Mutations In Sarcomeric Proteins Research Articles

Burst-like transcription of MYH7, allelic and contractile imbalance already in early stage hiPSC-cardiomyocytes indicate these as pathogenic factors in Hypertrophic Cardiomyopathy

Abstract Background Hypertrophic Cardiomyopathy (HCM) is caused by heterozygous mutations in sarcomeric proteins, which can cause hyper- or hypocontractiliy of cardiomyocytes. Previously we also observed highly variable force generation (contractile imbalance) among individual cardiomyocytes of HCM-patients with myosin (MYH7) or myosin-binding-protein-C mutations (MYBPC3), ranging from normal to highly altered values. Contractile imbalance is presumably caused by stochastic, burst-like transcription of mutant and wildtype allele, which induces unequal ratios of mutant vs. wildtype mRNA among individual cardiomyocytes. Variable force generation most likely is the result of also unequal fractions of mutated protein from cell to cell. Aim With this study we aimed to examine whether in addition to the effects of the mutation on sarcomere function, also allelic and contractile imbalance already exist at the beginning of disease development or whether both result from disease-related alterations in symptomatic HCM-patients. Methods and Results We studied this in patient-derived human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) with MYH7-mutation R723G as model for an early disease stage. These early, fetal-like cardiomyocytes developed typical HCM-related features like hypertrophy and increased myofibrillar disarray compared to WT-hiPSC-CMs. Calcium sensitivity was reduced, twitch kinetics were slowed down. To test whether MYH7 in these early-stage hiPSC-CMs also is transcribed in bursts or continuously, we performed RNA-fluorescence in situ hybridization (RNA-FISH). Nuclei without, with one and with two or more active transcription sites were observed which indicates stochastic, burst-like and independent transcription of the two MYH7-alleles. Ratios of mRNA from both alleles were quantified in individual cardiomyocytes by allele-specific single cell RT-PCR. We found highly variable ratios of mutated vs. wildtype mRNA among individual cardiomyocytes, similar to HCM-patient’s cardiac tissue, indicating unequal expression of mutant and wildtype mRNA from cell-to-cell. Furthermore, functional measurements on myofibrils from R723G-hiPSC-CMs revealed substantial variability in force generation at physiological calcium, compared to much smaller heterogeneity among WT-hiPSC-CMs. In addition, variability of twitch kinetics of intact hiPSC-CMs was also substantially increased among R723G- compared to WT-hiPSC-CMs. Altogether, this suggests that functional heterogeneity results from burst-like transcription in heterozygous HCM cardiomyocytes. Conclusions Our results in HCM-patient derived hiPSC-cardiomyocytes with a fetal-like developmental stage suggest that allelic and contractile imbalance among individual cardiomyocytes together with the mutation are present at the beginning of the disease. Thus, they most likely are exacerbating factors that contribute development of HCM hallmarks.

Advancements in the Diagnosis and Treatment of Hypertrophic Cardiomyopathy: A Comprehensive Review.

Hypertrophic cardiomyopathy (HCM) is characterized by excessive growth of myocardial tissue, most commonly due to genetic mutations in sarcomere proteins. This can lead to complications such as heart failure, mitral regurgitation, syncope, arrhythmias, sudden cardiac death, and myocardial ischemia. While we have come a long way in our understanding of the pathophysiology, genetics, and epidemiology of HCM, the past 10 years have seen significant advancements in diagnosis and treatment. As the body of evidence on hypertrophic cardiomyopathy continues to grow, a comprehensive review of the current literature is an invaluable resource in organizing this knowledge. By doing so, the vast progress that has been made thus far will be widely available to all experts in the field. This review provides a comprehensive analysis of the scientific literature, exploring both well-established and cutting-edge diagnostic and therapeutic options. It also presents a unique perspective by incorporating topics such as exercise testing, genetic testing, radiofrequency ablation, risk stratification, and symptomatic management in non-obstructive HCM. Lastly, this review highlights areas where current and future research is at the forefront of innovation in hypertrophic cardiomyopathy.

Genetic Basis of Hypertrophic Cardiomyopathy in Cats.

Hypertrophic cardiomyopathy (HCM) is a common cardiovascular condition in cats, affecting yth males and females of all ages. Some breeds, such as Ragdolls and Maine Coons, can develop HCM at a young age. The disease has a wide range of progression and severity, characterized by various pathological changes in the heart, including arteritis, fibrous tissue deposition, and myocardial cell hypertrophy. Left ventricular hypertrophy, which can restrict blood flow, is a common feature of HCM. The disease may persist into old age and eventually lead to heart failure and increased diastolic pressure. The basis of HCM in cats is thought to be genetic, although the exact mechanisms are not fully understood. Mutations in sarcomeric proteins, in particular myosin-binding protein C (MYBPC3), have been identified in cats with HCM. Two specific mutations, MYBPC3 [R818W] and MYBPC3 [A31P], have been classified as 'pathogenic'. Other variants in genes such as MYBPC3, TNNT2, ALMS1, and MYH7 are also associated with HCM. However, there are cases where cats without known genetic mutations still develop HCM, suggesting the presence of unknown genetic factors contributing to the disease. This work aims to summarise the new knowledge of HCM in cats and the alterations in cardiac tissue as a result of genetic variants.

Abstract Mo098: LMNA R190W Mutation Associated With Dilated Cardiomyopathy Causes Hypercontractility in iPSC-derived Cardiomyocytes and Engineered Heart Muscles

Familial dilated cardiomyopathy (DCM) caused by mutations in sarcomeric proteins have been extensively studied in vitro , however less is known about DCM caused by alterations in non-sarcomeric genes like Lamin A (LMNA). LMNA is a ubiquitously expressed nuclear intermediate filament protein that regulates nuclear structure, chromatin access and gene expression. LMNA mutations account for 6% of DCM, and affected patients develop drug-therapy resistant severe heart failure and lethal arrythmias that are not amenable to currently available therapies. Most identified LMNA-cardiomyopathy mutations have been associated with severely depressed cardiac systolic function in patients and cardiomyocyte hypocontractility in vitro . However, the underlying mechanisms are incompletely understood. This project examines the mechanisms by which a patient-derived pathogenic mutation, LMNA R190W, leads to cardiac dysfunction at the cellular and tissue levels. We hypothesize that LMNA R190W mutation causes dysregulated expression of calcium handling genes, eventually leading to altered contractility. First, we investigated early disease pathogenesis using iPSC-derived cardiomyocytes. Intriguingly, single cardiomyocyte traction force microscopy studies showed cardiomyocyte hypercontractility, and calcium flux assays revealed prolonged calcium transients. Second, in human engineered heart muscle tissues, LMNA CMs were also consistently hypercontractile. Through gene expression studies, we identified upregulation of a cardiac-specific sarcomeric calcium regulator, calsequestrin 2 (CASQ2), which modulates intracellular calcium availability and localization, and thereby indirectly impacts calcium-dependent contraction and electrophysiology. siRNA-mediated knockdown of CASQ2 in iPSC-CMs decreased cellular calcium content, suggesting Casq2 is necessary for increased calcium and contractility in LMNA R190W cells. These findings suggest that in the initial stages of LMNA R190W-associated cardiomyopathy, cardiomyocyte contractility is not diminished, but actually augmented, and this may be related to aberrant calcium handling. We posit that chronic inappropriate calcium overload may eventually lead to cell death, and predispose to cardiomyopathy. Understanding the initial processes driving the development of LMNA cardiomyopathy will inform more accurate mechanism-based subclassification of mutations, and the rational development of precision therapies.

Mechanisms of a novel regulatory light chain-dependent cardiac myosin inhibitor.

Hypertrophic cardiomyopathy (HCM) is a genetic disease of the heart characterized by thickening of the left ventricle (LV), hypercontractility, and impaired relaxation. HCM is caused primarily by heritable mutations in sarcomeric proteins, such as β myosin heavy chain. Until recently, medications in clinical use for HCM did not directly target the underlying contractile changes in the sarcomere. Here, we investigate a novel small molecule, RLC-1, identified in a bovine cardiac myofibril high-throughput screen. RLC-1 is highly dependent on the presence of a regulatory light chain to bind to cardiac myosin and modulate its ATPase activity. In demembranated rat LV trabeculae, RLC-1 decreased maximal Ca2+-activated force and Ca2+ sensitivity of force, while it increased the submaximal rate constant for tension redevelopment. In myofibrils isolated from rat LV, both maximal and submaximal Ca2+-activated force are reduced by nearly 50%. Additionally, the fast and slow phases of relaxation were approximately twice as fast as DMSO controls, and the duration of the slow phase was shorter. Structurally, x-ray diffraction studies showed that RLC-1 moved myosin heads away from the thick filament backbone and decreased the order of myosin heads, which is different from other myosin inhibitors. In intact trabeculae and isolated cardiomyocytes, RLC-1 treatment resulted in decreased peak twitch magnitude and faster activation and relaxation kinetics. In conclusion, RLC-1 accelerated kinetics and decreased force production in the demembranated tissue, intact tissue, and intact whole cells, resulting in a smaller cardiac twitch, which could improve the underlying contractile changes associated with HCM.

Modeling cardiomyocyte signaling and metabolism predicts genotype-to-phenotype mechanisms in hypertrophic cardiomyopathy

Familial hypertrophic cardiomyopathy (HCM) is a significant precursor of heart failure and sudden cardiac death, primarily caused by mutations in sarcomeric and structural proteins. Despite the extensive research on the HCM genotype, the complex and context-specific nature of many signaling and metabolic pathways linking the HCM genotype to phenotype has hindered therapeutic advancements for patients. Here, we have developed a computational model of HCM encompassing cardiomyocyte signaling and metabolic networks and their associated interactions. Utilizing a stochastic logic-based ODE approach, we linked cardiomyocyte signaling to the metabolic network through a gene regulatory network and post-translational modifications. We validated the model against published data on activities of signaling species in the HCM context and transcriptomes of two HCM mouse models (i.e., R403Q-αMyHC and R92W-TnT). Our model predicts that HCM mutation induces changes in metabolic functions such as ATP synthase deficiency and a transition from fatty acids to carbohydrate metabolism. The model indicated major shifts in glutamine-related metabolism and increased apoptosis after HCM-induced ATP synthase deficiency. We predicted that the transcription factors STAT, SRF, GATA4, TP53, and FoxO are the key regulators of cardiomyocyte hypertrophy and apoptosis in HCM in alignment with experiments. Moreover, we identified shared (e.g., activation of PGC1α by AMPK, and FHL1 by titin) and context-specific mechanisms (e.g., regulation of Ca2+ sensitivity by titin in HCM patients) that may control genotype-to-phenotype transition in HCM across different species or mutations. We also predicted potential combination drug targets for HCM (e.g., mavacamten plus ROS inhibitors) preventing or reversing HCM phenotype (i.e., hypertrophic growth, apoptosis, and metabolic remodeling) in cardiomyocytes. This study provides new insights into mechanisms linking genotype to phenotype in familial hypertrophic cardiomyopathy and offers a framework for assessing new treatments and exploring variations in HCM experimental models.

An In Silico Cardiomyocyte Reveals the Impact of Changes in CaMKII Signalling on Cardiomyocyte Contraction Kinetics in Hypertrophic Cardiomyopathy.

Hypertrophic cardiomyopathy (HCM) is characterised by asymmetric left ventricular hypertrophy, ventricular arrhythmias, and cardiomyocyte dysfunction that may cause sudden death. HCM is associated with mutations in sarcomeric proteins and is usually transmitted as an autosomal-dominant trait. The aim of this in silico study was to assess the mechanisms that underlie the altered electrophysiological activity, contractility, regulation of energy metabolism, and crossbridge cycling in HCM at the single-cell level. To investigate this, we developed a human ventricular cardiomyocyte model that incorporates electrophysiology, metabolism, and force generation. The model was validated by its ability to reproduce the experimentally observed kinetic properties of human HCM induced by (a) remodelling of several ion channels and Ca2+-handling proteins arising from altered Ca2+/calmodulin kinase II signalling pathways and (b) increased Ca2+ sensitivity of the myofilament proteins. Our simulation showed a decreased phosphocreatine-to-ATP ratio (-9%) suggesting a negative mismatch between energy expenditure and supply. Using a spatial myofilament half-sarcomere model, we also compared the fraction of detached, weakly bound, and strongly bound crossbridges in the control and HCM conditions. Our simulations showed that HCM has more crossbridges in force-producing states than in the control condition. In conclusion, our model reveals that impaired crossbridge kinetics is accompanied by a negative mismatch between the ATP supply and demand ratio. This suggests that improving this ratio may reduce the incidence of sudden death in HCM.

Sarcomere level mechanics of the fast skeletal muscle of the medaka fish larva.

The medaka fish (Oryzias latipes) is a vertebrate model used in developmental biology and genetics. Here we explore its suitability as a model for investigating the molecular mechanisms of human myopathies caused by mutations in sarcomeric proteins. To this end, the relevant mechanical parameters of the intact skeletal muscle of wild-type medaka are determined using the transparent tail at larval stage 40. Tails were mounted at sarcomere length of 2.1 μm in a thermoregulated trough containing physiological solution. Tetanic contractions were elicited at physiological temperature (10°C-30°C) by electrical stimulation, and sarcomere length changes were recorded with nanometer-microsecond resolution during both isometric and isotonic contractions with a striation follower. The force output has been normalized for the actual fraction of the cross section of the tail occupied by the myofilament lattice, as established with transmission electron microscopy (TEM), and then for the actual density of myofilaments, as established with X-ray diffraction. Under these conditions, the mechanical performance of the contracting muscle of the wild-type larva can be defined at the level of the half-thick filament, where ∼300 myosin motors work in parallel as a collective motor, allowing a detailed comparison with the established performance of the skeletal muscle of different vertebrates. The results of this study point out that the medaka fish larva is a suitable model for the investigation of the genotype/phenotype correlations and therapeutic possibilities in skeletal muscle diseases caused by mutations in sarcomeric proteins.NEW & NOTEWORTHY The suitability of the medaka fish as a model for investigating the molecular mechanisms of human myopathies caused by mutations of sarcomeric proteins is tested by combining structural analysis and sarcomere-level mechanics of the skeletal muscle of the tail of medaka larva. The mechanical performance of the medaka muscle, scaled at the level of the myosin-containing thick filament, together with its reduced genome duplication makes this model unique for investigations of the genotype/phenotype correlations in human myopathies.

Influence of sarcomeric protein mutations on myocardial function in a 3D-disease model of human iPSC-derived bioartificial cardiac tissue

Abstract Background Peripartum cardiomyopathy (PPCM) is a rare type of cardiomyopathy that occurs in women without prior history of heart disease at later stages of pregnancy or several months after childbirth (1). The disease is characterized by lowered left ventricular ejection fraction (LVEF<45%) and can lead to heart failure if left untreated (1). Approximately 20% of PPCM patients harbor sarcomeric mutations, from which titin truncating variants (TTNtv-s) have the highest pathogenic potential (2). However, the role of such genetic defects of the contractile apparatus on PPCM pathogenesis is not well understood. Purpose The study aims to establish an in vitro 3D disease model of PPCM to elucidate the role of sarcomeric mutations, including titin mutations, in its etiology. We hypothesize, that the disease phenotype can be uncovered in vitro via the stimulation of PPCM patient-derived Bioartificial Cardiac Tissues (BCTs), utilizing pregnancy-related factors in our custom-made bioreactors (3). Methods We selected three patients carrying previously unstudied mutations in the TTN gene for the study. The iPSC reprogramming was performed using a commercial, Sendai virus-based kit. Pluripotency was confirmed via flow cytometry and immunofluorescence stainings. The presence of mutations was confirmed by exome sequencing. Cardiomyocyte differentiation (4) and BCT generation (3) were carried out via established protocols. Following maturation, BCTs were stimulated with the pregnancy-related factors, and tissue forces were measured in the bioreactors. These forces include intrinsically generated (spontaneous) and electrically induced (paced) contraction forces (mN), as well as passive forces, which correlate with tissue stiffness. Results We successfully generated two clonal induced pluripotent stem cell (iPSC) lines from each patient. We confirmed that all of the cell lines were >90% positive for pluripotency markers. After differentiation, CMs contracted spontaneously from day 7 onwards and were >95% positive for cardiac markers (SA, MF20, cTnT). The BCTs remodeled and started contracting on days 1-2 after generation, similarly to wild-type tissues in the baseline conditions. Prolactin treatment of Patient A, harboring a missense mutation in titin, did not show significant functional effects. We confirmed, that patients B and C harbor TTNtvs, and tissues from these patients show a trend of altered stiffness after stimulation with repeated mechanical stretch cycles or β-adrenergic agonist isoprenaline. Further analysis of the underlying mechanisms investigating metabolic changes, signaling pathways, and transcriptomics are ongoing. Conclusion The established iPSC and tissue engineering technologies offer a valuable tool for the development of an iPS-CM-based 3D in vitro disease model for PPCM, which can be used for risk stratification of individual and combined sarcomeric mutations and the development of tailored therapeutic strategies.

P21-Activated Kinases Present a New Drug Target for Hypertrophic Cardiomyopathy

Expert review p21-Activated Kinases Present a New Drug Target for Hypertrophic Cardiomyopathy He Yu , and Lei Ming , * Department of Pharmacology, University of Oxford, Mansfield Road, Oxford, OX1 3QT, UK * Correspondence: ming.lei@pharm.ox.ac.uk Received: 17 February 2023 Accepted: 26 March 2023 Published: 21 August 2023 Abstract: Hypertrophic cardiomyopathy (HCM), primarily involving mutations in sarcomeric proteins, is the most common form of inherited heart disease and a leading cause of sudden death in young adults and athletes. HCM patients present with cardiac hypertrophy, fibrosis, and diastolic dysfunction often in a progressive manner. Despite significant progress made in understanding the molecular genetic basis of HCM, there remains a lack of effective and specific treatment for preventing disease progression in HCM. This article first provides an overview of recent progress in understanding the pathogenic basis of disease progression in HCM, in particular dysfunctional calcium handling, mitochondrial impairment, and endoplasmic reticulum stress. This article then analyses the evidence for critical roles of the multifunctional enzymes P21-activated kinase-1 and 2 (Pak1/2) in the heart and our opinion on their therapeutic value as a promising druggable target in pathological hypertrophy and associated ventricular arrhythmias.

Abstract P3123: Sex-related Differences In Cardiac Biomarkers And Ventricular Fibrosis In A Minipig Model Of Hypertrophic Cardiomyopathy

Hypertrophic Cardiomyopathy (HCM) is characterized by ventricular hypertrophy and stiffness resulting in part from interstitial fibrosis. While associated with autosomal dominant mutations in sarcomere proteins, it has been reported that males and females may have different clinical presentations and disease courses. We have previously shown that minipigs carrying the R403Q mutation in MYH7 demonstrate a phenotype that recapitulates human non-obstructive HCM with increased hypertrophy, markers of cardiac stress, and diastolic dysfunction. Under the hypothesis that sex-dependent differences in cardiac physiology can independently modulate disease phenotype, we evaluated ventricular fibrosis and cardiac biomarkers in both male and female mutant pigs. Purpose-bred Yucatan R403Q MYH7 heterozygous mutant minipigs of either sex (M: n=8, F: n=6) and wild-type littermates (M: n=4, F: n=14) were used; for the purposes of these comparisons, cloned male pigs were also included (R403Q: 8). Males were castrated, and all pigs received soybean-based feed. Circulating levels of both cardiac troponin T (cTnT) and brain natriuretic peptide (BNP), markers of cardiac injury and stress, were assessed. Interstitial fibrosis was assessed in left ventricular free wall (LV-FW) and apical tissue samples utilizing picrosirius red staining and semi-automated quantification (HALO). Male HCM pigs died earlier (<9M of age, P<0.05) and had higher serum biomarkers than females (cTnT levels (M: 143±17 vs F: 44±7 ng/L, P<0.05; BNP 1536±335 vs 4881±414 ng/L, P<0.05) Consistent with the higher cTnT levels, male HCM pigs had greater fibrosis areas than females in both LV-FW (11±3% vs 7±2%, P<0.05) and apical regions (13±1% vs. 8±2%, respectively, P<0.05). All HCM pigs had significantly increased fibrotic area vs WT controls (R403Q: 10±3% vs WT: 3±2%, P<0.05). Our findings demonstrate that despite a common genotype, female and male carriers of the HCM pathogenic R403Q mutation present different disease phenotypes, with castrated males showing greater fibrotic burden. Future studies to understand the mechanistic drivers of these differences should not only help elucidate the role of sex in HCM disease progression, but also the development of sex-informed therapies.

PO-01-158 MODELING AN ATRIAL FIBRILLATION-CAUSING TITIN MUTATION USING HUMAN IPSC-DERIVED ATRIAL CARDIOMYOCYTES

Atrial fibrillation (AF) affects more than 33 million people worldwide and, if left untreated, can lead to increased morbidity and mortality. Although AF has been classified as an ‘ion channelopathy’, next-generation sequencing has identified mutations in sarcomeric proteins like TTN, the gene encoding titin, that are associated with AF. Despite progress in understanding the genetic basis of AF, the translation of these discoveries to the bedside care of patients has been limited due to challenges in understanding the myocardial substrate for AF, especially that develops from the mutation in the structural protein. As human atrial tissue is rarely available and animal models are mechanistically limited, our goal is to model AF using mature human induced pluripotent stem cell-derived atrial cardiomyocytes (hiPSC-aCMs) by a CRISPR-Cas9-mediated single amino acid substitution of a rare missense ethnic-specific mutation (TTN_T32756I) in an immunoglobulin (Ig)-like domain of the A-band of titin that is enriched in AF-causing pathogenic variants. Isogenic TTN_T32756I hiPSC-aCM mutants were generated using the CRISPR-Cas9 technique. Cells were matured either with metabolic conditioning or co-culturing with atrial fibroblasts in a micropatterned platform. We used confocal microscopy to assess sarcomeric integrity, MuscleMotion to assess contractility, and optical voltage mapping to assess the electrophysiological properties of TTN_T32756I hiPSC-aCMs. T32756I results in a non-conservative amino acid change, which in-silico tools have previously predicted results in an impairment in titin function. Here, we show that TTN_T32756I hiPSC-aCM mutants display aberrant contractility (Fig. 1A-C) and Ca2+ homeostasis (Fig. 1D) leading to abnormal electrophysiology (Fig. 1E-F) at the cellular level without compromising the sarcomeric integrity of the atrial cardiomyocytes (Fig. 1G-H). Our results suggest that a single amino acid change could have a profound effect on titin function, further establishing titin as a major signaling hub for contractility. Ongoing studies will not only identify the key pathways and transcription factors involved in the pathogenesis of TTN_ T32756I mutant but also uncover the impact of the mutation on atrial action potential and cardiac ion channel activity. Our study will shed new light on the mechanisms by which TTN mutation cause AF and identify novel therapeutic targets for patients carrying AF-associated rare variants in the structural genes.

Altered coronary artery function, arteriogenesis and endothelial YAP signaling in postnatal hypertrophic cardiomyopathy.

Introduction: Hypertrophic cardiomyopathy (HCM) is a cardiovascular genetic disease caused largely by sarcomere protein mutations. Gaps in our understanding exist as to how maladaptive sarcomeric biophysical signals are transduced to intra- and extracellular compartments leading to HCM progression. To investigate early HCM progression, we focused on the onset of myofilament dysfunction during neonatal development and examined cardiac dynamics, coronary vascular structure and function, and mechano-transduction signaling in mice harboring a thin-filament HCM mutation. Methods: We studied postnatal days 7-28 (P7-P28) in transgenic (TG) TG-cTnT-R92Q and non-transgenic (NTG) mice using skinned fiber mechanics, echocardiography, biochemistry, histology, and immunohistochemistry. Results: At P7, skinned myofiber bundles exhibited an increased Ca2+-sensitivity (pCa50 TG: 5.97 ± 0.04, NTG: 5.84 ± 0.01) resulting from cTnT-R92Q expression on a background of slow skeletal (fetal) troponin I and α/β myosin heavy chain isoform expression. Despite the transition to adult isoform expressions between P7-P14, the increased Ca2+- sensitivity persisted through P28 with no apparent differences in gross morphology among TG and NTG hearts. At P7 significant diastolic dysfunction was accompanied by coronary flow perturbation (mean diastolic velocity, TG: 222.5 ± 18.81mm/s, NTG: 338.7 ± 28.07mm/s) along with localized fibrosis (TG: 4.36% ± 0.44%, NTG: 2.53% ± 0.47%). Increased phosphorylation of phospholamban (PLN) was also evident indicating abnormalities in Ca2+ homeostasis. By P14 there was a decline in arteriolar cross-sectional area along with an expansion of fibrosis (TG: 9.72% ± 0.73%, NTG: 2.72% ± 0.2%). In comparing mechano-transduction signaling in the coronary arteries, we uncovered an increase in endothelial YAP expression with a decrease in its nuclear to cytosolic ratio at P14 in TG hearts, which was reversed by P28. Conclusion: We conclude that those early mechanisms that presage hypertrophic remodeling in HCM include defective biophysical signals within the sarcomere that drive diastolic dysfunction, impacting coronary flow dynamics, defective arteriogenesis and fibrosis. Changes in mechano-transduction signaling between the different cellular compartments contribute to the pathogenesis of HCM.

Changes in myosin biomechanics influence growth and maturation of iPSC-cardiomyocytes.

Hypertrophic cardiomyopathy (HCM) is characterized by hypercontractility, cardiomyocyte hypertrophy, myofibril disarray, and altered energetics. Despite the identification of >1000 mutations in sarcomeric proteins, one-third of which are in β-cardiac myosin (MYH7), the mechanism by which altered force at the level of the sarcomere is transduced into cellular hypertrophy and other phenotypes is still incompletely understood. Our biochemical studies reveal surprising heterogeneity in the impact of different MYH7 mutations on myosin force generation and ATPase activity with some mutations reducing activity at the molecular level. Using CRISPR-edited hiPSC-cardiomyocytes (hiPSC-CMs), we studied the impact of myosin HCM mutations on the generation of contractile forces, hypertrophy, myofibril organization, and mitochondrial function, and compared cellular phenotypes with the effects of the mutations on myosin biomechanics. Our studies reveal a critical role for alterations in the myosin super-relaxed state (SRX) as a mechanism for cellular hypercontractility. To validate the fidelity of our findings to human disease, we compared hiPSC-CM results to those in 26 septal myectomy samples from HCM patients and 13 donor heart controls. In both hiPSC-CMs and myectomy samples we observed fiber disarray, altered mitochondrial metabolism, and widening of the Z-disc. A genome-wide key driver analysis revealed altered expression of 52 Z-disc-related genes in patient samples; 24 Z-disc genes in hiPSC-CMs; with 14 Z-disc genes shared between the two platforms. Activation of calcineurin pro-hypertrophic signaling provides a potential link between Z-disc mechano-sensation of sarcomeric forces and downstream hypertrophic signaling, which we explore using a vinculin FRET-tension sensor to directly measure intracellular force at the Z-disc. Our multi-scale approach, combined with both patient samples and CRISPR-edited hiPSC-CMs, confirms the fidelity of our in vitro model in recapitulating human disease and increases the potential translation of our findings to develop new precision-based HCM therapies.

The β-myosin G256E mutation impairs relaxation by altering transducer stiffness.

Associations between mutations in sarcomeric proteins and familial cardiomyopathies are myriad. However, detailed structural and functional studies are required to describe the mechanistic relationship between a mutation and its pathology. To accelerate such studies, we utilize a combined computational and experimental platform to probe how mutations to b-myosin lead to familial cardiomyopathies. Here, we report results on the HCN-associated MYH7 mutation G256E, which is located in the myosin transducer. Experimentally, the specific force generation of mutant G256E myofibrils was ∼2x greater than isogenic control myofibrils. The activation rate was similarly increased. The initial slow phase relaxation kinetics of G256E myosin were significantly reduced relative to isogenic controls, indicating a slower cross-bridge detachment rate. Using stopped flow kinetics, the ATP binding rate was reduced in G256E relative to WT. Molecular dynamics simulations of the rigor and myosin.ATP states showed that G256E led to reorganization of hydrogen bonding networks within the transducer region. Enhanced sampling MD simulations modeled the rigor (nucleotide free) to post-rigor (ATP-bound) structural transition along multiple reaction coordinates. The transition required that G256E myosins surmount a greater energetic barrier that describes the binding of switch 1 to ATP, rotation of the transducer backbone, and opening of the actin binding cleft. This increased barrier is attributed to salt bridges formed by the mutant Glu residue. Based on our combined computational and experimental results, we hypothesize that G256E leads to a hypercontractile and delayed relaxation phenotype via modulation of the transducer structure. This alters communication between the nucleotide binding pocket and the actin binding surface during steps in the chemo-mechanical cycle that involve transducer motion during nucleotide release-induced strong actin binding and ATP binding-induced release from actin. Other effects on myosin structure and its activation during contraction are being investigated.

Towards automated assessment of drug efficacy on cardiomyopathic human heart function.

Structural and functional abnormalities of ventricular myocardium related to Hypertrophic and Dilated Cardiomyopathies (HCM and DCM) are commonly caused by inherited mutations in sarcomeric proteins. Automating predictions of mutation and drug effects on human cardiac muscle function could enhance early diagnosis and evaluation of response to treatments for cardiomyopathies. However, the development of automation tools that integrate results from multiple experiments, conducted under various experimental conditions at different time and spatial scales from multiple species, is a significant challenge. Such automation tools usually require large sets of training data, which are extremely limited or even nonexistent from humans, thus any information generated could be significantly inaccurate or even misleading. Recent advances in multiscale computational tools, coupled with multiple experiments, for the translation of data concerning sarcomere level molecular interactions, including the effect of drugs, to the level of cardiac muscle fibers and tissues, might provide the most relevant approach for generating databases for automation algorithms. Using the MUSICO platform for precise modeling of protein-protein interactions and Ca2+ regulation in cardiac muscle cells, coupled with the finite element (FE) solver Mexie via Mijailovich-Prodanovic surrogate model, we can simulate experimental data from various sources. These tools collectively enable quantitative assessment of the changes in human cardiac muscle contractile responses caused by HCM and DCM extending from the molecular level to whole organ function, as well as prediction of improvements of cardiac muscle function by drugs. Our simulations successfully predicted pressure and volume changes due to troponin-C mutations and the effect of drugs, disopyramide and digoxin, in improving heart function in HCM and DCM, respectively, during multiple heartbeats in human heart. These simulations can potentially provide sufficient information for physicians to evaluate the progress of disease and the efficacy of administrated therapeutics.

HCM and DCM associated TNNT2 sarcomeric variants induce nucleus remodeling in human iPSC-CMs.

Hypertrophic cardiomyopathy (HCM) and dilated cardiomyopathy (DCM) are associated with sarcomeric protein mutations in thick- and thin-filament genes, particularly in the gene TNNT2, which encodes cardiac troponin T (cTnT). Mutations in cTnT can lead to altered contractility dynamics and a high incidence of sudden cardiac death. Human-induced pluripotent stem cells cardiomyocytes (hiPSC-CMs) model offers an effective method to investigate cardiac diseases in vitro. We analyze morphological and functional alterations in two common mutations associated with HCM and DCM, cTnT I79N and cTnT R141W, respectively. We performed experiments in physiologically relevant microenvironment and in the presence of two clinically relevant drugs to treat cardiomyopathies, mavacamten and omencativ mercabil. Cellular characterization confirmed successful maturation of cardiomyocytes and altered contractility consistent with human phenotypes. Stiffer microenvironment determined potential physiological conditions of our model to the human system. In addition, cardiomyocytes under constant physical influence respond to microenvironmental changes, such as energetic metabolism, signal transduction and propagation of electrical stimuli. Through mechanotransduction, the sarcomeric contractility is translated intracellularly to other organelles, including the nucleus. We analyze the mechanical effect of altered sarcomeric contraction, due to TNNT2 mutations, on the nuclear morphology and stiffness of hiPSC-CMs. We observed altered nuclear circularity, aspect ratio and area. We also observed alterations in the nucleus stiffness and protein expression for both HCM and DCM, with opposite effects. Drug treatment showed promising results for the model to correct both contractility and nuclear stiffness. Increased or diminished contractility imposed by TNNT2 pathogenic variants can trigger nuclear remodeling, potentially compromising cellular structure and composition. This supports that sarcomeric variants associated with cardiomyopathy plays a role in cardiomyocyte mechanotransduction.

Intrafamilial Phenotypical Variability Linked to PRKAG2 Mutation-Family Case Report and Review of the Literature.

PRKAG2 syndrome (PS) is a rare, early-onset autosomal dominant phenocopy of sarcomeric hypertrophic cardiomyopathy (HCM), that mainly presents with ventricular pre-excitation, cardiac hypertrophy and progressive conduction system degeneration. Its natural course, treatment and prognosis are significantly different from sarcomeric HCM. The clinical phenotypes of PRKAG2 syndrome often overlap with HCM due to sarcomere protein mutations, causing this condition to be frequently misdiagnosed. The syndrome is caused by mutations in the gene encoding for the γ2 regulatory subunit (PRKAG2) of 5' Adenosine Monophosphate-Activated Protein Kinase (AMPK), an enzyme that modulates glucose uptake and glycolysis. PRKAG2 mutations (OMIM#602743) are responsible for structural changes of AMPK, leading to an impaired myocyte glucidic uptake, and finally causing storage cardiomyopathy. We describe the clinical and investigative findings in a family with several affected members (NM_016203.4:c.905G>A or p.(Arg302Gln), heterozygous), highlighting the various phenotypes even in the same family, and the utility of genetic testing in diagnosing PS. The particularity of this family case is represented by the fact that the index patient was diagnosed at age 16 with cardiac hypertrophy and ventricular pre-excitation while his mother, by age 42, only had Wolff-Parkinson-White syndrome, without left ventricle hypertrophy. Both the grandmother and the great-grandmother underwent pacemaker implantation at a young age because of conduction abnormalities. Making the distinction between PS and sarcomeric HCM is actionable, given the early-onset of the disease, the numerous life-threatening consequences and the high rate of conduction disorders. In patients who exhibit cardiac hypertrophy coexisting with ventricular pre-excitation, genetic screening for PRKAG2 mutations should be considered.

Hypertrophic cardiomyopathy: Mutations to mechanisms to therapies.

Hypertrophic cardiomyopathy (HCM) affects more than 1 in 500 people in the general population with an extensive burden of morbidity in the form of arrhythmia, heart failure, and sudden death. More than 25 years since the discovery of the genetic underpinnings of HCM, the field has unveiled significant insights into the primary effects of these genetic mutations, especially for the myosin heavy chain gene, which is one of the most commonly mutated genes. Our group has studied the molecular effects of HCM mutations on human β-cardiac myosin heavy chain using state-of-the-art biochemical and biophysical tools for the past 10 years, combining insights from clinical genetics and structural analyses of cardiac myosin. The overarching hypothesis is that HCM-causing mutations in sarcomere proteins cause hypercontractility at the sarcomere level, and we have shown that an increase in the number of myosin molecules available for interaction with actin is a primary driver. Recently, two pharmaceutical companies have developed small molecule inhibitors of human cardiac myosin to counteract the molecular consequences of HCM pathogenesis. One of these inhibitors (mavacamten) has recently been approved by the FDA after completing a successful phase III trial in HCM patients, and the other (aficamten) is currently being evaluated in a phase III trial. Myosin inhibitors will be the first class of medication used to treat HCM that has both robust clinical trial evidence of efficacy and that targets the fundamental mechanism of HCM pathogenesis. The success of myosin inhibitors in HCM opens the door to finding other new drugs that target the sarcomere directly, as we learn more about the genetics and fundamental mechanisms of this disease.

Genotype and Phenotype Analysis Using a Hypertrophic Cardiomyopathy-Associated Gene Panel in Turkish Cardiomyopathy Patients

Objective: Hypertrophic cardiomyopathy (HCM) is an autosomal dominant disorder caused by mutations in sarcomeric proteins and characterized by hypertrophy of the heart muscle. 
 Materials and Methods: In the present study, 21 patients with HCM and some of their parents were evaluated via next-generation sequencing (NGS) using a targeted panel of 17 genes. 
 Results: Pathogenic or likely pathogenic variants were detected in six patients in the genes MYH7 (p.R663C, p.A423V), MYBPC3 (p.P955fs*95, p.K301fs*31), TNNT2 (p.R154Q), and TNNI3 (p.R204C).
 Conclusion: The genotype-phenotype correlations of these variants were discussed by comparing the clinical findings with the literature. p.R204C variant in the TNNI3 gene was found to be caused restrictive cardiomyopathy for the first time in the literature.