Calmodulin mutations affecting Gly114 impair binding to the NaV1.5 IQ-domain

Beyond the blueprint: decoding calmodulinopathy-a case report showcasing the utility of multifaceted treatments

Background

Calmodulinopathies are adrenergically-induced life-threatening arrhythmias. Available therapies are disquietingly insufficient, especially for CALM-LQTS (calmodulinopathy-associated long QT syndrome). This case report illustrates a novel mutation in CALM-LQTS and its response to multimodality treatment strategies.

Case summary

The proband was the first child born to a nonconsanguineous Indian couple, a 26-year-old woman and a 30-year-old man. The child was delivered prematurely, and at birth, a functional 2:1 atrioventricular block was noted with sinus bradycardia with a corrected QT by Bazzet's of 716 ms. Clinical exome sequencing of the proband revealed a novel missense variant c.287A>G in exon 5 of the CALM3 gene in a heterozygous state, resulting in an Asp96Gly change. The OMIM phenotype associated with it is long QT syndrome 16 (#618782). Despite receiving a dose of 4.5 mg/kg/day of propranolol, the child still had a persistent long QTc. Mexiletine was started at the trial dose of 1.5 mg/kg/day, and after 1 h, QTc was reduced to 507 ms from 560 ms. After a left-cardiac sympathectomy, he remains asymptomatic after 1.3 years of follow-up with a QTc value of 490 ms.

Discussion

CALM3 pathogenic variants are gain-of-function variants mainly affecting amino acids residing in the Ca2-binding loops. Earlier data suggested the role of the Nav1.5 channel in leading to persistent Na+ leaks resulting in LQTS. However, they only focused on LQTS-CALM1 and CALM2 models and did not include CALM3-related genes. Despite similarities, the precise impact of CaM on Nav1.5 channels still needs to be defined as CaV1.2. The exact role of mexiletine is not fully understood.

Arrhythmogenic calmodulin variants D131E and Q135P disrupt interaction with the L-type voltage-gated Ca2+ channel (Cav1.2) and reduce Ca2+-dependent inactivation

AIM

Long QT syndrome (LQTS) and catecholaminergic polymorphism ventricular tachycardia (CPVT) are inherited cardiac disorders often caused by mutations in ion channels. These arrhythmia syndromes have recently been associated with calmodulin (CaM) variants. Here, we investigate the impact of the arrhythmogenic variants D131E and Q135P on CaM's structure-function relationship. Our study focuses on the L-type calcium channel Cav1.2, a crucial component of the ventricular action potential and excitation-contraction coupling.

METHODS

We used circular dichroism (CD), 1H-15N HSQC NMR, and trypsin digestion to determine the structural and stability properties of CaM variants. The affinity of CaM for Ca2+ and interaction of Ca2+/CaM with Cav1.2 (IQ and NSCaTE domains) were investigated using intrinsic tyrosine fluorescence and isothermal titration calorimetry (ITC), respectively. The effect of CaM variants of Cav1.2 activity was determined using HEK293-Cav1.2 cells (B'SYS) and whole-cell patch-clamp electrophysiology.

RESULTS

Using a combination of protein biophysics and structural biology, we show that the disease-associated mutations D131E and Q135P mutations alter apo/CaM structure and stability. In the Ca2+-bound state, D131E and Q135P exhibited reduced Ca2+ binding affinity, significant structural changes, and altered interaction with Cav1.2 domains (increased affinity for Cav1.2-IQ and decreased affinity for Cav1.2-NSCaTE). We show that the mutations dramatically impair Ca2+-dependent inactivation (CDI) of Cav1.2, which would contribute to abnormal Ca2+ influx, leading to disrupted Ca2+ handling, characteristic of cardiac arrhythmia syndromes.

CONCLUSIONS

These findings provide insights into the molecular mechanisms behind arrhythmia caused by calmodulin mutations, contributing to our understanding of cardiac syndromes at a molecular and cellular level.

Role of Calmodulin in Cardiac Disease: Insights on Genotype and Phenotype

Calmodulin, a protein critically important for the regulation of all major cardiac ion channels, is the quintessential cellular calcium sensor and plays a key role in preserving cardiac electrical stability. Its unique importance is highlighted by the presence of 3 genes in 3 different chromosomes encoding for the same protein and by their extreme conservation. Indeed, all 3 calmodulin (CALM) genes are among the most constrained genes in the human genome, that is, the observed variants are much less than expected by chance. Not surprisingly, CALM variants are poorly tolerated and accompany significant clinical phenotypes, of which the most important are those associated with increased risk for life-threatening arrhythmias. Here, we review the current knowledge about calmodulin, its specific physiological, structural, and functional characteristics, and its importance for cardiovascular disease. Given our role in the development of this knowledge, we also share some of our views about currently unanswered questions, including the rational approaches to the clinical management of the affected patients. Specifically, we present some of the most critical information emerging from the International Calmodulinopathy Registry, which we established 10 years ago. Further progress clearly requires deep phenotypic information on as many carriers as possible through international contributions to the registry, in order to expand our knowledge about Calmodulinopathies and guide clinical management.

10th European Calcium Society symposium: The Ca2+-signaling toolkit in cell function, health and disease

The 10th European Calcium Society symposium, organized in Leuven, Belgium on November 15-17, 2023, focused on the role of Ca2+ signaling in cell function, health and disease. The symposium featured six scientific sessions, 16 invited speakers - of whom two were postdoctoral researchers - and 14 short talks. The talks covered various aspects of intracellular Ca2+ signaling and its implications in pathology. Each session was opened by one or more invited speakers, followed by a series of presentations from speakers selected from submitted abstracts. Through short talks, poster presentations, awards, and sustainable travel fellowships, the symposium also fostered opportunities for the active participation of early-career researchers. At least half of the short talks were allocated to early-career researchers, thereby offering a platform for the presentation of ongoing work and unpublished results. Presentations were also broadcast in real-time for online attendees. In this Meeting Review, we aim to capture the spirit of the meeting and discuss the main take-home messages that emerged during the symposium.

Allosteric changes in protein stability and dynamics as pathogenic mechanism for calmodulin variants not affecting Ca2+ coordinating residues

Mutations in the small, calcium-sensing, protein calmodulin cause cardiac arrhythmia and can ultimately prove lethal. Here, we report the impact of the G113R variant on the structure and dynamics of the calmodulin molecule, both in the presence and in the absence of calcium. We show that the mutation introduces minor changes into the structure of calmodulin and that it changes the thermostability and thus the degree of foldedness at human body temperature. The mutation also severely impacts the intramolecular mobility of calmodulin, especially in the apo form. Glycine 113 acts as an alpha-helical C-capping residue in both apo/ - and Ca2+/calmodulin, but its exchange to arginine has very different effects on the apo and Ca2+ forms. The majority of arrhythmogenic calmodulin variants identified affects residues in the Ca2+ coordinating loops of the two C-domain EF-Hands, causing a 'direct impact on Ca2+ binding'. However, G113R lies outside a Ca2+ coordinating loop and acts differently and more similar to the previously characterized arrhythmogenic N53I. Therefore, we suggest that altered apo/CaM dynamics may be a novel general disease mechanism, defining low-calcium target affinity - or Ca2+ binding kinetics - critical for timely coordination of essential ion-channels in the excitation-contraction cycle.

Arrhythmia-associated calmodulin variants interact with KCNQ1 to confer aberrant membrane trafficking and function

Missense variants in calmodulin (CaM) predispose patients to arrhythmias associated with high mortality rates ("calmodulinopathy"). As CaM regulates many key cardiac ion channels, an understanding of disease mechanism associated with CaM variant arrhythmias requires elucidating individual CaM variant effects on distinct channels. One key CaM regulatory target is the KCNQ1 (KV7.1) voltage-gated potassium channel that carries the IKs current. Yet, relatively little is known as to how CaM variants interact with KCNQ1 or affect its function. Here, we take a multipronged approach employing a live-cell fluorescence resonance energy transfer binding assay, fluorescence trafficking assay, and functional electrophysiology to characterize >10 arrhythmia-associated CaM variants for effect on KCNQ1 CaM binding, membrane trafficking, and channel function. We identify one variant (G114W) that exhibits severely weakened binding to KCNQ1 but find that most other CaM variants interact with similar binding affinity to KCNQ1 when compared with CaM wild-type over physiological Ca2+ ranges. We further identify several CaM variants that affect KCNQ1 and IKs membrane trafficking and/or baseline current activation kinetics, thereby delineating KCNQ1 dysfunction in calmodulinopathy. Lastly, we identify CaM variants with no effect on KCNQ1 function. This study provides extensive functional data that reveal how CaM variants contribute to creating a proarrhythmic substrate by causing abnormal KCNQ1 membrane trafficking and current conduction. We find that CaM variant regulation of KCNQ1 is not uniform with effects varying from benign to significant loss of function, suggesting how CaM variants predispose patients to arrhythmia via the dysregulation of multiple cardiac ion channels. Classification: Biological, Health, and Medical Sciences, Physiology.