Integrated multi-omics mapping of mitochondrial dysfunction and substrate preference in Barth syndrome cardiac tissue.

Loss of tafazzin results in decreased myoblast differentiation in C2C12 cells: A myoblast model of Barth syndrome and cardiolipin deficiency

Barth syndrome (BTHS) is a serious X-linked, metabolic, multisystem disorder characterized by cardiomyopathy, neutropenia, myopathy, and growth delay. Because early diagnosis and appropriate treatment are of key importance for the survival of affected boys, we developed a biochemical BTHS screening method based on analysis of the monolysocardiolipin:cardiolipin ratio in bloodspots. We performed chloroform/methanol extraction on quarter-inch punches of dried bloodspots on Guthrie cards from BTHS patients and controls. Extracts were dried (60 degrees C, N(2)) and reconstituted in CHCl(3)/methanol/H(2)O [50:45:5 vol/vol/vol, 0.1% NH(3) (25%)]. HPLC-tandem mass spectrometry analysis was performed with a normal-phase HPLC column and multiple reaction monitoring transitions for monolysocardiolipin (MLCL) and cardiolipin (CL) with a total run time of 10 min. The ratio of MLCL and CL was used as screening parameter. All BTHS patients (n = 31) had monolysocardiolipin:cardiolipin ratios >0.40 and all controls (n = 215) had monolysocardiolipin:cardiolipin ratios <0.23. Using a cutoff point of 0.30, a blind test of 206 samples (199 controls, 7 BTHS) had sensitivity and specificity of 100%. Bloodspots could be stored at 4 degrees C or room temperature for >1 year without affecting the test outcome. Three neonatal Guthrie cards of BTHS patients taken 3.6 to 5.8 years previously were correctly identified as positive for BTHS. HPLC-tandem mass spectrometry analysis of dried bloodspots is an unambiguous screening test for BTHS with potential for rapid screening of neonates suspected of having BTHS, making remote and retrospective diagnosis accessible for a disease that is almost certainly underdiagnosed.

Molecular Studies of Neutropenia in Barth Syndrome.

Barth syndrome (BTHS) is an X-linked disorder characterised by cardiac and skeletal myopathy, growth delay, neutropenia and 3-methylglutaconic aciduria (3-MGCA). Patients have TAZ gene mutations which affect metabolism of cardiolipin, resulting in low tetralinoleoyl cardiolipin (CL4), an increase in its precursor, monolysocardiolipin (MLCL), and an increased MLCL/CL4 ratio. During development of a diagnostic service for BTHS, leukocyte CL4 was measured in 156 controls and 34 patients with genetically confirmed BTHS. A sub-group of seven subjects from three unrelated families was identified with leukocyte CL4 concentrations within the control range. This had led to initial false negative disease detection in two of these patients. MLCL/CL4 in this subgroup was lower than in other BTHS patients but higher than controls, with no overlap between the groups. TAZ gene mutations in these families are all predicted to be pathological. This report describes the clinical histories of these seven individuals with an atypical phenotype: some features were typical of BTHS (five have had cardiomyopathy, one family has a history of male infant deaths, three have growth delay and five have 3-MGCA) but none has persistent neutropenia, five have excellent exercise tolerance and two adults are asymptomatic. This report also emphasises the importance of measurement of MLCL/CL4 ratio rather than CL4 alone in the biochemical diagnosis of the BTHS.

Barth Syndrome (BTHS) is a rare X‐linked genetic disorder caused by a mutation in the Tafazzin gene (taz), an enzyme involved in the remodelling pathway of cardiolipin (CL). Mutation in taz results in a biochemical deficiency of CL and accumulation of monolysocardiolipin (MLCL). We investigated the contribution of another enzyme, monolysocardiolipin acyltransferase‐1 (MLCL AT‐1), to the remodelling pathway of CL in human lymphoblasts. MLCL AT‐1 or taz or both were knocked down using RNAi in normal or BTHS lymphoblasts and MLCL AT‐1 enzyme activity examined. MLCL AT‐1 enzyme activity was reduced approximately 50% (p&lt;0.05) when MLCL AT‐1 was knocked down in normal human lymphoblasts and unaltered when taz was knocked down. Knock down of both MLCL AT‐1 and taz simultaneously did not result in a further reduction in MLCL AT‐1 activity compared to knock down of MLCL AT‐1 alone. Expression of MLCL AT‐1 in BTHS lymphoblasts with different mutations in taz elevated CL synthesis and mass over 2‐fold (p&lt;0.05) in these cells compared to controls. These studies indicate that MLCL AT‐1 may act independently of taz. This work was supported by grants from the Manitoba Health Research Council and the Barth Syndrome Foundation (USA &amp; Canada).

Barth syndrome (BTHS) is a rare, X-linked recessive, infantile-onset debilitating disorder characterized by early-onset cardiomyopathy, skeletal muscle myopathy, growth delay, and neutropenia, with a worldwide incidence of 1/300,000–400,000 live births. The high mortality rate throughout infancy in BTHS patients is related primarily to progressive cardiomyopathy and a weakened immune system. BTHS is caused by defects in the TAZ gene that encodes tafazzin, a transacylase responsible for the remodeling and maturation of the mitochondrial phospholipid cardiolipin (CL), which is critical to normal mitochondrial structure and function (i.e., ATP generation). A deficiency in tafazzin results in up to a 95% reduction in levels of structurally mature CL. Because the heart is the most metabolically active organ in the body, with the highest mitochondrial content of any tissue, mitochondrial dysfunction plays a key role in the development of heart failure in patients with BTHS. Changes in mitochondrial oxidative phosphorylation reduce the ability of mitochondria to meet the ATP demands of the human heart as well as skeletal muscle, namely ATP synthesis does not match the rate of ATP consumption. The presence of several cardiomyopathic phenotypes have been described in BTHS, including dilated cardiomyopathy, left ventricular noncompaction, either alone or in conjunction with other cardiomyopathic phenotypes, endocardial fibroelastosis, hypertrophic cardiomyopathy, and an apical form of hypertrophic cardiomyopathy, among others, all of which can be directly attributed to the lack of CL synthesis, remodeling, and maturation with subsequent mitochondrial dysfunction. Several mechanisms by which these cardiomyopathic phenotypes exist have been proposed, thereby identifying potential targets for treatment. Dysfunction of the sarcoplasmic reticulum Ca2+-ATPase pump and inflammation potentially triggered by circulating mitochondrial components have been identified. Currently, treatment modalities are aimed at addressing symptomatology of HF in BTHS, but do not address the underlying pathology. One novel therapeutic approach includes elamipretide, which crosses the mitochondrial outer membrane to localize to the inner membrane where it associates with cardiolipin to enhance ATP synthesis in several organs, including the heart. Encouraging clinical results of the use of elamipretide in treating patients with BTHS support the potential use of this drug for management of this rare disease.

Barth syndrome (BTHS) is an X-linked recessive disease where patients most commonly die from cardiomyopathy-induced heart failure before middle age. BTHS is caused by mutations in the tafazzin (TAZ) gene, resulting in defective TAZ protein. TAZ is an enzyme that generates mature cardiolipin (CL) from monolysocardiolipin (MLCL) in the mitochondrial membrane, a reaction essential for normal mitochondrial function. Current therapies can only treat the symptoms of BTHS. In this study, we propose an enzyme replacement therapy for BTHS which utilizes recombinant human TAZ fused to a cell penetrating peptide (hTAZ-CTP) to facilitate tissue uptake. The efficacy of this protein was tested in vitro on C2C12 TAZ-knockout (TAZ-KO) skeletal myoblasts and in vivo on a myocardial-specific TAZ conditional knockout mouse, modelling the cardiomyopathy associated with BTHS. In vitro tests of TAZ-KO cells, using oxygen consumption rate as a measure of mitochondrial activity, showed treatment of the cells with hTAZ-CTP effected a partial rescue of the fatty acid oxidation capabilities of the TAZ-KO cells. In vivo tests showed that BTHS mice display increasing septal wall thickness over time, an effect halted upon treatment with hTAZ-CTP. Pressure-volume (PV) loop analysis indicated that heart function, impaired in the vehicle-treated BTHS mouse, was similar between treated mice and normal mice. The ratio of MLCL/CL, a direct measure of TAZ enzymatic activity, was measured in heart mitochondria isolated from BTHS and control mice after treatment. The vehicle treated BTHS mouse showed the high MLCL/CL ratio typical of BTHS patients, whereas the MLCL/CL ratios in protein-treated mice matched the much lower ratio of the control mice. Similarly, oxygen consumption rate measurements of these isolated heart mitochondria demonstrated partial rescue by hTAZ-CTP treatment. Coupled with the lack of toxicity observed in the liver, spleen, kidney, and heart due to hTAZ-CTP injection, these results indicate that TAZ enzyme replacement therapy has great potential as a future treatment for BTHS.

The energy demands of the adult mammalian heart are met largely by ATP generated via oxidation of fatty acids in a high capacity mitochondrial system. Peroxisome proliferator-activated receptor γ coactivator 1 (PGC-1)-α and -β serve as inducible transcriptional coregulators of genes involved in mitochondrial biogenesis and metabolism. Whether PGC-1 plays a role in the regulation of mitochondrial structure is unknown. In this study, mice with combined deficiency of PGC-1α and PGC-1β (PGC-1αβ(-/-)) in adult heart were analyzed. PGC-1αβ(-/-) hearts exhibited a distinctive mitochondrial cristae-stacking abnormality suggestive of a phospholipid abnormality as has been described in humans with genetic defects in cardiolipin (CL) synthesis (Barth syndrome). A subset of molecular species, containing n-3 polyunsaturated species in the CL, phosphatidylcholine, and phosphatidylethanolamine profiles, was reduced in PGC-1αβ-deficient hearts. Gene expression profiling of PGC-1αβ(-/-) hearts revealed reduced expression of the gene encoding CDP-diacylglycerol synthase 1 (Cds1), an enzyme that catalyzes the proximal step in CL biosynthesis. Cds1 gene promoter-reporter cotransfection experiments and chromatin immunoprecipitation studies demonstrated that PGC-1α coregulates estrogen-related receptors to activate the transcription of the Cds1 gene. We conclude that the PGC-1/estrogen-related receptor axis coordinately regulates metabolic and membrane structural programs relevant to the maintenance of high capacity mitochondrial function in heart.

Cardiolipin deficiency affects respiratory chain function and organization in an induced pluripotent stem cell model of Barth syndrome

Barth syndrome is an X‐linked disorder characterized by cardiomyopathy, skeletal myopathy, and neutropenia, caused by deleterious variants in TAFAZZIN. This gene encodes a phospholipid‐lysophospholipid transacylase that is required for the remodeling of the mitochondrial phospholipid cardiolipin (CL). Biochemically, individuals with Barth syndrome have a deficiency of mature CL and accumulation of the remodeling intermediate monolysocardiolipin (MLCL). Diagnosis typically relies on mass spectrometric measurement of CL and MLCL in cells or tissues, and we previously described a method in blood spot that uses a specific MLCL/CL ratio as diagnostic biomarker. Here, we describe the evolution of our blood spot assay that is based on the implementation of reversed phase‐UHPLC separation followed by full scan high resolution mass spectrometry. In addition to the MLCL/CL ratio, our improved method also generates a complete CL spectrum allowing the interrogation of the CL fatty acid composition, which considerably enhances the diagnostic reliability. This addition negates the need for a confirmatory test in lymphocytes thereby providing a shorter turn‐around‐time while achieving a more certain test result. As one of the few laboratories that offer this assay, we also evaluated the diagnostic yield and performance from 2006 to 2021 encompassing the use of both the original and improved assay. In this period, we performed 796 diagnostic analyses of which 117 (15%) were characteristic of Barth syndrome. In total, we diagnosed 93 unique individuals with Barth syndrome, including three females, which together amounts to about 40% of all reported individuals with Barth syndrome in the world.

Loss of Tafazzin (TAZ) Function and Accelerated Apoptosis of Human Bone Marrow Stem and Myeloid Progenitors in Barth Syndrome.

Barth syndrome (BTHS) is a rare X-linked disorder that is characterized by cardiac and skeletal myopathy, neutropenia and growth abnormalities. The disease is caused by mutations in the tafazzin (TAZ) gene encoding an enzyme involved in the acyl chain remodeling of the mitochondrial phospholipid cardiolipin (CL). Biochemically, this leads to decreased levels of mature CL and accumulation of the intermediate monolysocardiolipin (MLCL). At a cellular level, this causes mitochondrial fragmentation and reduced stability of the respiratory chain supercomplexes. However, the exact mechanism through which tafazzin deficiency leads to disease development remains unclear. We therefore aimed to elucidate the pathways affected in BTHS cells by employing proteomic and metabolic profiling assays. Complexome profiling of patient skin fibroblasts revealed significant effects for about 200 different mitochondrial proteins. Prominently, we found a specific destabilization of higher order oxidative phosphorylation (OXPHOS) supercomplexes, as well as changes in complexes involved in cristae organization and CL trafficking. Moreover, the key metabolic complexes 2-oxoglutarate dehydrogenase (OGDH) and branched-chain ketoacid dehydrogenase (BCKD) were profoundly destabilized in BTHS patient samples. Surprisingly, metabolic flux distribution assays using stable isotope tracer-based metabolomics did not show reduced flux through the TCA cycle. Overall, insights from analyzing the impact of TAZ mutations on the mitochondrial complexome provided a better understanding of the resulting functional and structural consequences and thus the pathological mechanisms leading to Barth syndrome.

Phospholipid abnormalities in children with Barth syndrome

Background: Barth syndrome (BTHS) is a disorder caused by mutations in the TAFAZZIN gene, which disrupts cardiolipin (CL) metabolism and leads to cardiac and skeletal myopathy, neutropenia, and 3-methylglutaconic aciduria. Altered CL impairs mitochondrial function, contributing to symptoms of BTHS. Despite extensive research, the molecular mechanisms underlying BTHS remain unclear, and no cure exists. Mitochondrial protein quality control (MPQC) is crucial for maintaining mitochondrial homeostasis, yet its role in BTHS is underexplored. Our preliminary data indicate elevated levels of Caseinolytic peptidase B (CLPB), a mitochondrial chaperonin localized in the intermembrane space (IMS) with disaggregase activity, in BTHS patient-derived cells, and Tafazzin-deficient BTHS mice. Hypothesis: Our data-driven hypothesis proposes that CLPB regulates the quality control of IMS proteins, mitochondrial function, and bioenergetics to support cardiac health. However, this adaptive response becomes maladaptive during BTHS pathology. Aim: We aim to understand CLPB’s function in BTHS and explore its potential as a therapeutic target. Methods: We generated CLPB knockouts in both control and Tafazzin -/- C2C12 cells, as well as a CLPB knockdown mouse model in Tafazzin fl/fl (control) and Tafazzin fl/fl x aMHC-Cre. Using cellular, molecular, and physiological approaches, we evaluated CLPB’s impact on mitochondrial homeostasis and its therapeutic potential in BTHS. Results: CLPB loss improves NADH and calcium retention capacity without affecting mitochondrial respiration rate&amp;membrane potential, ATP, and mtDNA content in Tafazzin -/- -Clpb -/- compared to control, Clpb -/- and Tafazzin -/- C2C12 cells. To explore the underlying mechanisms behind changes in the metabolic state of Tafazzin -/- -Clpb -/- cells, we analyzed transcripts of CL regulators (ALCLAT1 and CLS1), mitochondrial biogenesis (PGC1a, Tfam, and NRF1/2), and mtUPR (ATF4/5, HSP70, CHOP, and SOD2) markers. The Tafazzin -/- -Clpb -/- activate mitochondrial biogenesis and CL synthesis by elevating PGC1a and CLS1 transcripts, while their mtUPR transcript profile is comparable to control cells. Furthermore, echocardiographic analysis shows restoration of ejection fraction in CLPB KD and Tafazzin fl/fl x aMHC-Cre -CLPB KD mice. Conclusion: These findings highlight CLPB’s crucial role in IMS proteins quality control and mitochondrial homeostasis, providing a basis for new therapeutic avenues against mitochondrial dysfunction in BTHS.

Barth syndrome (BTHS) is an X-linked autosomal recessive disease caused by mutations in the tafazzin (TAZ) gene. These mutations lead to hypotonia, cyclic neutropenia, 3-methyglutaconic aciduria, and the most common cause of mortality in patients, cardiomyopathy. The TAZ gene encodes an enzyme that generates mature cardiolipin (CL) from monolysocardiolipin (MLCL)in the mitochondrial membrane, which is essential for normal mitochondrial morphology and function. Currently, there is no effective therapy for BTHS. In this study, we test an enzyme replacement therapy for BTHS in myocardial-specific TAZ conditional knockout mice which model the cardiomyopathy of BTHS. Serial echocardiograms showed that the BTHS mice developed increased septal wall thickness at 5 weeks of age. The BTHS mice were treated for 12 weeks with either vehicle or recombinant human TAZ fused to a cell penetrating peptide (hTAZ-CTP) to facilitate tissue uptake. During the treatment period, septal wall thickness in the vehicle-treated mouse continued to increase, whereas it remained stable in those treated with hTAZ-CTP . Pressure-volume (PV) loop analysis indicated that heart function was impaired in the vehicle-treated BTHS mouse while the protein-treated mice were shown to have PV loops similar to normal mice. The ratio of MLCL/CL, a direct measure of TAZ enzymatic activity, was measured in heart mitochondria isolated from BTHS and control floxed allele mice after treatment. The MLCL/CL ratio in the vehicle treated BTHS mouse was 20.4, consistent with a BTHS phenotype, whereas the MLCL/CL ratios in protein-treated and control mice were 0.01, indicating that injection of hTAZ-CTP successfully rescued the function of TAZ in BTHS mice. Histological observation of liver, spleen, kidney, and heart did not show any sign of toxicity for hTAZ-CTP injection. These results indicate that TAZ enzyme replacement therapy has great potential as a future treatment for BTHS.