Inherited Arrhythmia: An Update. Biochem Pharmacol 2022; 200:115059. [DOI: 10.1016/j.bcp.2022.115059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 04/18/2022] [Accepted: 04/19/2022] [Indexed: 11/19/2022]
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15
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Krahn AD, Tfelt-Hansen J, Tadros R, Steinberg C, Semsarian C, Han HC. Latent Causes of Sudden Cardiac Arrest. JACC Clin Electrophysiol 2022; 8:806-821. [PMID: 35738861 DOI: 10.1016/j.jacep.2021.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/09/2021] [Accepted: 12/29/2021] [Indexed: 11/30/2022]
Abstract
Inherited arrhythmia syndromes are a common cause of apparently unexplained cardiac arrest or sudden cardiac death. These include long QT syndrome and Brugada syndrome, with a well-recognized phenotype in most patients with sufficiently severe disease to lead to cardiac arrest. Less common and typically less apparent conditions that may not be readily evident include catecholaminergic polymorphic ventricular tachycardia, short QT syndrome and early repolarization syndrome. In cardiac arrest patients whose extensive testing does not reveal an underlying etiology, a diagnosis of idiopathic ventricular fibrillation or short-coupled ventricular fibrillation is assigned. This review summarizes our current understanding of the less common inherited arrhythmia syndromes and provides clinicians with a practical approach to diagnosis and management.
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Affiliation(s)
- Andrew D Krahn
- Center for Cardiovascular Innovation, Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Jacob Tfelt-Hansen
- The Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Forensic Medicine, Faculty of Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Rafik Tadros
- Cardiovascular Genetics Center, Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Québec, Canada
| | - Christian Steinberg
- Institut universitaire de cardiologie et pneumologie de Québec (IUCPQ-UL), Laval University, Inherited Arrhythmia Services, Départment of Cardiology and Cardiac Surgery, Québec, Canada
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Hui-Chen Han
- Center for Cardiovascular Innovation, Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada; Victorian Heart Institute, Monash University, Clayton, Victoria, Australia
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16
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The function and regulation of calsequestrin-2: implications in calcium-mediated arrhythmias. Biophys Rev 2022; 14:329-352. [PMID: 35340602 PMCID: PMC8921388 DOI: 10.1007/s12551-021-00914-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 11/14/2021] [Indexed: 01/09/2023] Open
Abstract
Cardiac arrhythmias are life-threatening events in which the heart develops an irregular rhythm. Mishandling of Ca2+ within the myocytes of the heart has been widely demonstrated to be an underlying mechanism of arrhythmogenesis. This includes altered function of the ryanodine receptor (RyR2)-the primary Ca2+ release channel located to the sarcoplasmic reticulum (SR). The spontaneous leak of SR Ca2+ via RyR2 is a well-established contributor in the development of arrhythmic contractions. This leak is associated with increased channel activity in response to changes in SR Ca2+ load. RyR2 activity can be regulated through several avenues, including interactions with numerous accessory proteins. One such protein is calsequestrin-2 (CSQ2), which is the primary Ca2+-buffering protein within the SR. The capacity of CSQ2 to buffer Ca2+ is tightly associated with the ability of the protein to polymerise in response to changing Ca2+ levels. CSQ2 can itself be regulated through phosphorylation and glycosylation modifications, which impact protein polymerisation and trafficking. Changes in CSQ2 modifications are implicated in cardiac pathologies, while mutations in CSQ2 have been identified in arrhythmic patients. Here, we review the role of CSQ2 in arrhythmogenesis including evidence for the indirect and direct regulation of RyR2 by CSQ2, and the consequences of a loss of functional CSQ2 in Ca2+ homeostasis and Ca2+-mediated arrhythmias. Supplementary Information The online version contains supplementary material available at 10.1007/s12551-021-00914-6.
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17
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Wilson AD, Hu J, Sigalas C, Venturi E, Valdivia HH, Valdivia CR, Lei M, Musgaard M, Sitsapesan R. The V2475F CPVT1 mutation yields distinct RyR2 channel populations that differ in their responses to cytosolic Ca 2+ and Mg 2. J Physiol 2021; 599:5179-5201. [PMID: 34676560 PMCID: PMC8996374 DOI: 10.1113/jp281707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 09/30/2021] [Indexed: 11/08/2022] Open
Abstract
Catecholaminergic polymorphic ventricular tachycardia type 1 (CPVT1) is a lethal genetic disease causing arrhythmias and sudden cardiac death in children and young adults and is linked to mutations in the cardiac ryanodine receptor (RyR2). The effects of CPVT1 mutations on RyR2 ion-channel function are often investigated using purified recombinant RyR2 channels homozygous for the mutation. However, CPVT1 patients are heterozygous for the disease, so this approach does not reveal the true changes to RyR2 function across the entire RyR2 population of channels in the heart. We therefore investigated the native cardiac RyR2 single-channel abnormalities in mice heterozygous for the CPVT1 mutation, V2475F(+/-)-RyR2, and applied molecular modelling techniques to investigate the possible structural changes that could initiate any altered function. We observed that increased sensitivity of cardiac V2475F(+/-)-RyR2 channels to both activating and inactivating levels of cytosolic Ca2+ , plus attenuation of Mg2+ inhibition, were the most marked changes. Severity of abnormality was not uniform across all channels, giving rise to multiple sub-populations with differing functional characteristics. For example, 46% of V2475F(+/-)-RyR2 channels exhibited reduced Mg2+ inhibition and 23% were actually activated by Mg2+ . Using homology modelling, we discovered that V2475 is situated at a hinge between two regions of the RyR2 helical domain 1 (HD1). Our model proposes that detrimental functional changes to RyR2 arise because mutation at this critical site reduces the angle between these regions. Our results demonstrate the necessity of characterising the total heterozygous population of CPVT1-mutated channels in order to understand CPVT1 phenotypes in patients. KEY POINTS: RyR2 mutations can cause type-1 catecholaminergic polymorphic ventricular tachycardia (CPVT1), a lethal, autosomal-dominant arrhythmic disease. However, the changes in RyR2 ion-channel function that result from the many different patient mutations are rarely investigated in detail and often only recombinant RyR2, homozygous for the mutation, is studied. As CPVT1 is a heterozygous disease and the tetrameric RyR2 channels expressed in the heart will contain varying numbers of mutated monomers, we have investigated the range of RyR2 single-channel abnormalities found in the hearts of mice heterozygous for the CPVT1 mutation, V2475F(+/-)-RyR2. Specific alterations to ligand regulation of V2475F(+/-)-RyR2 were observed. Multiple sub-populations of channels exhibited varying degrees of abnormality. In particular, an increased sensitivity to activating and inactivating cytosolic [Ca2+ ], and reduced sensitivity to Mg2+ inhibition were evident. Our results provide mechanistic insight into the changes to RyR2 gating that destabilise sarcoplasmic reticulum Ca2+ -release causing life-threatening arrhythmias in V2475F(+/-)-CPVT1 patients.
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Affiliation(s)
| | - Jianshu Hu
- Department of Pharmacology, University of Oxford, Oxford, UK
| | | | - Elisa Venturi
- Department of Pharmacology, University of Oxford, Oxford, UK
| | - Héctor H Valdivia
- Department of Medicine, Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, USA
| | - Carmen R Valdivia
- Department of Medicine, Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, USA
| | - Ming Lei
- Department of Pharmacology, University of Oxford, Oxford, UK
| | - Maria Musgaard
- Department of Chemistry and Biomolecular Sciences, University of Ottawa, Ottawa, Ontario, Canada
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18
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Song J, Luo Y, Jiang Y, He J. Advances in the Molecular Genetics of Catecholaminergic Polymorphic Ventricular Tachycardia. Front Pharmacol 2021; 12:718208. [PMID: 34483927 PMCID: PMC8415552 DOI: 10.3389/fphar.2021.718208] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/05/2021] [Indexed: 11/13/2022] Open
Abstract
Catecholaminergic polymorphic ventricular tachycardia is a primary arrhythmogenic syndrome with genetic features most commonly seen in adolescents, with syncope and sudden death following exercise or agitation as the main clinical manifestations. The mechanism of its occurrence is related to the aberrant release of Ca2+ from cardiomyocytes caused by abnormal RyR2 channels or CASQ2 proteins under conditions of sympathetic excitation, thus inducing a delayed posterior exertional pole, manifested by sympathetic excitation inducing adrenaline secretion, resulting in bidirectional or polymorphic ventricular tachycardia. The mortality rate of the disease is high, but patients usually do not have organic heart disease, the clinical manifestations may not be obvious, and no significant abnormal changes in the QT interval are often observed on electrocardiography. Therefore, the disease is often easily missed and misdiagnosed. A number of genetic mutations have been linked to the development of this disease, and the mechanisms are different. In this paper, we would like to summarize the possible genes related to catecholaminergic polymorphic ventricular tachycardia in order to review the genetic tests currently performed, and to further promote the development of genetic testing techniques and deepen the research on the molecular level of this disease.
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Affiliation(s)
- Junxia Song
- Departments of Cardiology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders (Chongqing), China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yanhong Luo
- Endocrinology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders (Chongqing), China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Ying Jiang
- Departments of Cardiology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders (Chongqing), China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Jianfeng He
- Departments of Cardiology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders (Chongqing), China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
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19
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Sun Z, Wang L, Han L, Wang Y, Zhou Y, Li Q, Wu Y, Talabieke S, Hou Y, Wu L, Liu R, Fu Z, You H, Li BY, Zheng Y, Luo D. Functional Calsequestrin-1 Is Expressed in the Heart and Its Deficiency Is Causally Related to Malignant Hyperthermia-Like Arrhythmia. Circulation 2021; 144:788-804. [PMID: 34162222 DOI: 10.1161/circulationaha.121.053255] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Calsequestrins (Casqs), comprising the Casq1 and Casq2 isoforms, buffer Ca2+ and regulate its release in the sarcoplasmic reticulum (SR) of skeletal and cardiac muscle, respectively. Human inherited diseases associated with mutations in CASQ1 or CASQ2 include malignant hyperthermia/environmental heat stroke (MH/EHS) and catecholaminergic polymorphic ventricular tachycardia. However, patients with an MH/EHS event often suffer from arrhythmia for which the underlying mechanism remains unknown. Methods: Working hearts from conventional (Casq1-KO) and cardiac-specific (Casq1-CKO) Casq1 knockout mice were monitored in vivo and ex vivo by electrocardiogram and electrical mapping, respectively. MH was induced by 2% isoflurane and treated intraperitoneally with dantrolene. Time-lapse imaging was used to monitor intracellular Ca2+ activity in isolated mouse cardiomyocytes or neonatal rat ventricular myocytes (NRVMs) with knockdown, over-expression or truncation of the Casq1 gene. Conformational change in both Casqs was determined by crosslinking Western blot analysis. Results: Like MH/EHS patients, Casq1-KO and Casq1-CKO mice had faster basal heart rate, and ventricular tachycardia upon exposure to 2% isoflurane, which could be relieved by dantrolene. Basal sinus tachycardia and ventricular ectopic electrical triggering also occurred in Casq1-KO hearts ex vivo. Accordingly, the ventricular cardiomyocytes from Casq1-CKO mice displayed dantrolene-sensitive increased Ca2+ waves and diastole premature Ca2+ transients/oscillations upon isoflurane. NRVMs with Casq1-knockdown had enhanced spontaneous Ca2+ sparks/transients upon isoflurane, while cells over-expressing Casq1 exhibited decreased Ca2+ sparks/transients that were absent in cells with truncation of 9 amino acids at the C-terminus of Casq1. Structural evaluation showed that most of the Casq1 protein was present as a polymer and physically interacted with RyR2 in the ventricular SR. The Casq1 isoform was also expressed in human myocardium. Mechanistically, exposure to 2% isoflurane or heating at 41ºC induced Casq1 oligomerization in mouse ventricular and skeletal muscle tissues, leading to a reduced Casq1/RyR2 interaction and increased RyR2 activity in the ventricle. Conclusions: Casq1 is expressed in the heart, where it regulates SR Ca2+ release and heart rate. Casq1 deficiency independently causes MH/EHS-like ventricular arrhythmia by trigger-induced Casq1 oligomerization and a relief of its inhibitory effect on RyR2-mediated Ca2+ release, thus revealing a new inherited arrhythmia and a novel mechanism for MH/EHS arrhythmogenesis.
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Affiliation(s)
- Zhipeng Sun
- Department of Pharmacology, School of Basic Medical Sciences, Beijing Key Laboratory of Metabolic Disturbance Related Cardiovascular Disease, Capital Medical University, Beijing 100069, P. R. China
| | - Luqi Wang
- Department of Pharmacology, School of Basic Medical Sciences, Beijing Key Laboratory of Metabolic Disturbance Related Cardiovascular Disease, Capital Medical University, Beijing 100069, P. R. China
| | - Lu Han
- Beijing Lab for Cardiovascular Precision Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing 100011, P. R. China
| | - Yue Wang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100011, P. R. China
| | - Yuan Zhou
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing 100011, P. R. China
| | - Qiang Li
- Department of Pharmacology, School of Basic Medical Sciences, Beijing Key Laboratory of Metabolic Disturbance Related Cardiovascular Disease, Capital Medical University, Beijing 100069, P. R. China
| | - Yongquan Wu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100011, P. R. China
| | - Shaletanati Talabieke
- Department of Pharmacology, School of Basic Medical Sciences, Beijing Key Laboratory of Metabolic Disturbance Related Cardiovascular Disease, Capital Medical University, Beijing 100069, P. R. China
| | - Yunlong Hou
- College of Integrated Traditional Chinese and Western Medicine, Hebei University of Chinese Medicine; National Key Laboratory of Collateral Disease Research and Innovative Chinese Medicine, Shijiazhuang 050200, P. R. China
| | - Lulin Wu
- Department of Pharmacology, School of Basic Medical Sciences, Beijing Key Laboratory of Metabolic Disturbance Related Cardiovascular Disease, Capital Medical University, Beijing 100069, P. R. China
| | - Ronghua Liu
- Department of Pharmacology, School of Basic Medical Sciences, Beijing Key Laboratory of Metabolic Disturbance Related Cardiovascular Disease, Capital Medical University, Beijing 100069, P. R. China
| | - Zhiping Fu
- Department of Pharmacology, School of Basic Medical Sciences, Beijing Key Laboratory of Metabolic Disturbance Related Cardiovascular Disease, Capital Medical University, Beijing 100069, P. R. China
| | - Hongjie You
- Department of Pharmacology, School of Basic Medical Sciences, Beijing Key Laboratory of Metabolic Disturbance Related Cardiovascular Disease, Capital Medical University, Beijing 100069, P. R. China
| | - Bai-Yan Li
- Department of Pharmacology, School of Pharmacy, Harbin Medical University, Harbin, 150081, P. R. China
| | - Yuanyuan Zheng
- Department of Pharmacology, School of Basic Medical Sciences, Beijing Key Laboratory of Metabolic Disturbance Related Cardiovascular Disease, Capital Medical University, Beijing 100069, P. R. China
| | - Dali Luo
- Department of Pharmacology, School of Basic Medical Sciences, Beijing Key Laboratory of Metabolic Disturbance Related Cardiovascular Disease, Capital Medical University, Beijing 100069, P. R. China
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Precision Medicine in Catecholaminergic Polymorphic Ventricular Tachycardia: JACC Focus Seminar 5/5. J Am Coll Cardiol 2021; 77:2592-2612. [PMID: 34016269 DOI: 10.1016/j.jacc.2020.12.073] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/14/2020] [Accepted: 12/21/2020] [Indexed: 11/20/2022]
Abstract
In this final of a 5-part Focus Seminar series on precision medicine, we focus on catecholaminergic polymorphic ventricular tachycardia (CPVT). This focus on CPVT allows us to take a "deep dive" and explore the full extent of the precision medicine opportunities for a single cardiovascular condition at a level that was not possible in the preceding articles. As a new paradigm presented in this article, it has become clear that CPVT can occur as either a typical or atypical form. Although there is a degree of overlap between the typical and atypical forms, it is notable that they arise due to different underlying genetic changes, likely exhibiting differing mechanisms of action, and presenting with different phenotypic features. The recognition of these differing forms of CPVT and their different etiologies and mechanisms is an important step toward implementing rapidly emerging precision medicine approaches that will tailor novel therapies to specific gene defects.
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21
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Xu M, Zhang K, Song J. Targeted Therapy in Cardiovascular Disease: A Precision Therapy Era. Front Pharmacol 2021; 12:623674. [PMID: 33935716 PMCID: PMC8085499 DOI: 10.3389/fphar.2021.623674] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 03/22/2021] [Indexed: 12/12/2022] Open
Abstract
Targeted therapy refers to exploiting the specific therapeutic drugs against the pathogenic molecules (a protein or a gene) or cells. The drug specifically binds to disease-causing molecules or cells without affecting normal tissue, thus enabling personalized and precision treatment. Initially, therapeutic drugs included antibodies and small molecules, (e.g. nucleic acid drugs). With the advancement of the biology technology and immunotherapy, the gene editing and cell editing techniques are utilized for the disease treatment. Currently, targeted therapies applied to treat cardiovascular diseases (CVDs) mainly include protein drugs, gene editing technologies, nucleic acid drugs and cell therapy. Although targeted therapy has demonstrated excellent efficacy in pre-clinical and clinical trials, several limitations need to be recognized and overcome in clinical application, (e.g. off-target events, gene mutations, etc.). This review introduces the mechanisms of different targeted therapies, and mainly describes the targeted therapy applied in the CVDs. Furthermore, we made comparative analysis to clarify the advantages and disadvantages of different targeted therapies. This overview is expected to provide a new concept to the treatment of the CVDs.
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Affiliation(s)
- Mengda Xu
- Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Kailun Zhang
- Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China,*Correspondence: Kailun Zhang, ; Jiangping Song,
| | - Jiangping Song
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China,*Correspondence: Kailun Zhang, ; Jiangping Song,
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22
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Ravindran D, Kok C, Farraha M, Selvakumar D, Clayton ZE, Kumar S, Chong J, Kizana E. Gene and Cell Therapy for Cardiac Arrhythmias. Clin Ther 2020; 42:1911-1922. [PMID: 32988632 DOI: 10.1016/j.clinthera.2020.09.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/19/2020] [Accepted: 09/01/2020] [Indexed: 12/21/2022]
Abstract
PURPOSE In the last decade, interest in gene therapy as a therapeutic technology has increased, largely driven by an exciting yet modest number of successful applications for monogenic diseases. Setbacks in the use of gene therapy for cardiac disease have motivated efforts to develop vectors with enhanced tropism for the heart and more efficient delivery methods. Although monogenic diseases are the logical target, cardiac arrhythmias represent a group of conditions amenable to gene therapy because of focal targets (biological pacemakers, nodal conduction, or stem cell-related arrhythmias) or bystander effects on cells not directly transduced because of electrical coupling. METHODS This review provides a contemporary narrative of the field of gene therapy for experimental cardiac arrhythmias, including those associated with stem cell transplant. Recent articles published in the English language and available through the PubMed database and other prominent literature are discussed. FINDINGS The promise of gene therapy has been realized for a handful of monogenic diseases and is actively being pursued for cardiac applications in preclinical models. With improved vectors, it is likely that cardiac disease will also benefit from this technology. Cardiac arrhythmias, whether inherited or acquired, are a group of conditions with a potentially lower threshold for phenotypic correction and as such hold unique potential as targets for cardiac gene therapy. IMPLICATIONS There has been a proliferation of research on the potential of gene therapy for cardiac arrhythmias. This body of investigation forms a strong basis on which further developments, particularly with viral vectors, are likely to help this technology progress along its translational trajectory.
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Affiliation(s)
- Dhanya Ravindran
- Centre for Heart Research, The Westmead Institute for Medical Research, The University of Sydney, Sydney, New South Wales, Australia; Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Cindy Kok
- Centre for Heart Research, The Westmead Institute for Medical Research, The University of Sydney, Sydney, New South Wales, Australia; Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Melad Farraha
- Centre for Heart Research, The Westmead Institute for Medical Research, The University of Sydney, Sydney, New South Wales, Australia
| | - Dinesh Selvakumar
- Centre for Heart Research, The Westmead Institute for Medical Research, The University of Sydney, Sydney, New South Wales, Australia; Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia; Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Zoe E Clayton
- Centre for Heart Research, The Westmead Institute for Medical Research, The University of Sydney, Sydney, New South Wales, Australia; Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Saurabh Kumar
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia; Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia
| | - James Chong
- Centre for Heart Research, The Westmead Institute for Medical Research, The University of Sydney, Sydney, New South Wales, Australia; Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia; Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Eddy Kizana
- Centre for Heart Research, The Westmead Institute for Medical Research, The University of Sydney, Sydney, New South Wales, Australia; Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia; Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia.
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23
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Ng K, Titus EW, Lieve KV, Roston TM, Mazzanti A, Deiter FH, Denjoy I, Ingles J, Till J, Robyns T, Connors SP, Steinberg C, Abrams DJ, Pang B, Scheinman MM, Bos JM, Duffett SA, van der Werf C, Maltret A, Green MS, Rutberg J, Balaji S, Cadrin-Tourigny J, Orland KM, Knight LM, Brateng C, Wu J, Tang AS, Skanes AC, Manlucu J, Healey JS, January CT, Krahn AD, Collins KK, Maginot KR, Fischbach P, Etheridge SP, Eckhardt LL, Hamilton RM, Ackerman MJ, Noguer FRI, Semsarian C, Jura N, Leenhardt A, Gollob MH, Priori SG, Sanatani S, Wilde AAM, Deo RC, Roberts JD. An International Multicenter Evaluation of Inheritance Patterns, Arrhythmic Risks, and Underlying Mechanisms of CASQ2-Catecholaminergic Polymorphic Ventricular Tachycardia. Circulation 2020; 142:932-947. [PMID: 32693635 PMCID: PMC7484339 DOI: 10.1161/circulationaha.120.045723] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Genetic variants in calsequestrin-2 (CASQ2) cause an autosomal recessive form of catecholaminergic polymorphic ventricular tachycardia (CPVT), although isolated reports have identified arrhythmic phenotypes among heterozygotes. Improved insight into the inheritance patterns, arrhythmic risks, and molecular mechanisms of CASQ2-CPVT was sought through an international multicenter collaboration. METHODS Genotype-phenotype segregation in CASQ2-CPVT families was assessed, and the impact of genotype on arrhythmic risk was evaluated using Cox regression models. Putative dominant CASQ2 missense variants and the established recessive CASQ2-p.R33Q variant were evaluated using oligomerization assays and their locations mapped to a recent CASQ2 filament structure. RESULTS A total of 112 individuals, including 36 CPVT probands (24 homozygotes/compound heterozygotes and 12 heterozygotes) and 76 family members possessing at least 1 presumed pathogenic CASQ2 variant, were identified. Among CASQ2 homozygotes and compound heterozygotes, clinical penetrance was 97.1% and 26 of 34 (76.5%) individuals had experienced a potentially fatal arrhythmic event with a median age of onset of 7 years (95% CI, 6-11). Fifty-one of 66 CASQ2 heterozygous family members had undergone clinical evaluation, and 17 of 51 (33.3%) met diagnostic criteria for CPVT. Relative to CASQ2 heterozygotes, CASQ2 homozygote/compound heterozygote genotype status in probands was associated with a 3.2-fold (95% CI, 1.3-8.0; P=0.013) increased hazard of a composite of cardiac syncope, aborted cardiac arrest, and sudden cardiac death, but a 38.8-fold (95% CI, 5.6-269.1; P<0.001) increased hazard in genotype-positive family members. In vitro turbidity assays revealed that p.R33Q and all 6 candidate dominant CASQ2 missense variants evaluated exhibited filamentation defects, but only p.R33Q convincingly failed to dimerize. Structural analysis revealed that 3 of these 6 putative dominant negative missense variants localized to an electronegative pocket considered critical for back-to-back binding of dimers. CONCLUSIONS This international multicenter study of CASQ2-CPVT redefines its heritability and confirms that pathogenic heterozygous CASQ2 variants may manifest with a CPVT phenotype, indicating a need to clinically screen these individuals. A dominant mode of inheritance appears intrinsic to certain missense variants because of their location and function within the CASQ2 filament structure.
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Affiliation(s)
- Kevin Ng
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Western University, London, Ontario, Canada
- Cairns Hospital, Queensland, Australia
| | - Erron W. Titus
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California, USA
| | - Krystien V. Lieve
- Amsterdam University Medical Centre, University of Amsterdam, Heart Centre, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart
| | - Thomas M. Roston
- Heart Rhythm Services, Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Andrea Mazzanti
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart
- Molecular Cardiology, Istituti Clinici Scientifici Maugeri, Istituto di Ricovero e Cura a Carattere Scientifico and Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Frederick H. Deiter
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California, USA
| | - Isabelle Denjoy
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart
- Service de Cardiologie et CNMR Maladies Cardiacques Héréditaires Rares, Hôpital Bichat, Paris, France
| | - Jodie Ingles
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia
| | - Jan Till
- Department of Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Tomas Robyns
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart
- Department of Cardiovascular Disease, University Hospitals Leuven, Leuven, Belgium
| | - Sean P. Connors
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Memorial University, St. John’s, Newfoundland and Labrador, Canada
| | | | - Dominic J. Abrams
- Inherited Cardiac Arrhythmia Program, Boston Children’s Hospital, Harvard Medical School, Massachusetts, USA
| | - Benjamin Pang
- Arrhythmia Service, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Melvin M. Scheinman
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - J. Martijn Bos
- Departments of Cardiovascular Medicine (Division of Heart Rhythm Services), Pediatric and Adolescent Medicine (Division of Pediatric Cardiology), and Molecular Pharmacology & Experimental Therapeutics (Windland Smith Rice Sudden Death Genomics Laboratory), Mayo Clinic, Rochester, Minnesota, USA
| | - Stephen A. Duffett
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Memorial University, St. John’s, Newfoundland and Labrador, Canada
| | - Christian van der Werf
- Amsterdam University Medical Centre, University of Amsterdam, Heart Centre, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart
| | - Alice Maltret
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart
- Service de Cardiologie et CNMR Maladies Cardiacques Héréditaires Rares, Hôpital Bichat, Paris, France
| | - Martin S. Green
- Arrhythmia Service, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Julie Rutberg
- Arrhythmia Service, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Seshadri Balaji
- Department of Pediatrics, Division of Cardiology, Oregon Health & Science University, Portland, Oregon, USA
| | - Julia Cadrin-Tourigny
- Cardiovascular Genetics Center, Montreal Heart Institute, Université de Montréal, Montréal, Canada
| | - Kate M. Orland
- University of Wisconsin-Madison Inherited Arrhythmia Clinic, Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Linda M. Knight
- Children’s Healthcare of Atlanta, Sibley Heart Center Cardiology, Atlanta, Georgia, USA
| | - Caitlin Brateng
- Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jeremy Wu
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Western University, London, Ontario, Canada
| | - Anthony S. Tang
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Western University, London, Ontario, Canada
| | - Allan C. Skanes
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Western University, London, Ontario, Canada
| | - Jaimie Manlucu
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Western University, London, Ontario, Canada
| | - Jeff S. Healey
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Craig T. January
- University of Wisconsin-Madison Inherited Arrhythmia Clinic, Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Cellular and Molecular Arrhythmia Research Program, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Andrew D. Krahn
- Heart Rhythm Services, Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kathryn K. Collins
- Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kathleen R. Maginot
- Department of Pediatrics, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Peter Fischbach
- Children’s Healthcare of Atlanta, Sibley Heart Center Cardiology, Atlanta, Georgia, USA
| | - Susan P. Etheridge
- Department of Pediatrics, University of Utah, and Primary Children’s Hospital, Salt Lake City, Utah, USA
| | - Lee L. Eckhardt
- University of Wisconsin-Madison Inherited Arrhythmia Clinic, Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Cellular and Molecular Arrhythmia Research Program, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Robert M. Hamilton
- The Labatt Family Heart Centre (Department of Pediatrics) and Translational Medicine, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | - Michael J. Ackerman
- Departments of Cardiovascular Medicine (Division of Heart Rhythm Services), Pediatric and Adolescent Medicine (Division of Pediatric Cardiology), and Molecular Pharmacology & Experimental Therapeutics (Windland Smith Rice Sudden Death Genomics Laboratory), Mayo Clinic, Rochester, Minnesota, USA
| | | | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia
| | - Natalia Jura
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California, USA
- Department of Cellular and Molecular Pharmacology, University of California San Francisco, San Francisco, California, USA
| | - Antoine Leenhardt
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart
- Service de Cardiologie et CNMR Maladies Cardiacques Héréditaires Rares, Hôpital Bichat, Paris, France
| | - Michael H. Gollob
- Department of Physiology and Department of Medicine, Toronto General Hospital, University of Toronto, Ontario, Canada
| | - Silvia G. Priori
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart
- Molecular Cardiology, Istituti Clinici Scientifici Maugeri, Istituto di Ricovero e Cura a Carattere Scientifico and Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Shubhayan Sanatani
- Department of Pediatrics, Children’s Heart Centre, BC Children’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Arthur A. M. Wilde
- Amsterdam University Medical Centre, University of Amsterdam, Heart Centre, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart
| | - Rahul C. Deo
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California, USA
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
- One Brave Idea and Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - Jason D. Roberts
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Western University, London, Ontario, Canada
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24
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Liu MB, Priori SG, Qu Z, Weiss JN. Stabilizer Cell Gene Therapy: A Less-Is-More Strategy to Prevent Cardiac Arrhythmias. Circ Arrhythm Electrophysiol 2020; 13:e008420. [PMID: 32718183 DOI: 10.1161/circep.120.008420] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In cardiac gene therapy to improve contractile function, achieving gene expression in the majority of cardiac myocytes is essential. In preventing cardiac arrhythmias, however, this goal may not be as important since transduction efficiencies as low as 40% suppressed ventricular arrhythmias in genetically modified mice with catecholaminergic polymorphic ventricular tachycardia. METHODS Using computational modeling, we simulated 1-, 2-, and 3-dimensional tissue under a variety of conditions to test the ability of genetically engineered nonarrhythmogenic stabilizer cells to suppress triggered activity due to delayed or early afterdepolarizations. RESULTS Due to source-sink relationships in cardiac tissue, a minority (20%-50%) of randomly distributed stabilizer cells engineered to be nonarrhythmogenic can suppress the ability of arrhythmogenic cells to generate delayed and early afterdepolarizations-related arrhythmias. Stabilizer cell gene therapy strategy can be designed to correct a specific arrhythmogenic mutation, as in the catecholaminergic polymorphic ventricular tachycardia mice studies, or more generally to suppress delayed or early afterdepolarizations from any cause by overexpressing the inward rectifier K channel Kir2.1 in stabilizer cells. CONCLUSIONS This promising antiarrhythmic strategy warrants further testing in experimental models to evaluate its clinical potential.
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Affiliation(s)
- Michael B Liu
- Departments of Medicine/Cardiology (M.B.L., Z.Q., J.N.W.), David Geffen School of Medicine, University of California, Los Angeles.,Physiology (M.B.L., J.N.W.), David Geffen School of Medicine, University of California, Los Angeles
| | - Silvia G Priori
- Department of Molecular Medicine, University of Pavia, Italy (S.G.P.).,Istituti Clinici Scientifici Maugeri, IRCCS, Pavia Italy (S.G.P.).,Centro de Investigaciones Cardiovasculares Carlos III, Madrid, Spain (S.G.P.)
| | - Zhilin Qu
- Departments of Medicine/Cardiology (M.B.L., Z.Q., J.N.W.), David Geffen School of Medicine, University of California, Los Angeles.,Computational Medicine (Z.Q.), David Geffen School of Medicine, University of California, Los Angeles
| | - James N Weiss
- Departments of Medicine/Cardiology (M.B.L., Z.Q., J.N.W.), David Geffen School of Medicine, University of California, Los Angeles.,Physiology (M.B.L., J.N.W.), David Geffen School of Medicine, University of California, Los Angeles
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25
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Bezzerides VJ, Prondzynski M, Carrier L, Pu WT. Gene therapy for inherited arrhythmias. Cardiovasc Res 2020; 116:1635-1650. [PMID: 32321160 PMCID: PMC7341167 DOI: 10.1093/cvr/cvaa107] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 03/13/2020] [Accepted: 04/15/2020] [Indexed: 01/16/2023] Open
Abstract
Inherited arrhythmias are disorders caused by one or more genetic mutations that increase the risk of arrhythmia, which result in life-long risk of sudden death. These mutations either primarily perturb electrophysiological homeostasis (e.g. long QT syndrome and catecholaminergic polymorphic ventricular tachycardia), cause structural disease that is closely associated with severe arrhythmias (e.g. hypertrophic cardiomyopathy), or cause a high propensity for arrhythmia in combination with altered myocardial structure and function (e.g. arrhythmogenic cardiomyopathy). Currently available therapies offer incomplete protection from arrhythmia and fail to alter disease progression. Recent studies suggest that gene therapies may provide potent, molecularly targeted options for at least a subset of inherited arrhythmias. Here, we provide an overview of gene therapy strategies, and review recent studies on gene therapies for catecholaminergic polymorphic ventricular tachycardia and hypertrophic cardiomyopathy caused by MYBPC3 mutations.
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Affiliation(s)
- Vassilios J Bezzerides
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115, USA
| | - Maksymilian Prondzynski
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115, USA
| | - Lucie Carrier
- Institute of Experimental and Clinical Pharmacology and Toxicology, Cardiovascular Research Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), partner site, Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - William T Pu
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115, USA
- Harvard Stem Cell Institute, 7 Divinity Avenue, Cambridge, MA 02138, USA
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26
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Wleklinski MJ, Kannankeril PJ, Knollmann BC. Molecular and tissue mechanisms of catecholaminergic polymorphic ventricular tachycardia. J Physiol 2020; 598:2817-2834. [PMID: 32115705 PMCID: PMC7699301 DOI: 10.1113/jp276757] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 02/03/2020] [Indexed: 12/21/2022] Open
Abstract
Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a stress-induced cardiac channelopathy that has a high mortality in untreated patients. Our understanding has grown tremendously since CPVT was first described as a clinical syndrome in 1995. It is now established that the deadly arrhythmias are caused by unregulated 'pathological' calcium release from the sarcoplasmic reticulum (SR), the major calcium storage organelle in striated muscle. Important questions remain regarding the molecular mechanisms that are responsible for the pathological calcium release, regarding the tissue origin of the arrhythmic beats that initiate ventricular tachycardia, and regarding optimal therapeutic approaches. At present, mutations in six genes involved in SR calcium release have been identified as the genetic cause of CPVT: RYR2 (encoding ryanodine receptor calcium release channel), CASQ2 (encoding cardiac calsequestrin), TRDN (encoding triadin), CALM1, CALM2 and CALM3 (encoding identical calmodulin protein). Here, we review each CPVT subtype and how CPVT mutations alter protein function, RyR2 calcium release channel regulation, and cellular calcium handling. We then discuss research and hypotheses surrounding the tissue mechanisms underlying CPVT, such as the pathophysiological role of sinus node dysfunction in CPVT, and whether the arrhythmogenic beats originate from the conduction system or the ventricular working myocardium. Finally, we review the treatments that are available for patients with CPVT, their efficacy, and how therapy could be improved in the future.
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Affiliation(s)
- Matthew J Wleklinski
- Vanderbilt Center for Arrhythmia Research and Therapeutics, Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Prince J Kannankeril
- Vanderbilt Center for Arrhythmia Research and Therapeutics, Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bjӧrn C Knollmann
- Vanderbilt Center for Arrhythmia Research and Therapeutics, Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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27
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Wang Q, Michalak M. Calsequestrin. Structure, function, and evolution. Cell Calcium 2020; 90:102242. [PMID: 32574906 DOI: 10.1016/j.ceca.2020.102242] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/05/2020] [Accepted: 06/06/2020] [Indexed: 12/25/2022]
Abstract
Calsequestrin is the major Ca2+ binding protein in the sarcoplasmic reticulum (SR), serves as the main Ca2+ storage and buffering protein and is an important regulator of Ca2+ release channels in both skeletal and cardiac muscle. It is anchored at the junctional SR membrane through interactions with membrane proteins and undergoes reversible polymerization with increasing Ca2+ concentration. Calsequestrin provides high local Ca2+ at the junctional SR and communicates changes in luminal Ca2+ concentration to Ca2+ release channels, thus it is an essential component of excitation-contraction coupling. Recent studies reveal new insights on calsequestrin trafficking, Ca2+ binding, protein evolution, protein-protein interactions, stress responses and the molecular basis of related human muscle disease, including catecholaminergic polymorphic ventricular tachycardia (CPVT). Here we provide a comprehensive overview of calsequestrin, with recent advances in structure, diverse functions, phylogenetic analysis, and its role in muscle physiology, stress responses and human pathology.
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Affiliation(s)
- Qian Wang
- Department of Biochemistry, University of Alberta, Edmonton, AB, T6H 2S7, Canada
| | - Marek Michalak
- Department of Biochemistry, University of Alberta, Edmonton, AB, T6H 2S7, Canada.
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28
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Liu Y, Zhou K, Li J, Agvanian S, Caldaruse AM, Shaw S, Hitzeman TC, Shaw RM, Hong T. In Mice Subjected to Chronic Stress, Exogenous cBIN1 Preserves Calcium-Handling Machinery and Cardiac Function. JACC Basic Transl Sci 2020; 5:561-578. [PMID: 32613144 PMCID: PMC7315191 DOI: 10.1016/j.jacbts.2020.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 03/11/2020] [Accepted: 03/11/2020] [Indexed: 12/16/2022]
Abstract
Heart failure is an important, and growing, cause of morbidity and mortality. Half of patients with heart failure have preserved ejection fraction, for whom therapeutic options are limited. Here we report that cardiac bridging integrator 1 gene therapy to maintain subcellular membrane compartments within cardiomyocytes can stabilize intracellular distribution of calcium-handling machinery, preserving diastolic function in hearts stressed by chronic beta agonist stimulation and pressure overload. This study identifies that maintenance of intracellular architecture and, in particular, membrane microdomains at t-tubules, is important in the setting of sympathetic stress. Stabilization of membrane microdomains may be a pathway for future therapeutic development.
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Key Words
- AAV9, adeno-associated virus 9
- ANOVA, analysis of variance
- AR, adrenergic receptor
- ATPase, adenosine triphosphatase
- BW, body weight
- CAMKII, Ca2+/calmodulin-dependent protein kinase
- CMV, cytomegalovirus
- Di-8-ANNEPs, 4-[2-[6-(Dioctylamino)-2-naphthalenyl]ethenyl]-1-(3-sulfopropyl)-pyridinium, inner salt
- EC, excitation contraction
- EDV, end diastolic volume
- EF, ejection fraction
- GFP, green fluorescent protein
- HF, heart failure
- HR, heart rate
- HT, heterozygote
- HW, heart weight
- ISO, isoproterenol
- LSD, least significant difference
- LTCC, voltage-dependent L-type calcium channel
- LV, left ventricular
- LW, lung weight
- PBS, phosphate-buffered saline
- PKA, protein kinase A
- PLN, phospholamban
- RWT, relative wall thickness
- RyR, ryanodine receptor
- SD, standard deviation
- SEM, standard error of the mean
- SERCA2a, sarcoplasmic reticulum calcium ATPase pump 2a
- SR, sarcoplasmic reticulum
- STORM, stochastic optical reconstruction microscopy
- TAC, transverse aortic constriction
- TEM, transmission electron microscopy
- WT, wild type
- cBIN1, cardiac bridging integrator 1
- diastolic dysfunction
- heart failure
- jSR, junctional sarcoplasmic reticulum
- pressure overload
- sympathetic overdrive
- t-tubule
- t-tubule, transverse-tubule
- vg, vector genome
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Affiliation(s)
- Yan Liu
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Kang Zhou
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jing Li
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Sosse Agvanian
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Seiji Shaw
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Tara C Hitzeman
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah
| | - Robin M Shaw
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah
| | - TingTing Hong
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.,Departments of Medicine, Cedars-Sinai Medical Center and UCLA, Los Angeles, California
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29
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Abstract
While clinical gene therapy celebrates its first successes, with several products already approved for clinical use and several hundreds in the final stages of the clinical approval pipeline, there is not a single gene therapy approach that has worked for the heart. Here, we review the past experience gained in the several cardiac gene therapy clinical trials that had the goal of inducing therapeutic angiogenesis in the ischemic heart and in the attempts at modulating cardiac function in heart failure. Critical assessment of the results so far achieved indicates that the efficiency of cardiac gene delivery remains a major hurdle preventing success but also that improvements need to be sought in establishing more reliable large animal models, choosing more effective therapeutic genes, better designing clinical trials, and more deeply understanding cardiac biology. We also emphasize a few areas of cardiac gene therapy development that hold great promise for the future. In particular, the transition from gene addition studies using protein-coding cDNAs to the modulation of gene expression using small RNA therapeutics and the improvement of precise gene editing now pave the way to applications such as cardiac regeneration after myocardial infarction and gene correction for inherited cardiomyopathies that were unapproachable until a decade ago.
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Affiliation(s)
- Antonio Cannatà
- From the King's College London, British Heart Foundation Centre of Research Excellence, School of Cardiovascular Medicine and Sciences, United Kingdom (A.C., H.A., M.G.).,Department of Medical, Surgical and Health Sciences, University of Trieste, Italy (A.C., G.S., M.G.)
| | - Hashim Ali
- From the King's College London, British Heart Foundation Centre of Research Excellence, School of Cardiovascular Medicine and Sciences, United Kingdom (A.C., H.A., M.G.).,Molecular Medicine Laboratory, International Centre for Genetic Engineering and Biotechnology (ICGEB), Trieste, Italy (H.A., M.G.)
| | - Gianfranco Sinagra
- Department of Medical, Surgical and Health Sciences, University of Trieste, Italy (A.C., G.S., M.G.)
| | - Mauro Giacca
- From the King's College London, British Heart Foundation Centre of Research Excellence, School of Cardiovascular Medicine and Sciences, United Kingdom (A.C., H.A., M.G.).,Department of Medical, Surgical and Health Sciences, University of Trieste, Italy (A.C., G.S., M.G.).,Molecular Medicine Laboratory, International Centre for Genetic Engineering and Biotechnology (ICGEB), Trieste, Italy (H.A., M.G.)
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30
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Clemens DJ, Tester DJ, Giudicessi JR, Bos JM, Rohatgi RK, Abrams DJ, Balaji S, Crotti L, Faure J, Napolitano C, Priori SG, Probst V, Rooryck-Thambo C, Roux-Buisson N, Sacher F, Schwartz PJ, Silka MJ, Walsh MA, Ackerman MJ. International Triadin Knockout Syndrome Registry. CIRCULATION-GENOMIC AND PRECISION MEDICINE 2020; 12:e002419. [PMID: 30649896 DOI: 10.1161/circgen.118.002419] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Triadin knockout syndrome (TKOS) is a rare, inherited arrhythmia syndrome caused by recessive null mutations in TRDN-encoded cardiac triadin. Based previously on 5 triadin null patients, TKOS has been characterized by extensive T-wave inversions, transient QT prolongation, and severe disease expression of exercise-induced cardiac arrest in early childhood refractory to conventional therapy. METHODS We have established the International Triadin Knockout Syndrome Registry to include patients who have genetically proven homozygous/compound heterozygous TRDN null mutations. Clinical/genetic data were collected using an online survey generated through REDCap. RESULTS Currently, the International Triadin Knockout Syndrome Registry includes 21 patients (11 males, average age of 18 years) from 16 families. Twenty patients (95%) presented with either cardiac arrest (15, 71%) or syncope (5, 24%) at an average age of 3 years. Mild skeletal myopathy/proximal muscle weakness was noted in 6 (29%) patients. Of the 19 surviving patients, 16 (84%) exhibit T-wave inversions, and 10 (53%) have transient QT prolongation > 480 ms. Eight of 9 patients had ventricular ectopy on exercise stress testing. Thirteen (68%) patients have received implantable defibrillators. Despite various treatment strategies, 14 (74%) patients have had recurrent breakthrough cardiac events. CONCLUSION TKOS is a potentially lethal disease characterized by T-wave inversions in the precordial leads, transient QT prolongation in some, and recurrent ventricular arrhythmias at a young age despite aggressive treatment. Patients displaying this phenotype should undergo TRDN genetic testing as TKOS may be a cause for otherwise unexplained cardiac arrest in young children. As gene therapy advances, enrollment into the International Triadin Knockout Syndrome Registry is encouraged to better understand TKOS and to ready a well-characterized cohort for future TRDN gene therapy trials.
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Affiliation(s)
- Daniel J Clemens
- Windland Smith Rice Sudden Death Genomics Laboratory, Department of Molecular Pharmacology and Experimental Therapeutics, Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, and Division of Heart Rhythm Services, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (D.J.C., D.J.T., J.R.G., J.M.B., R.K.R., M.J.A.)
| | - David J Tester
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (D.J.A.)
| | - John R Giudicessi
- Windland Smith Rice Sudden Death Genomics Laboratory, Department of Molecular Pharmacology and Experimental Therapeutics, Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, and Division of Heart Rhythm Services, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (D.J.C., D.J.T., J.R.G., J.M.B., R.K.R., M.J.A.)
| | - J Martijn Bos
- Windland Smith Rice Sudden Death Genomics Laboratory, Department of Molecular Pharmacology and Experimental Therapeutics, Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, and Division of Heart Rhythm Services, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (D.J.C., D.J.T., J.R.G., J.M.B., R.K.R., M.J.A.)
| | - Ram K Rohatgi
- Windland Smith Rice Sudden Death Genomics Laboratory, Department of Molecular Pharmacology and Experimental Therapeutics, Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, and Division of Heart Rhythm Services, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (D.J.C., D.J.T., J.R.G., J.M.B., R.K.R., M.J.A.)
| | - Dominic J Abrams
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (D.J.A.)
| | - Seshadri Balaji
- Doernbecher Children's Hospital, Oregon Health and Science University, Portland (S.B.)
| | - Lia Crotti
- Center for Cardiac Arrhythmias of Genetic Origin & Laboratory of Cardiovascular Genetics, Istituto Auxologico Italiano, IRCCS, Milan (L.C., P.J.S.).,IRCCS Department of Cardiovascular, Neural & Metabolic Sciences, San Luca Hospital, Istituto Auxologico Italiano (L.C.).,Department of Medicine and Surgery University of Milano-Bicocca, Italy (L.C.)
| | - Julien Faure
- Centre Hospitalier Universitaire de Grenoble Alpes (J.F., N.R.-B.).,Institut des Neurosciences de Grenoble, INSERM U1216, Grenoble, France (J.F., N.R.-B.)
| | - Carlo Napolitano
- Molecular Cardiology and Medicine Division, Istituti Clinici Scientifici Maugeri, IRCCS (C.N., S.G.P.).,Department of Molecular Medicine, University of Pavia, Italy (C.N., S.G.P.)
| | - Silvia G Priori
- Molecular Cardiology and Medicine Division, Istituti Clinici Scientifici Maugeri, IRCCS (C.N., S.G.P.).,Department of Molecular Medicine, University of Pavia, Italy (C.N., S.G.P.)
| | - Vincent Probst
- Reference Center for Rare Arrhythmic Disorders, Cardiologic Department, Nantes University Hospital, France (V.P.).,L'institut du thorax, INSERM 1087, Nantes, France (V.P.)
| | - Caroline Rooryck-Thambo
- Electrophysiology and Heart Modeling Institute, Bordeaux University Hospital, IHU Liryc, University of Bordeaux, Pessac-Bordeaux, France (C.R.-T., F.S.)
| | - Nathalie Roux-Buisson
- Centre Hospitalier Universitaire de Grenoble Alpes (J.F., N.R.-B.).,Institut des Neurosciences de Grenoble, INSERM U1216, Grenoble, France (J.F., N.R.-B.)
| | - Frederic Sacher
- Electrophysiology and Heart Modeling Institute, Bordeaux University Hospital, IHU Liryc, University of Bordeaux, Pessac-Bordeaux, France (C.R.-T., F.S.)
| | - Peter J Schwartz
- Center for Cardiac Arrhythmias of Genetic Origin & Laboratory of Cardiovascular Genetics, Istituto Auxologico Italiano, IRCCS, Milan (L.C., P.J.S.)
| | - Michael J Silka
- Children's Hospital Los Angeles, University of Southern California (M.J.S.)
| | - Mark A Walsh
- Paediatric Cardiology, University Hospital Bristol, United Kingdom (M.A.W.)
| | - Michael J Ackerman
- Windland Smith Rice Sudden Death Genomics Laboratory, Department of Molecular Pharmacology and Experimental Therapeutics, Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, and Division of Heart Rhythm Services, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (D.J.C., D.J.T., J.R.G., J.M.B., R.K.R., M.J.A.)
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31
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50 Years of Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT) – Time to Explore the Dark Side of the Moon. Heart Lung Circ 2020; 29:520-528. [DOI: 10.1016/j.hlc.2019.10.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/02/2019] [Accepted: 10/28/2019] [Indexed: 12/16/2022]
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32
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Kistamás K, Veress R, Horváth B, Bányász T, Nánási PP, Eisner DA. Calcium Handling Defects and Cardiac Arrhythmia Syndromes. Front Pharmacol 2020; 11:72. [PMID: 32161540 PMCID: PMC7052815 DOI: 10.3389/fphar.2020.00072] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 01/24/2020] [Indexed: 12/13/2022] Open
Abstract
Calcium ions (Ca2+) play a major role in the cardiac excitation-contraction coupling. Intracellular Ca2+ concentration increases during systole and falls in diastole thereby determining cardiac contraction and relaxation. Normal cardiac function also requires perfect organization of the ion currents at the cellular level to drive action potentials and to maintain action potential propagation and electrical homogeneity at the tissue level. Any imbalance in Ca2+ homeostasis of a cardiac myocyte can lead to electrical disturbances. This review aims to discuss cardiac physiology and pathophysiology from the elementary membrane processes that can cause the electrical instability of the ventricular myocytes through intracellular Ca2+ handling maladies to inherited and acquired arrhythmias. Finally, the paper will discuss the current therapeutic approaches targeting cardiac arrhythmias.
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Affiliation(s)
- Kornél Kistamás
- Department of Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.,Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, United Kingdom
| | - Roland Veress
- Department of Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Balázs Horváth
- Department of Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Tamás Bányász
- Department of Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Péter P Nánási
- Department of Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.,Department of Dental Physiology, Faculty of Dentistry, University of Debrecen, Debrecen, Hungary
| | - David A Eisner
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, United Kingdom
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33
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Pathophysiology of Calcium Mediated Ventricular Arrhythmias and Novel Therapeutic Options with Focus on Gene Therapy. Int J Mol Sci 2019; 20:ijms20215304. [PMID: 31653119 PMCID: PMC6862059 DOI: 10.3390/ijms20215304] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 10/16/2019] [Accepted: 10/21/2019] [Indexed: 12/19/2022] Open
Abstract
Cardiac arrhythmias constitute a major health problem with a huge impact on mortality rates and health care costs. Despite ongoing research efforts, the understanding of the molecular mechanisms and processes responsible for arrhythmogenesis remains incomplete. Given the crucial role of Ca2+-handling in action potential generation and cardiac contraction, Ca2+ channels and Ca2+ handling proteins represent promising targets for suppression of ventricular arrhythmias. Accordingly, we report the different roles of Ca2+-handling in the development of congenital as well as acquired ventricular arrhythmia syndromes. We highlight the therapeutic potential of gene therapy as a novel and innovative approach for future arrhythmia therapy. Furthermore, we discuss various promising cellular and mitochondrial targets for therapeutic gene transfer currently under investigation.
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34
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Cacheux M, Fauconnier J, Thireau J, Osseni A, Brocard J, Roux-Buisson N, Brocard J, Fauré J, Lacampagne A, Marty I. Interplay between Triadin and Calsequestrin in the Pathogenesis of CPVT in the Mouse. Mol Ther 2019; 28:171-179. [PMID: 31607542 DOI: 10.1016/j.ymthe.2019.09.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 08/28/2019] [Accepted: 09/06/2019] [Indexed: 01/07/2023] Open
Abstract
Recessive forms of catecholaminergic polymorphic ventricular tachycardia (CPVT) are induced by mutations in genes encoding triadin or calsequestrin, two proteins that belong to the Ca2+ release complex, responsible for intracellular Ca2+ release triggering cardiac contractions. To better understand the mechanisms of triadin-induced CPVT and to assay multiple therapeutic interventions, we used a triadin knockout mouse model presenting a CPVT-like phenotype associated with a decrease in calsequestrin protein level. We assessed different approaches to rescue protein expression and to correct intracellular Ca2+ release and cardiac function: pharmacological treatment with kifunensine or a viral gene transfer-based approach, using adeno-associated virus serotype 2/9 (AAV2/9) encoding the triadin or calsequestrin. We observed that the levels of triadin and calsequestrin are intimately linked, and that reduction of both proteins contributes to the CPVT phenotype. Different combinations of triadin and calsequestrin expression level were obtained using these therapeutic approaches. A full expression of each is not necessary to correct the phenotype; a fine-tuning of the relative re-expression of both triadin and calsequestrin is required to correct the CPVT phenotype and rescue the cardiac function. AAV-mediated gene delivery of calsequestrin or triadin and treatment with kifunensine are potential treatments for recessive forms of CPVT due to triadin mutations.
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Affiliation(s)
- Marine Cacheux
- Grenoble Institut Neurosciences, INSERM, Grenoble Alpes University, U1216, CHU Grenoble Alpes, 38700 La Tronche, France
| | - Jérémy Fauconnier
- University of Montpellier, INSERM U1046, CNRS 9214, CHU Montpellier, 34295 Montpellier, France
| | - Jérôme Thireau
- University of Montpellier, INSERM U1046, CNRS 9214, CHU Montpellier, 34295 Montpellier, France
| | - Alexis Osseni
- Grenoble Institut Neurosciences, INSERM, Grenoble Alpes University, U1216, CHU Grenoble Alpes, 38700 La Tronche, France
| | - Jacques Brocard
- Grenoble Institut Neurosciences, INSERM, Grenoble Alpes University, U1216, CHU Grenoble Alpes, 38700 La Tronche, France
| | - Nathalie Roux-Buisson
- Grenoble Institut Neurosciences, INSERM, Grenoble Alpes University, U1216, CHU Grenoble Alpes, 38700 La Tronche, France
| | - Julie Brocard
- Grenoble Institut Neurosciences, INSERM, Grenoble Alpes University, U1216, CHU Grenoble Alpes, 38700 La Tronche, France
| | - Julien Fauré
- Grenoble Institut Neurosciences, INSERM, Grenoble Alpes University, U1216, CHU Grenoble Alpes, 38700 La Tronche, France
| | - Alain Lacampagne
- University of Montpellier, INSERM U1046, CNRS 9214, CHU Montpellier, 34295 Montpellier, France.
| | - Isabelle Marty
- Grenoble Institut Neurosciences, INSERM, Grenoble Alpes University, U1216, CHU Grenoble Alpes, 38700 La Tronche, France.
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Pironet A, Syam N, Vandewiele F, Van den Haute C, Kerselaers S, Pinto S, Vande Velde G, Gijsbers R, Vennekens R. AAV9-Mediated Overexpression of TRPM4 Increases the Incidence of Stress-Induced Ventricular Arrhythmias in Mice. Front Physiol 2019; 10:802. [PMID: 31316392 PMCID: PMC6610516 DOI: 10.3389/fphys.2019.00802] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 06/06/2019] [Indexed: 11/13/2022] Open
Abstract
Ca2+ activated non-selective (CAN) cation channels have been described in cardiomyocytes since the advent of the patch clamp technique. It has been hypothesized that this type of ion channel contributes to the triggering of cardiac arrhythmias. TRPM4 is to date the only molecular candidate for a CAN cation channel in cardiomyocytes. Its significance for arrhythmogenesis in living animals remains, however, unclear. In this study, we have tested whether increased expression of wild-type (WT) TRPM4 augments the risk of arrhythmias in living mice. Overexpression of WT TRPM4 was achieved via tail vein injection of adeno-associated viral vector serotype 9 (AAV9) particles, which have been described to be relatively cardiac specific in mice. Subsequently, we performed ECG-measurements in freely moving mice to determine their in vivo cardiac phenotype. Though cardiac muscle was transduced with TRPM4 viral particles, the majority of viral particles accumulated in the liver. We did not observe any difference in arrhythmic incidents during baseline conditions. Instead, WT mice that overexpress TRPM4 were more vulnerable to develop premature ventricular ectopic beats during exercise-induced β-adrenergic stress. Conduction abnormalities were rare and not more frequent in transduced mice compare to WT mice. Taken together, we provide evidence that overexpression of TRPM4 increases the susceptibility of living mice to stress-induced arrhythmias.
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Affiliation(s)
- Andy Pironet
- Laboratory of Ion Channel Research, TRP Research Platform Leuven, VIB Center for Brain and Disease, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Ninda Syam
- Laboratory of Ion Channel Research, TRP Research Platform Leuven, VIB Center for Brain and Disease, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Frone Vandewiele
- Laboratory of Ion Channel Research, TRP Research Platform Leuven, VIB Center for Brain and Disease, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Chris Van den Haute
- Molecular Virology and Gene Therapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Sara Kerselaers
- Laboratory of Ion Channel Research, TRP Research Platform Leuven, VIB Center for Brain and Disease, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Silvia Pinto
- Laboratory of Ion Channel Research, TRP Research Platform Leuven, VIB Center for Brain and Disease, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Greetje Vande Velde
- Biomedical MRI, Department of Imaging & Pathology, KU Leuven, Leuven, Belgium
| | - Rik Gijsbers
- Molecular Virology and Gene Therapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Rudi Vennekens
- Laboratory of Ion Channel Research, TRP Research Platform Leuven, VIB Center for Brain and Disease, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
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Bezzerides VJ, Caballero A, Wang S, Ai Y, Hylind RJ, Lu F, Heims-Waldron DA, Chambers KD, Zhang D, Abrams DJ, Pu WT. Gene Therapy for Catecholaminergic Polymorphic Ventricular Tachycardia by Inhibition of Ca 2+/Calmodulin-Dependent Kinase II. Circulation 2019; 140:405-419. [PMID: 31155924 PMCID: PMC7274838 DOI: 10.1161/circulationaha.118.038514] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Catecholaminergic polymorphic ventricular tachycardia (CPVT), an inherited cardiac arrhythmia characterized by adrenergically triggered arrhythmias, is inadequately treated by current standard of care. Ca2+/calmodulin-dependent protein kinase II (CaMKII), an adrenergically activated kinase that contributes to arrhythmogenesis in heart disease models, is a candidate therapeutic target in CPVT. However, translation of CaMKII inhibition has been limited by the need for selective CaMKII inhibition in cardiomyocytes. Here, we tested the hypothesis that CaMKII inhibition with a cardiomyocyte-targeted gene therapy strategy would suppress arrhythmia in CPVT mouse models. METHODS We developed AAV9-GFP-AIP, an adeno-associated viral vector in which a potent CaMKII inhibitory peptide, autocamtide-2-related inhibitory peptide [AIP], is fused to green fluorescent protein (GFP) and expressed from a cardiomyocyte selective promoter. The vector was delivered systemically. Arrhythmia burden was evaluated with invasive electrophysiology testing in adult mice. AIP was also tested on induced pluripotent stem cells derived from patients with CPVT with different disease-causing mutations to determine the effectiveness of our proposed therapy on human induced pluripotent stem cell-derived cardiomyocytes and different pathogenic genotypes. RESULTS AAV9-GFP-AIP was robustly expressed in the heart without significant expression in extracardiac tissues, including the brain. Administration of AAV9-GFP-AIP to neonatal mice with a known CPVT mutation (RYR2R176Q/+) effectively suppressed ventricular arrhythmias induced by either β-adrenergic stimulation or programmed ventricular pacing, without significant proarrhythmic effect. Intravascular delivery of AAV9-GFP-AIP to adolescent mice transduced ≈50% of cardiomyocytes and was effective in suppressing arrhythmia in CPVT mice. Induced pluripotent stem cell-derived cardiomyocytes derived from 2 different patients with CPVT with different pathogenic mutations demonstrated increased frequency of abnormal calcium release events, which was suppressed by a cell-permeable form of AIP. CONCLUSIONS This proof-of-concept study showed that AAV-mediated delivery of a CaMKII peptide inhibitor to the heart was effective in suppressing arrhythmias in a murine model of CPVT. CaMKII inhibition also reversed the arrhythmia phenotype in human CPVT induced pluripotent stem cell-derived cardiomyocyte models with different pathogenic mutations.
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Affiliation(s)
- Vassilios J Bezzerides
- Basic and Translational Cardiovascular Research and Inherited Cardiac Arrhythmias Programs, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (V.J.B., A.C., S.W., Y.A., R.J.H., F.L., D.A.H.-W., K.D.C., D.Z., D.J.A., W.T.P.)
| | - Ana Caballero
- Basic and Translational Cardiovascular Research and Inherited Cardiac Arrhythmias Programs, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (V.J.B., A.C., S.W., Y.A., R.J.H., F.L., D.A.H.-W., K.D.C., D.Z., D.J.A., W.T.P.)
| | - Suya Wang
- Basic and Translational Cardiovascular Research and Inherited Cardiac Arrhythmias Programs, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (V.J.B., A.C., S.W., Y.A., R.J.H., F.L., D.A.H.-W., K.D.C., D.Z., D.J.A., W.T.P.)
| | - Yulan Ai
- Basic and Translational Cardiovascular Research and Inherited Cardiac Arrhythmias Programs, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (V.J.B., A.C., S.W., Y.A., R.J.H., F.L., D.A.H.-W., K.D.C., D.Z., D.J.A., W.T.P.)
| | - Robyn J Hylind
- Basic and Translational Cardiovascular Research and Inherited Cardiac Arrhythmias Programs, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (V.J.B., A.C., S.W., Y.A., R.J.H., F.L., D.A.H.-W., K.D.C., D.Z., D.J.A., W.T.P.)
| | - Fujian Lu
- Basic and Translational Cardiovascular Research and Inherited Cardiac Arrhythmias Programs, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (V.J.B., A.C., S.W., Y.A., R.J.H., F.L., D.A.H.-W., K.D.C., D.Z., D.J.A., W.T.P.)
| | - Danielle A Heims-Waldron
- Basic and Translational Cardiovascular Research and Inherited Cardiac Arrhythmias Programs, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (V.J.B., A.C., S.W., Y.A., R.J.H., F.L., D.A.H.-W., K.D.C., D.Z., D.J.A., W.T.P.)
| | - Kristina D Chambers
- Basic and Translational Cardiovascular Research and Inherited Cardiac Arrhythmias Programs, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (V.J.B., A.C., S.W., Y.A., R.J.H., F.L., D.A.H.-W., K.D.C., D.Z., D.J.A., W.T.P.)
| | - Donghui Zhang
- Basic and Translational Cardiovascular Research and Inherited Cardiac Arrhythmias Programs, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (V.J.B., A.C., S.W., Y.A., R.J.H., F.L., D.A.H.-W., K.D.C., D.Z., D.J.A., W.T.P.)
| | - Dominic J Abrams
- Basic and Translational Cardiovascular Research and Inherited Cardiac Arrhythmias Programs, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (V.J.B., A.C., S.W., Y.A., R.J.H., F.L., D.A.H.-W., K.D.C., D.Z., D.J.A., W.T.P.)
| | - William T Pu
- Basic and Translational Cardiovascular Research and Inherited Cardiac Arrhythmias Programs, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (V.J.B., A.C., S.W., Y.A., R.J.H., F.L., D.A.H.-W., K.D.C., D.Z., D.J.A., W.T.P.).,Harvard Stem Cell Institute, Cambridge, MA (W.T.P.)
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Nattel S. Allele-Specific Gene Silencing: Another Step in the Inexorable Advance of Gene Therapy for Cardiac Arrhythmia Management. Circ Res 2019; 121:480-482. [PMID: 28819033 DOI: 10.1161/circresaha.117.311541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Stanley Nattel
- From the Department of Medicine and Research Center, Montreal Heart Institute and Université de Montréal; Departments of Medicine and Pharmacology and Therapeutics, McGill University, Montreal, Canada; Institute of Pharmacology, West German Heart and Vascular Center, Faculty of Medicine, University Duisburg-Essen, Essen, Germany.
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38
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Flores DJ, Duong T, Brandenberger LO, Mitra A, Shirali A, Johnson JC, Springer D, Noguchi A, Yu ZX, Ebert SN, Ludwig A, Knollmann BC, Levin MD, Pfeifer K. Conditional ablation and conditional rescue models for Casq2 elucidate the role of development and of cell-type specific expression of Casq2 in the CPVT2 phenotype. Hum Mol Genet 2019; 27:1533-1544. [PMID: 29452352 DOI: 10.1093/hmg/ddy060] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 02/12/2018] [Indexed: 01/30/2023] Open
Abstract
Cardiac calsequestrin (Casq2) associates with the ryanodine receptor 2 channel in the junctional sarcoplasmic reticulum to regulate Ca2+ release into the cytoplasm. Patients carrying mutations in CASQ2 display low resting heart rates under basal conditions and stress-induced polymorphic ventricular tachycardia (CPVT). In this study, we generate and characterize novel conditional deletion and conditional rescue mouse models to test the influence of developmental programs on the heart rate and CPVT phenotypes. We also compare the requirements for Casq2 function in the cardiac conduction system (CCS) and in working cardiomyocytes. Our study shows that the CPVT phenotype is dependent upon concurrent loss of Casq2 function in both the CCS and in working cardiomyocytes. Accordingly, restoration of Casq2 in only the CCS prevents CPVT. In addition, occurrence of CPVT is independent of the developmental history of Casq2-deficiency. In contrast, resting heart rate depends upon Casq2 gene activity only in the CCS and upon developmental history. Finally, our data support a model where low basal heart rate is a significant risk factor for CPVT.
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Affiliation(s)
- Daniel J Flores
- Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA
| | - ThuyVy Duong
- Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA
| | - Luke O Brandenberger
- Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA
| | - Apratim Mitra
- Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA
| | - Aditya Shirali
- Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA
| | - John C Johnson
- Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA
| | - Danielle Springer
- Murine Phenotyping Core, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Audrey Noguchi
- Murine Phenotyping Core, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Zu-Xi Yu
- Pathology Core, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Steven N Ebert
- Division of Metabolic and Cardiovascular Sciences, Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, FL 32827, USA
| | - Andreas Ludwig
- Institut fuer Experimentelle und Klinische Pharmakologie und Toxikologie, Friedrich-Alexander-Universitaet Erlangen-Nuernberg, Erlangen 91054, Germany
| | - Bjorn C Knollmann
- Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Mark D Levin
- Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Karl Pfeifer
- Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA
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Hylind RJ, Chandler SF, Skinner JR, Abrams DJ. Genetic Testing for Inherited Cardiac Arrhythmias: Current State-of-the-Art and Future Avenues. J Innov Card Rhythm Manag 2018; 9:3406-3416. [PMID: 32494476 PMCID: PMC7252877 DOI: 10.19102/icrm.2018.091102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 03/14/2018] [Indexed: 12/24/2022] Open
Abstract
The seminal discovery that sequence variation in genes encoding cardiac ion channels was behind the inherited cardiac arrhythmic syndromes has led to major advances in understanding the functional biological mechanisms of cardiomyocyte depolarization and repolarization. The cost and speed with which these genes can now be sequenced have allowed for genetic testing to become a major component of clinical care and have led to important ramifications, yet interpretation of specific variants needs to be performed within the context of the clinical findings in the proband and extended family. As technology continues to advance, the promise of therapeutic manipulation of certain genetic pathways grows ever more real.
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Affiliation(s)
- Robyn J. Hylind
- Inherited Cardiac Arrhythmia Program, Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Stephanie F. Chandler
- Inherited Cardiac Arrhythmia Program, Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Jonathan R. Skinner
- Green Lane Paediatric and Congenital Cardiac Services, Starship Children’s Hospital, Auckland, New Zealand
- Department of Paediatrics, Child and Youth Health, The University of Auckland, Auckland, New Zealand
| | - Dominic J. Abrams
- Inherited Cardiac Arrhythmia Program, Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
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Spartalis M, Spartalis E, Tzatzaki E, Tsilimigras DI, Moris D, Kontogiannis C, Livanis E, Iliopoulos DC, Voudris V, Theodorakis GN. Novel approaches for the treatment of ventricular tachycardia. World J Cardiol 2018; 10:52-59. [PMID: 30079151 PMCID: PMC6068734 DOI: 10.4330/wjc.v10.i7.52] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 03/24/2018] [Accepted: 06/27/2018] [Indexed: 02/06/2023] Open
Abstract
Ventricular tachycardia (VT) is a crucial cause of sudden cardiac death (SCD) and a primary cause of mortality and morbidity in patients with structural cardiac disease. VT includes clinical disorders varying from benign to life-threatening. Most life-threatening episodes are correlated with coronary artery disease, but the risk of SCD varies in certain populations, with various underlying heart conditions, specific family history, and genetic variants. The targets of VT management are symptom alleviation, improved quality of life, reduced implantable cardioverter defibrillator shocks, prevention of reduction of left ventricular function, reduced risk of SCD, and improved overall survival. Antiarrhythmic drug therapy and endocardial catheter ablation remains the cornerstone of guideline-endorsed VT treatment strategies in patients with structural cardiac abnormalities. Novel strategies such as epicardial ablation, surgical cryoablation, transcoronary alcohol ablation, pre-procedural imaging, and stereotactic ablative radiotherapy are an appealing area of research. In this review, we gathered all recent advances in innovative therapies as well as experimental evidence focusing on different aspects of VT treatment that could be significant for future favorable clinical applications.
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Affiliation(s)
- Michael Spartalis
- ESC Working Group on Cardiac Cellular Electrophysiology, Sophia Antipolis Cedex 06903, France
- Division of Cardiology, Onassis Cardiac Surgery Center, Athens 17674, Greece
| | - Eleftherios Spartalis
- Laboratory of Experimental Surgery and Surgical Research, University of Athens Medical School, Athens 11527, Greece
| | - Eleni Tzatzaki
- Division of Cardiology, Onassis Cardiac Surgery Center, Athens 17674, Greece
| | - Diamantis I Tsilimigras
- Laboratory of Experimental Surgery and Surgical Research, University of Athens Medical School, Athens 11527, Greece
| | - Demetrios Moris
- Department of Surgery, Duke University, Durham, NC 27710, United States
| | - Christos Kontogiannis
- Department of Clinical Therapeutics, “Alexandra” Hospital, University of Athens, Athens 11528, Greece
| | - Efthimios Livanis
- Division of Cardiology, Onassis Cardiac Surgery Center, Athens 17674, Greece
| | - Dimitrios C Iliopoulos
- Laboratory of Experimental Surgery and Surgical Research, University of Athens Medical School, Athens 11527, Greece
| | - Vassilis Voudris
- Division of Cardiology, Onassis Cardiac Surgery Center, Athens 17674, Greece
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Abstract
PURPOSE OF REVIEW Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a life-threatening syndrome defined by exercise-induced or emotion-induced ventricular arrhythmias, typically caused by gain-of-function mutations in RYR2-encoded ryanodine receptor-2 (RyR2). This review will discuss recent advances and ongoing challenges in devising genotype-specific CPVT therapies. RECENT FINDINGS CPVT patients were once universally thought to be at high risk of sudden death; however, as more cases emerge, CPVT is being re-defined as a complex syndrome of variable expressivity. Treatment was traditionally limited to β-blockers and implantable cardioverter defibrillators, and although β-blockers remain a mainstay of treatment, implantable cardioverter defibrillator use is associated with adverse events and should be limited. New applications for older therapies, like flecainide and cardiac denervation, appear to better target the mechanistic basis of CPVT arrhythmias. Recent advances in our understanding of RyR2 structure and function can help in identifying novel therapeutic targets. SUMMARY CPVT is usually related to RyR2 or associated proteins. Emerging studies reveal several genotype-phenotype correlations, which may eventually influence therapeutic decision-making. Flecainide has improved CPVT outcomes and will likely have broader clinical indications in the near future. Gene therapy has shown promise in animal models but has yet to be studied in humans. Sudden death can occur as a sentinel symptom, making preventive therapy that targets molecular mechanism(s) of arrhythmia a key area of ongoing investigation. VIDEO ABSTRACT.
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Liu B, Walton SD, Ho HT, Belevych AE, Tikunova SB, Bonilla I, Shettigar V, Knollmann BC, Priori SG, Volpe P, Radwański PB, Davis JP, Györke S. Gene Transfer of Engineered Calmodulin Alleviates Ventricular Arrhythmias in a Calsequestrin-Associated Mouse Model of Catecholaminergic Polymorphic Ventricular Tachycardia. J Am Heart Assoc 2018; 7:JAHA.117.008155. [PMID: 29720499 PMCID: PMC6015318 DOI: 10.1161/jaha.117.008155] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a familial arrhythmogenic syndrome characterized by sudden death. There are several genetic forms of CPVT associated with mutations in genes encoding the cardiac ryanodine receptor (RyR2) and its auxiliary proteins including calsequestrin (CASQ2) and calmodulin (CaM). It has been suggested that impairment of the ability of RyR2 to stay closed (ie, refractory) during diastole may be a common mechanism for these diseases. Here, we explore the possibility of engineering CaM variants that normalize abbreviated RyR2 refractoriness for subsequent viral‐mediated delivery to alleviate arrhythmias in non–CaM‐related CPVT. Methods and Results To that end, we have designed a CaM protein (GSH‐M37Q; dubbed as therapeutic CaM or T‐CaM) that exhibited a slowed N‐terminal Ca dissociation rate and prolonged RyR2 refractoriness in permeabilized myocytes derived from CPVT mice carrying the CASQ2 mutation R33Q. This T‐CaM was introduced to the heart of R33Q mice through recombinant adeno‐associated viral vector serotype 9. Eight weeks postinfection, we performed confocal microscopy to assess Ca handling and recorded surface ECGs to assess susceptibility to arrhythmias in vivo. During catecholamine stimulation with isoproterenol, T‐CaM reduced isoproterenol‐promoted diastolic Ca waves in isolated CPVT cardiomyocytes. Importantly, T‐CaM exposure abolished ventricular tachycardia in CPVT mice challenged with catecholamines. Conclusions Our results suggest that gene transfer of T‐CaM by adeno‐associated viral vector serotype 9 improves myocyte Ca handling and alleviates arrhythmias in a calsequestrin‐associated CPVT model, thus supporting the potential of a CaM‐based antiarrhythmic approach as a therapeutic avenue for genetically distinct forms of CPVT.
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Affiliation(s)
- Bin Liu
- Department of Physiology and Cell Biology, Davis Heart and Lung Research Institute, Ohio State University, Columbus, OH.,Department of Biological Sciences, Mississippi State University, Starkville, MI
| | - Shane D Walton
- Department of Physiology and Cell Biology, Davis Heart and Lung Research Institute, Ohio State University, Columbus, OH
| | - Hsiang-Ting Ho
- Department of Physiology and Cell Biology, Davis Heart and Lung Research Institute, Ohio State University, Columbus, OH
| | - Andriy E Belevych
- Department of Physiology and Cell Biology, Davis Heart and Lung Research Institute, Ohio State University, Columbus, OH
| | - Svetlana B Tikunova
- Department of Physiology and Cell Biology, Davis Heart and Lung Research Institute, Ohio State University, Columbus, OH
| | - Ingrid Bonilla
- Department of Physiology and Cell Biology, Davis Heart and Lung Research Institute, Ohio State University, Columbus, OH
| | - Vikram Shettigar
- Department of Physiology and Cell Biology, Davis Heart and Lung Research Institute, Ohio State University, Columbus, OH
| | - Bjorn C Knollmann
- Division of Clinical Pharmacology, Vanderbilt University School of Medicine, Vanderbilt, TN
| | - Silvia G Priori
- Division of Cardiology and Molecular Cardiology, Maugeri Foundation-University of Pavia, Italy
| | - Pompeo Volpe
- Department of Biomedical Sciences, University of Padova, Italy
| | - Przemysław B Radwański
- Department of Physiology and Cell Biology, Davis Heart and Lung Research Institute, Ohio State University, Columbus, OH
| | - Jonathan P Davis
- Department of Physiology and Cell Biology, Davis Heart and Lung Research Institute, Ohio State University, Columbus, OH
| | - Sándor Györke
- Department of Physiology and Cell Biology, Davis Heart and Lung Research Institute, Ohio State University, Columbus, OH
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Affiliation(s)
- Gaetano Thiene
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Italy
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Affiliation(s)
- Jordi Heijman
- From the Department of Cardiology, Cardiovascular Research Institute Maastricht, Faculty of Health, Medicine, and Life Sciences, Maastricht University, The Netherlands (J.H.); Department of Medicine, Montreal Heart Institute and Université de Montréal, Canada (J.-B.G., S.N.); University Hospital of Saint-Étienne, University Jean Monnet, Saint-Étienne, France (J.-B.G.); Institute of Pharmacology, West German Heart and Vascular Center, Faculty of Medicine, University Duisburg-Essen (D.D., S.N.); and
| | - Jean-Baptiste Guichard
- From the Department of Cardiology, Cardiovascular Research Institute Maastricht, Faculty of Health, Medicine, and Life Sciences, Maastricht University, The Netherlands (J.H.); Department of Medicine, Montreal Heart Institute and Université de Montréal, Canada (J.-B.G., S.N.); University Hospital of Saint-Étienne, University Jean Monnet, Saint-Étienne, France (J.-B.G.); Institute of Pharmacology, West German Heart and Vascular Center, Faculty of Medicine, University Duisburg-Essen (D.D., S.N.); and
| | - Dobromir Dobrev
- From the Department of Cardiology, Cardiovascular Research Institute Maastricht, Faculty of Health, Medicine, and Life Sciences, Maastricht University, The Netherlands (J.H.); Department of Medicine, Montreal Heart Institute and Université de Montréal, Canada (J.-B.G., S.N.); University Hospital of Saint-Étienne, University Jean Monnet, Saint-Étienne, France (J.-B.G.); Institute of Pharmacology, West German Heart and Vascular Center, Faculty of Medicine, University Duisburg-Essen (D.D., S.N.); and
| | - Stanley Nattel
- From the Department of Cardiology, Cardiovascular Research Institute Maastricht, Faculty of Health, Medicine, and Life Sciences, Maastricht University, The Netherlands (J.H.); Department of Medicine, Montreal Heart Institute and Université de Montréal, Canada (J.-B.G., S.N.); University Hospital of Saint-Étienne, University Jean Monnet, Saint-Étienne, France (J.-B.G.); Institute of Pharmacology, West German Heart and Vascular Center, Faculty of Medicine, University Duisburg-Essen (D.D., S.N.); and
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Abstract
Although the mechanism of sudden cardiac death (SCD) in heart failure is not completely known, genetic variations are known to play key roles in this process. Increasing numbers of mutations and variants are being discovered through genome-wide association studies. The genetic variations involved in the mechanisms of SCD have aroused widespread concern. Comprehensive understanding of the genetic variations involved in SCD may help prevent it. To this end, we briefly reviewed the genetic variations involved in SCD and their associations and interactions, and observed that cardiac ion channels are the core molecules involved in this process. Genetic variations involved in cardiac structure, cardiogenesis and development, cell division and differentiation, and DNA replication and transcription are all speculated to be loci involved in SCD. Additionally, the systems involved in neurohumoral regulation as well as substance and energy metabolism are also potentially responsible for susceptibility to SCD. They form an elaborate network and mutually interact with each other to govern the fate of SCD-susceptible individuals.
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Falconer D, Papageorgiou N, Androulakis E, Alfallouji Y, Lim WY, Providencia R, Tousoulis D. Biological therapies targeting arrhythmias: are cells and genes the answer? Expert Opin Biol Ther 2017; 18:237-249. [PMID: 29202595 DOI: 10.1080/14712598.2018.1410130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Arrhythmias can cause symptoms ranging from simple dizziness to life-threatening circulatory collapse. Current management includes medical therapy and procedures such as catheter ablation or device implantation. However, these strategies still pose a risk of serious side effects, and some patients remain symptomatic. Advancement in our understanding of how arrhythmias develop on the cellular level has made more targeted approaches possible. In addition, contemporary studies have found that several genes are involved in the pathogenesis of arrhythmias. AREAS COVERED In the present review, the authors explore the cellular and genetic mechanisms leading to arrhythmias as well as the progress that has been made in using both gene and cell therapy to treat tachy- and bradyarrhythmias. They also consider why gene and cell therapy has resulted into a few clinical trials with promising results, however still not applicable in routine clinical practice. EXPERT OPINION The question currently is whether such biological therapies could replace current established approaches. The contemporary evidence suggests that despite recent advances in this field, it will need more work in experimental models before this is applied into clinical practice. Gene and cell studies targeting conduction and repolarization are promising, but still not ready for use in the clinical setting.
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Affiliation(s)
| | | | | | | | - Wei Yao Lim
- b Barts Heart Centre, St Bartholomew's Hospital , London , UK
| | - Rui Providencia
- b Barts Heart Centre, St Bartholomew's Hospital , London , UK
| | - Dimitris Tousoulis
- d 1st Cardiology Department , Hippokration Hospital, Athens University Medical School , Athens , Greece
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Abstract
PURPOSE OF REVIEW In this chapter we will discuss the most recent and relevant evidences published in the field of inherited arrhythmogenic disorders, focusing on the so called 'channelopathies' that are associated with sudden cardiac death (SCD) in children: long QT syndrome (LQTS), short QT syndrome (SQTS), Brugada syndrome (BrS), and catecholaminergic polymorphic ventricular tachycardia (CPVT). RECENT FINDINGS We will discuss the latest diagnostic criteria for channelopathies released by the European Society of Cardiology, the new data on BrS in children and the recent evidence supporting a genotype-specific therapy for LQTS type 3. Moreover, we will present further insights into the risk stratification of the children affected by LQTS, analyzing the role of imaging for the prediction of life-threatening arrhythmias. In addition, we will offer a perspective on how to deal with genetic results in families affected by SCD at very young ages. SUMMARY The selected publications will aid pediatricians in their clinical work when managing little patients with inherited arrhythmias, providing the most recent information for diagnosis, risk stratification, and management.
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Padrón-Barthe L, Domínguez F, Garcia-Pavia P, Lara-Pezzi E. Animal models of arrhythmogenic right ventricular cardiomyopathy: what have we learned and where do we go? Insight for therapeutics. Basic Res Cardiol 2017; 112:50. [PMID: 28688053 DOI: 10.1007/s00395-017-0640-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 07/03/2017] [Indexed: 01/01/2023]
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a rare genetically-determined cardiac heart muscle disorder characterized by fibro-fatty replacement of the myocardium that results in heart failure and sudden cardiac death (SCD), predominantly in young males. The disease is often caused by mutations in genes encoding proteins of the desmosomal complex, with a significant minority caused by mutations in non-desmosomal proteins. Existing treatment options are based on SCD prevention with the implantable cardioverter defibrillator, antiarrhythmic drugs, and anti-heart failure medication. Heart transplantation may also be required and there is currently no cure. Several genetically modified animal models have been developed to characterize the disease, assess its progression, and determine the influence of potential environmental factors. These models have also been very valuable for translational therapeutic approaches, to screen new treatment options that prevent and/or reverse the disease. Here, we review the available ARVC animal models reported to date, highlighting the most important pathophysiological findings and discussing the effect of treatments tested so far in this setting. We also describe gaps in our knowledge of the disease, with the goal of stimulating research and improving patient outcomes.
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Affiliation(s)
| | - Fernando Domínguez
- CIBER Cardiovascular Diseases (CIBERCV), Madrid, Spain.,Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, Manuel de Falla, 2, Majadahonda, 28222, Madrid, Spain
| | - Pablo Garcia-Pavia
- CIBER Cardiovascular Diseases (CIBERCV), Madrid, Spain. .,Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, Manuel de Falla, 2, Majadahonda, 28222, Madrid, Spain. .,Francisco de Vitoria University, Madrid, Spain.
| | - Enrique Lara-Pezzi
- CIBER Cardiovascular Diseases (CIBERCV), Madrid, Spain. .,Myocardial Pathophysiology Area, Centro Nacional de Investigaciones Cardiovasculares Carlos III, Melchor Fernandez Almagro, 3, 28029, Madrid, Spain. .,Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK.
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50
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Murphy NP, Lubbers ER, Mohler PJ. Advancements in the use of gene therapy for cardiac arrhythmia. Heart Rhythm 2017; 14:1061-1062. [PMID: 28385673 PMCID: PMC5942548 DOI: 10.1016/j.hrthm.2017.03.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Indexed: 01/16/2023]
Affiliation(s)
- Nathaniel P Murphy
- Department of Physiology & Cell Biology, Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Internal Medicine, Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ellen R Lubbers
- Department of Physiology & Cell Biology, Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Internal Medicine, Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Peter J Mohler
- Department of Physiology & Cell Biology, Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Internal Medicine, Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio.
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