Gene Editing and Gene-Based Therapeutics for Cardiomyopathies

Emerging Therapeutic Strategies for Heart Failure: A Comprehensive Review of Novel Pharmacological and Molecular Targets

Heart failure (HF) is a complex clinical syndrome characterized by the heart's inability to meet the body's metabolic demands. HF remains a global health challenge with high morbidity and mortality. Outcomes of beta-blockers, angiotensin receptor-neprilysin inhibitors (ARNIs), and mineralocorticoid receptor antagonists (MRAs) in HF remain suboptimal. HF is a heterogeneous syndrome driven by neurohormonal dysregulation, fibrosis, metabolic disturbances, and inflammation, contributing to symptoms like dyspnea, fatigue, and fluid retention. Recent advances in pharmacological therapies, including sodium-glucose cotransporter 2 inhibitors (SGLT2 inhibitors), soluble guanylate cyclase stimulators (sGC stimulators), and cardiac myosin activators, have shown promise in HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF), offering mechanism-specific interventions. Moreover, molecular-targeted therapies, such as clustered regularly interspaced short palindromic repeats (CRISPR)-associated protein 9 (Cas9) gene editing, RNA-based therapeutics, and adeno-associated virus serotype 9-sarcoplasmic reticulum calcium ATPase 2a (AAV9-SERCA2a gene) therapy, are emerging as potential disease-modifying treatments aimed at addressing genetic and inflammatory drivers of cardiomyopathies. Artificial intelligence (AI) is transforming HF care by enhancing predictive modelling, risk stratification, and precision medicine, with applications in multi-omics data integration. AI-driven tools, including machine learning (ML) algorithms, improve echocardiographic phenotyping, optimize treatment strategies, and refine patient selection for therapies. Despite these promising developments, challenges such as data quality, standardization, scalability, and regulatory barriers remain. Furthermore, gene therapies' long-term safety and efficacy are still uncertain, with concerns about immune responses, off-target effects, and sustained gene expression. Regenerative medicine strategies, including induced pluripotent stem cells (iPSC)-derived cardiomyocytes, extracellular vesicles (EVs), and 3D-bioprinted cardiac patches, offer potential solutions for myocardial repair. However, immune rejection, graft integration, and long-term viability remain significant obstacles. Additionally, high costs associated with novel biologics and gene-based therapies limit accessibility, particularly in low-resource settings. The future of HF management depends on overcoming these translational challenges. Key steps include validating AI-driven phenotyping tools in clinical trials, advancing scalable biomanufacturing technologies, and refining regulatory frameworks to facilitate clinical integration. By addressing these barriers, precision medicine, AI, and regenerative therapies can transform HF management, providing more personalized, effective, and accessible treatments and ultimately improving patient outcomes globally.

Dilated cardiomyopathy: from genes and molecules to potential treatments

Dilated cardiomyopathy is a myocardial condition marked by the enlargement of the heart's ventricular chambers and the gradual decline in systolic function, frequently resulting in congestive heart failure. Dilated cardiomyopathy has obvious familial characteristics, and mutations in related pathogenic genes can account for about 50% of patients with dilated cardiomyopathy. The most common genes related to dilated cardiomyopathy include TTN, LMNA, MYH7, etc. With more and more research on these genes, it will undoubtedly provide more potential targets and therapeutic pathways for the treatment of dilated cardiomyopathy. In addition, myocardial inflammation, myocardial metabolism abnormalities and cardiomyocyte apoptosis all have an important impact on the pathogenesis of dilated cardiomyopathy. Approximately half of sudden deaths among children and adolescents, along with the majority of patients undergoing heart transplantation, stem from cardiomyopathy. Therefore, precise and prompt clinical diagnosis holds paramount importance. Currently, diagnosis primarily hinges on the patient's medical background and imaging tests, with the significance of genetic testing steadily gaining prominence. The primary treatment for dilated cardiomyopathy remains heart transplantation. However, the scarcity of donors and the risk of severe immune rejection underscore the pressing need for novel therapies. Presently, research is actively exploring preclinical treatments like stem cell therapy as potential solutions.

Revolutionizing Cardiac Care: The Role of Gene Therapy in Treating Cardiomyopathy

Gene therapy presents a method for addressing types of cardiomyopathies that play a substantial role in heart failure. This innovative approach, leveraging technologies such as clustered regularly interspaced short palindromic repeats/Cas9 for modifying genomes, holds promise for lasting treatments or potential cures that go beyond therapies. It is essential to grasp the workings of gene therapy, including gene silencing, clustered regularly interspaced short palindromic repeats genome editing, and enhancing sarcomere function to effectively apply it to treating cardiomyopathy. Examining current trials will shed light on the advancements and accomplishments in this field while also addressing the obstacles, uncertainties, and opportunities ahead. Delving into the possibilities of gene therapy involves exploring targets and inventive delivery methods that underscore the evolving landscape of research in this domain hinting at a future brimming with opportunities to transform care. The progress made in using gene therapy to treat cardiomyopathies represents the progress of medicine in driving forward scientific innovation to provide more precise and enduring solutions for patients. Continuously refining gene therapy techniques and deepening our knowledge of genetics are factors that will shape the future direction of cardiac care. The potential of gene therapy does not just benefit individuals with cardiomyopathy but also represents a move toward effective treatments for various genetic conditions. This signifies a step in the pursuit of holistic healthcare solutions.

Pharmacotherapy for Cancer Treatment-Related Cardiac Dysfunction and Heart Failure in Childhood Cancer Survivors

The number of childhood cancer survivors is increasing rapidly. According to American Association for Cancer Research, there are more than 750,000 childhood cancer survivors in the United States and Europe. As the number of childhood cancer survivors increases, so does cancer treatment-related cardiac dysfunction (CTRCD), leading to heart failure (HF). It has been reported that childhood cancer survivors who received anthracyclines are 15 times more likely to have late cancer treatment-related HF and have a 5-fold higher risk of death from cardiovascular (CV) disease than the general population. CV disease is the leading cause of death in childhood cancer survivors. The increasing need to manage cancer survivor patients has led to the rapid creation and adaptation of cardio-oncology. Cardio-oncology is a multidisciplinary science that monitors, treats, and prevents CTRCD. Many guidelines and position statements have been published to help diagnose and manage CTRCD, including those from the American Society of Clinical Oncology, the European Society of Cardiology, the Canadian Cardiovascular Society, the European Society of Medical Oncology, the International Late Effects of Childhood Cancer Guideline Harmonization Group, and many others. However, there remains a gap in identifying high-risk patients likely to develop cardiomyopathy and HF in later life, thus reducing primary and secondary measures being instituted, and when to start treatment when there is echocardiographic evidence of left ventricular (LV) dysfunctions without symptoms of HF. There are no randomized controlled clinical trials for treatment for CTRCD leading to HF in childhood cancer survivors. The treatment of HF due to cancer treatment is similar to the guidelines for general HF. This review describes the latest pharmacologic therapy for preventing and treating LV dysfunction and HF in childhood cancer survivors based on expert consensus guidelines and extrapolating data from adult HF trials.

Cardiac Organoids: A 3D Technology for Modeling Heart Development and Disease

Cardiac organoids (COs) are miniaturized and simplified organ structures that can be used in heart development biology, drug screening, disease modeling, and regenerative medicine. This cardiac organoid (CO) model is revolutionizing our perspective on answering major cardiac physiology and pathology issues. Recently, many research groups have reported various methods for modeling the heart in vitro. However, there are differences in methodologies and concepts. In this review, we discuss the recent advances in cardiac organoid technologies derived from human embryonic stem cells (hESCs) and human-induced pluripotent stem cells (hiPSCs), with a focus on the summary of methods for organoid generation. In addition, we introduce CO applications in modeling heart development and cardiovascular diseases and discuss the prospects for and common challenges of CO that still need to be addressed. A detailed understanding of the development of CO will help us design better methods, explore and expand its application in the cardiovascular field.

Genome Editing for the Understanding and Treatment of Inherited Cardiomyopathies

Cardiomyopathies are diseases of heart muscle, a significant percentage of which are genetic in origin. Cardiomyopathies can be classified as dilated, hypertrophic, restrictive, arrhythmogenic right ventricular or left ventricular non-compaction, although mixed morphologies are possible. A subset of neuromuscular disorders, notably Duchenne and Becker muscular dystrophies, are also characterized by cardiomyopathy aside from skeletal myopathy. The global burden of cardiomyopathies is certainly high, necessitating further research and novel therapies. Genome editing tools, which include zinc finger nucleases (ZFNs), transcription activator-like effector nucleases (TALENs) and clustered regularly interspaced short palindromic repeats (CRISPR) systems have emerged as increasingly important technologies in studying this group of cardiovascular disorders. In this review, we discuss the applications of genome editing in the understanding and treatment of cardiomyopathy. We also describe recent advances in genome editing that may help improve these applications, and some future prospects for genome editing in cardiomyopathy treatment.

Practical Aspects in Genetic Testing for Cardiomyopathies and Channelopathies

Genetic testing has an increasingly important role in the diagnosis and management of cardiac disorders, where it confirms the diagnosis, aids prognostication and risk stratification and guides treatment. A genetic diagnosis in the proband also enables clarification of the risk for family members by cascade testing. Genetics in cardiac disorders is complex where epigenetic and environmental factors might come into interplay. Incomplete penetrance and variable expressivity is also common. Genetic results in cardiac conditions are mostly probabilistic and should be interpreted with all available clinical information. With this complexity in cardiac genetics, testing is only indicated in patients with a strong suspicion of an inheritable cardiac disorder after a full clinical evaluation. In this review we discuss the genetics underlying the major cardiomyopathies and channelopathies, and the practical aspects of diagnosing these conditions in the laboratory.

Allelic imbalance and haploinsufficiency in MYBPC3-linked hypertrophic cardiomyopathy

Mutations in cardiac myosin binding protein C (MYBPC3) represent the most frequent cause of familial hypertrophic cardiomyopathy (HCM), making up approximately 50% of identified HCM mutations. MYBPC3 is distinct among other sarcomere genes associated with HCM in that truncating mutations make up the vast majority, whereas nontruncating mutations predominant in other sarcomere genes. Several studies using myocardial tissue from HCM patients have found reduced abundance of wild-type MYBPC3 compared to control hearts, suggesting haploinsufficiency of full-length MYBPC3. Further, decreased mutant versus wild-type mRNA and lack of truncated mutant MYBPC3 protein has been demonstrated, highlighting the presence of allelic imbalance. In this review, we will begin by introducing allelic imbalance and haploinsufficiency, highlighting the broad role each plays within the spectrum of human disease. We will subsequently focus on the roles allelic imbalance and haploinsufficiency play within MYBPC3-linked HCM. Finally, we will explore the implications of these findings on future directions of HCM research. An improved understanding of allelic imbalance and haploinsufficiency may help us better understand genotype-phenotype relationships in HCM and develop novel targeted therapies, providing exciting future research opportunities.