Buccal mucosa cells as a potential diagnostic tool to study onset and progression of arrhythmogenic cardiomyopathy

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Netherlands Cardio Vascular Research Initiative (CVON) and 'Stichting Vriendenloterij'

Background

Arrhythmogenic cardiomyopathy (ACM) is predominantly caused by pathogenic variants in genes encoding desmosomal proteins (most often plakophilin-2). However, such variants are also found in genes encoding non-desmosomal proteins, such as phospholamban (PLN, p.Arg14del variant). Previous research showed that plakoglobin protein levels and localization in cardiac tissue of ACM patients, and p.Arg14del patients diagnosed with an ACM phenotype, are disturbed and this could be an additional tool to identify variant carriers at risk of developing ACM. Information about plakoglobin status can only be obtained via endocardial biopsies, however, this technique has major drawbacks, and therefore an alternative is needed. A promising new non-invasive tool is the use of buccal mucosa cells (BMC), as it has been reported that effects of pathogenic variants in desmosomal genes are reflected in non-cardiac tissues like BMC smears that also express those genes.

Purpose

To investigate the clinical usability of BMC as a tool to classify patients at risk of developing ACM by comparing controls with preclinical variant carriers and symptomatic ACM patients, and patients carrying the PLN p.Arg14del variant being preclinical, diagnosed with ACM or dilated cardiomyopathy (DCM).

Methods

BMC of 33 ACM patients (19 males, 28 with a PKP2 mutation), 17 PLN p.Arg14del patients (6 males, 3 diagnosed with ACM, 7 DCM and 7 preclinical carriers) and 34 controls (14 males), were collected on glass slides, fixed and labelled with anti-plakoglobin antibodies diluted 1:5.000, 1:10.000, 1:20.000 and 1:40.000, and scored for their membrane labelling.

Results

Data revealed that for each dilution, plakoglobin protein levels at the membrane were significantly reduced in BMC obtained from ACM patients (both in symptomatic patients and in preclinical variant carriers) when compared to controls. This effect was independent from age and sex of the patients. Dilutions 1:5.000 and 1:10.000 showed a moderate to strong correlation with the revised 2010 Task Force Criteria Score (TFC) which is commonly used for ACM diagnosis (rs  = -0.67, n=64, p<0.0001 and rs = -0.71, n=64, p<0.0001 resp.). In contrast, plakoglobin scores of PLN p.Arg14del patients were comparable to controls (p>0.209).

Conclusion

There is a significant reduction of plakoglobin protein in BMC of ACM patients and carriers with variants predisposing to ACM, but not for patients carrying the PLN p.Arg14del variant when compared to controls. However, for clinical diagnosis of the individual ACM patient, this method is not discriminative enough to distinguish true patients from preclinical variant carriers and controls, because of high interindividual variability.

Buccal mucosa cells as a diagnostic tool in patients with arrhythmogenic cardiomyopathy

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Netherlands Cardio Vascular Research Initiative (CVON): the Dutch heart foundation

Background

Arrhythmogenic cardiomyopathy (ACM) is predominantly caused by mutations in genes encoding desmosomal proteins (most often multiple different mutations in plakophilin-2), however also mutations in non-desmosomal proteins like phospholamban (PLN, PLNR14Del) are found. Previous investigations showed that plakoglobin protein levels and localization in cardiac tissue of ACM patients is disturbed and this could be a valuable additional tool to discriminate between non-affected family members and those being at risk during progression of the disease. Information about cardiac plakoglobin status can only be obtained via endocardial biopsies, however, this technique has major draw-backs and risks, and therefore an alternative is needed. A promising new non-invasive tool is the use of buccal mucosa cells (BMC), as it has been reported that effects of mutations in desmosomal proteins are additionally reflected in non-cardiac tissues like buccal mucosa smears that do also express those desmosomal genes.

Purpose

To investigate the clinical usability of BMC as tool to classify patients at risk of developing ACM by comparing healthy controls with asymptomatic and symptomatic classical ACM patients, and patients carrying a PLNR14Del mutation.

Methods and results

BMC of 84 human subjects, 33 ACM patients (19 males, 28 with a PKP2 mutation), 17 PLN patients (6 males) and 34 healthy controls (14 males), were collected on glass slides, fixed and labelled with anti-plakoglobin antibodies diluted 1:5.000, 1:10.000, 1:20.000 and 1:40.000, and scored for their membrane labelling. Data revealed that for each applied dilution, plakoglobin protein levels at the membrane were significantly reduced in BMC obtained from ACM patients compared to healthy controls. This effect appeared independent from age and sex of the patients. Furthermore, dilutions 1:5.000 and 1:10.000 showed a moderate correlation with the revised 2010 Task Force Criteria Score (TFC) which are commonly used for ACM diagnosis (Rs -0.67, n = 64, p <0.0001 and Rs -0.71, n = 64, p < 0.0001 resp.) In contrast, plakoglobin scores of PLN patients were similar to controls.

Conclusion

On the population level, there is a significant reduction of plakoglobin protein in BMC membranes of ACM patients but not for patients bearing the PLNR14Del mutation when compared to healthy controls. However, for clinical diagnosis of the individual patient, this method is most likely not discriminative enough to distinguish patients from healthy controls, because of the high interindividual variability.

A combined CaMKII inhibition and mineralocorticoid receptor antagonism via eplerenone inhibits functional deterioration in chronic pressure overloaded mice

In the diseased and remodelled heart, increased activity and expression of Ca^2+/ calmodulin-dependent protein kinase II (CaMKII), an excess of fibrosis, and a decreased electrical coupling and cellular excitability leads to disturbed calcium homeostasis and tissue integrity. This subsequently leads to increased arrhythmia vulnerability and contractile dysfunction. Here, we investigated the combination of CaMKII inhibition (using genetically modified mice expressing the autocamtide-3-related-peptide (AC3I)) together with eplerenone treatment (AC3I-Epler) to prevent electrophysiological remodelling, fibrosis and subsequent functional deterioration in a mouse model of chronic pressure overload. We compared AC3I-Epler mice with mice only subjected to mineralocorticoid receptor (MR) antagonism (WT-Epler) and mice with only CaMKII inhibition (AC3I-No). Our data show that a combined CaMKII inhibition together with MR antagonism mitigates contractile deterioration as was manifested by a preservation of ejection fraction, fractional shortening, global longitudinal strain, peak strain and contractile synchronicity. Furthermore, patchy fibrosis formation was reduced, potentially via inhibition of pro-fibrotic TGF-β/SMAD3 signalling, which related to a better global contractile performance and a slightly depressed incidence of arrhythmias. Furthermore, the level of patchy fibrosis appeared significantly correlated to eplerenone dose. The addition of eplerenone to CaMKII inhibition potentiates the effects of CaMKII inhibition on pro-fibrotic pathways. As a result of the applied strategy, limiting patchy fibrosis adheres to a higher synchronicity of contraction and an overall better contractile performance which fits with a tempered arrhythmogenesis.

Emerging molecular therapies targeting myocardial infarction-related arrhythmias

Cardiac disease is the leading cause of death in the developed world. Ventricular arrhythmias associated with myocardial ischaemia and/or infarction are a major contributor to cardiovascular mortality, and require improved prevention and treatment. Drugs, devices, and radiofrequency catheter ablation have made important inroads, but have significant limitations ranging from incomplete success to undesired toxicities and major side effects. These limitations derive from the nature of the intervention. Drugs are frequently ineffective, target the entire heart, and often do not deal with the specific arrhythmia trigger or substrate. Devices can terminate rapid rhythms but at best indirectly affect the underlying disease, while ablation, even when appropriately targeted, induces additional tissue damage. In contrast, exploration of gene and cell therapies are expected to provide a targeted, non-destructive, and potentially regenerative approach to ischaemia- and infarction-related arrhythmias. Although these approaches are in the early stages of development, they carry substantial potential to advance arrhythmia prevention and treatment.

New antiarrhythmic targets to control intracellular calcium handling

Sudden cardiac death due to ventricular arrhythmias is a major problem. Drug therapies to prevent SCD do not provide satisfying results, leading to the demand for new antiarrhythmic strategies. New targets include Ca²⁺/Calmodulin-dependent protein kinase II (CaMKII), the Na/Ca exchanger (NCX), the Ryanodine receptor (RyR, and its associated protein FKBP12.6 (Calstabin)) and the late component of the sodium current (I_Na-Late), all related to intracellular calcium (Ca²⁺) handling. In this review, drugs interfering with these targets (SEA-0400, K201, KN-93, W7, ranolazine, sophocarpine, and GS-967) are evaluated and their future as clinical compounds is considered. These new targets prove to be interesting; however more insight into long-term drug effects is necessary before clinical applicability becomes reality.

Effect of skeletal muscle Na(+) channel delivered via a cell platform on cardiac conduction and arrhythmia induction

BACKGROUND

In depolarized myocardial infarct epicardial border zones, the cardiac sodium channel is largely inactivated, contributing to slow conduction and reentry. We have demonstrated that adenoviral delivery of the skeletal muscle Na(+) channel (SkM1) to epicardial border zones normalizes conduction and reduces induction of ventricular tachycardia/ventricular fibrillation. We now studied the impact of canine mesenchymal stem cells (cMSCs) in delivering SkM1.

METHODS AND RESULTS

cMSCs were isolated and transfected with SkM1. Coculture experiments showed cMSC/SkM1 but not cMSC alone and maintained fast conduction at depolarized potentials. We studied 3 groups in the canine 7d infarct: sham, cMSC, and cMSC/SkM1. In vivo epicardial border zones electrograms were broad and fragmented in sham, narrower in cMSCs, and narrow and unfragmented in cMSC/SkM1 (P<0.05). During programmed electrical stimulation of epicardial border zones, QRS duration in cMSC/SkM1 was shorter than in cMSC and sham (P<0.05). Programmed electrical stimulation-induced ventricular tachycardia/ventricular fibrillation was equivalent in all groups (P>0.05).

CONCLUSION

cMSCs provide efficient delivery of SkM1 current. The interventions performed (cMSCs or cMSC/SkM1) were neither antiarrhythmic nor proarrhythmic. Comparing outcomes with cMSC/SkM1 and viral gene delivery highlights the criticality of the delivery platform to SkM1 antiarrhythmic efficacy.

SkM1 and Cx32 improve conduction in canine myocardial infarcts yet only SkM1 is antiarrhythmic

AIMS

Reentry accounts for most life-threatening arrhythmias, complicating myocardial infarction, and therapies that consistently prevent reentry from occurring are lacking. In this study, we compare antiarrhythmic effects of gene transfer of green fluorescent protein (GFP; sham), the skeletal muscle sodium channel (SkM1), the liver-specific connexin (Cx32), and SkM1/Cx32 in the subacute canine infarct.

METHODS AND RESULTS

Immediately after ligation of the left anterior descending artery, viral constructs were implanted in the epicardial border zone (EBZ). Five to 7 days later, efficient restoration of impulse propagation (narrow QRS and local electrogram duration) occurred in SkM1, Cx32, and SkM1/Cx32 groups (P< 0.05 vs. GFP). Programmed electrical stimulation from the EBZ induced sustained ventricular tachycardia (VT)/ventricular fibrillation (VF) in 15/22 GFP dogs vs. 2/12 SkM1, 6/14 Cx32, and 8/10 SkM1/Cx32 (P< 0.05 SkM1 vs. GFP). GFP, SkM1, and SkM1/Cx32 had predominantly polymorphic VT/VF, whereas in Cx32 dogs, monomorphic VT predominated (P< 0.05 for Cx32 vs. GFP). Tetrazolium red staining showed significantly larger infarcts in Cx32- vs. GFP-treated animals (P< 0.05).

CONCLUSION

Whereas SkM1 gene transfer reduces the incidence of inducible VT/VF, Cx32 therapy to improve gap junctional conductance results in larger infarct size, a different VT morphology, and no antiarrhythmic efficacy.