A missense mutation in a highly conserved region of CASQ2 is associated with autosomal recessive catecholamine-induced polymorphic ventricular tachycardia in Bedouin families from Israel

Cardiac arrest in a mother and daughter and the identification of a novel RYR2 variant, predisposing to low penetrant catecholaminergic polymorphic ventricular tachycardia in a four‐generation Canadian family

Background

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a rare inherited arrhythmia syndrome characterized by adrenergically driven ventricular arrhythmia predominantly caused by pathogenic variants in the cardiac ryanodine receptor (RyR2). We describe a novel variant associated with cardiac arrest in a mother and daughter.

Methods

Initial sequencing of the RYR2 gene identified a novel variant (c.527G > T, p.R176L) in the index case (the mother), and her daughter. Structural analysis demonstrated the variant was located within the N‐terminal domain of RyR2, likely leading to a gain‐of‐function effect facilitating enhanced calcium ion release. Four generation cascade genetic and clinical screening was carried out.

Results

Thirty‐eight p.R176L variant carriers were identified of 94 family members with genetic testing, and 108 family members had clinical evaluations. Twelve carriers were symptomatic with previous syncope and 2 additional survivors of cardiac arrest were identified. Thirty‐two had clinical features suggestive of CPVT. Of 52 noncarriers, 11 had experienced previous syncope with none exhibiting any clinical features of CPVT. A documented arrhythmic event rate of 2.89/1000 person‐years across all carriers was calculated.

Conclusion

The substantial variability in phenotype and the lower than previously reported penetrance is illustrative of the importance of exploring family variants beyond first‐degree relatives.

iPCS Cell Modeling of Inherited Cardiac Arrhythmias

OPINION STATEMENT

The study of inherited cardiac disorders is hampered by the lack of suitable in vitro human cardiac disease models and relevant functional assays. A potential solution to this cell-sourcing challenge may be the recently described human induced pluripotent stem cell (hiPSC) technology. Pioneering studies were successful in establishing patient-specific, hiPSC-derived cardiomyocyte models of the most common inherited cardiac arrhythmogenic disorders, such as the different long QT syndrome subtypes (types 1, 2, 3, 8), overlap syndrome LQTS3/Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia (CPVT) types 1 and 2, and arrhythmogenic right ventricular cardiomyopathy (ARVC). These studies initially demonstrated the ability of the generated hiPSC models to recapitulate the disease processes in the culture dish. More recently, such studies were also able to provide new mechanistic insights into the disease processes, as well as to derive a unique drug-screening platform to test existing and novel therapeutic treatment options in an environment resembling the human physiological milieu. Moreover, initial evidence suggests that such models can help to optimize drug treatment in a personalized manner in the future. Nevertheless, several hurdles still exist for using hiPSC-based models for the aforementioned tasks, such as the hiPSC-derived cardiomyocytes' relatively immature phenotype, and also the resulting cell heterogeneity. Extensive research work is ongoing to address these challenges, as well as to add new opportunities for the field by utilizing recent advances in gene editing technologies. Here, we discuss the significant findings that hiPSC-based models have provided for each of the inherited cardiac arrhythmia syndromes so far, and the current challenges that this technique is facing.

Functional consequences of stably expressing a mutant calsequestrin (CASQ2D307H) in the CASQ2 null background

The role of calsequestrin (CASQ2) in cardiac sarcoplasmic reticulum (SR) calcium (Ca(2+)) transport has gained significant attention since point mutations in CASQ2 were reported to cause ventricular arrhythmia. In the present study, we have critically evaluated the functional consequences of expressing the CASQ2(D307H) mutant protein in the CASQ2 null mouse. We recently reported that the mutant CASQ2(D307H) protein can be stably expressed in CASQ2 null hearts, and it targets appropriately to the junctional SR (Kalyanasundaram A, Bal NC, Franzini-Armstrong C, Knollmann BC, Periasamy M. J Biol Chem 285: 3076-3083, 2010). In this study, we found that introduction of CASQ2(D307H) protein in the CASQ2 null background partially restored triadin 1 levels, which were decreased in the CASQ2 null mice. Despite twofold expression (relative to wild-type CASQ2), the mutant protein failed to increase SR Ca(2+) load. We also found that the Ca(2+) transient decays slower in the CASQ2 null and CASQ2(D307H) cells. CASQ2(D307H) myocytes, when rhythmically paced and challenged with isoproterenol, exhibit spontaneous Ca(2+) waves similar to CASQ2 null myocytes; however, the stability of Ca(2+) cycling was increased in the CASQ2(D307H) myocytes. In the presence of isoproterenol, Ca(2+)-transient amplitude in CASQ2(D307H) myocytes was significantly decreased, possibly indicating an inherent defect in Ca(2+) buffering capacity and release from the mutant CASQ2 at high Ca(2+) concentrations. We also observed polymorphic ventricular tachycardia in the CASQ2(D307H) mice, although lesser than in the CASQ2 null mice. These data suggest that CASQ2(D307H) point mutation may affect Ca(2+) buffering capacity and Ca(2+) release. We propose that poor interaction between CASQ2(D307H) and triadin 1 could affect ryanodine receptor 2 stability, thereby increasing susceptibility to delayed afterdepolarizations and triggered arrhythmic activity.

Histidine-rich calcium binding protein: the new regulator of sarcoplasmic reticulum calcium cycling

The histidine-rich calcium binding protein (HRC) is a novel regulator of sarcoplasmic reticulum (SR) Ca(2+)-uptake, storage and release. Residing in the SR lumen, HRC binds Ca(2+) with high capacity but low affinity. In vitro phosphorylation of HRC affects ryanodine affinity of the ryanodine receptor (RyR), suggesting a functional role of HRC on SR Ca(2+)-release. Indeed, acute HRC overexpression in isolated rodent cardiomyocytes decreases Ca(2+)-induced Ca(2+)-release, increases SR Ca(2+)-load, and impairs contractility. The HRC effects on RyR may be regulated by the Ca(2+)-sensitivity of its interaction with triadin. However, HRC also affects the SR Ca(2+)-ATPase, as shown by HRC overexpression in transgenic mouse hearts, which resulted in reduced SR Ca(2+)-uptake rates, cardiac remodeling and hypertrophy. In fact, in vitro generated evidence suggests that HRC directly interacts with SR Ca(2+)-ATPase2, supporting a dual role of HRC in Ca(2+)-homeostasis: regulation of both SR Ca(2+)-uptake and Ca(2+)-release. Furthermore, HRC plays an important role in myocyte differentiation and in antiapoptotic cardioprotection against ischemia/reperfusion induced cardiac injury. Interestingly, HRC has been linked with familiar cardiac conduction disease and an HRC polymorphism was shown to associate with malignant ventricular arrhythmias in the background of idiopathic dilated cardiomyopathy. This review summarizes studies, which have established the critical role of HRC in Ca(2+)-homeostasis, suggesting its importance in cardiac physiology and pathophysiology.

Dysregulated sarcoplasmic reticulum calcium release: potential pharmacological target in cardiac disease

In the heart, Ca(2+) released from the intracellular Ca(2+) storage site, the sarcoplasmic reticulum (SR), is the principal determinant of cardiac contractility. SR Ca(2+) release is controlled by dedicated molecular machinery, composed of the cardiac ryanodine receptor (RyR2) and a number of accessory proteins, including FKBP12.6, calsequestrin (CASQ2), triadin (TRD) and junctin (JN). Acquired and genetic defects in the components of the release channel complex result in a spectrum of abnormal Ca(2+) release phenotypes ranging from arrhythmogenic spontaneous Ca(2+) releases and Ca(2+) alternans to the uniformly diminished systolic Ca(2+) release characteristic of heart failure. In this article, we will present an overview of the structure and molecular components of the SR and Ca(2+) release machinery and its modulation by different intracellular factors, such as Ca(2+) levels inside the SR as well as phosphorylation and redox modification of RyR2s. We will also discuss the relationships between abnormal SR Ca(2+) release and various cardiac disease phenotypes, including, arrhythmias and heart failure, and consider SR Ca(2+) release as a potential therapeutic target.