A Dystrophin Exon-52 Deleted Miniature Pig Model of Duchenne Muscular Dystrophy and Evaluation of Exon Skipping

Duchenne muscular dystrophy (DMD) is a lethal X-linked recessive disorder caused by mutations in the DMD gene and the subsequent lack of dystrophin protein. Recently, phosphorodiamidate morpholino oligomer (PMO)-antisense oligonucleotides (ASOs) targeting exon 51 or 53 to reestablish the DMD reading frame have received regulatory approval as commercially available drugs. However, their applicability and efficacy remain limited to particular patients. Large animal models and exon skipping evaluation are essential to facilitate ASO development together with a deeper understanding of dystrophinopathies. Using recombinant adeno-associated virus-mediated gene targeting and somatic cell nuclear transfer, we generated a Yucatan miniature pig model of DMD with an exon 52 deletion mutation equivalent to one of the most common mutations seen in patients. Exon 52-deleted mRNA expression and dystrophin deficiency were confirmed in the skeletal and cardiac muscles of DMD pigs. Accordingly, dystrophin-associated proteins failed to be recruited to the sarcolemma. The DMD pigs manifested early disease onset with severe bodywide skeletal muscle degeneration and with poor growth accompanied by a physical abnormality, but with no obvious cardiac phenotype. We also demonstrated that in primary DMD pig skeletal muscle cells, the genetically engineered exon-52 deleted pig DMD gene enables the evaluation of exon 51 or 53 skipping with PMO and its advanced technology, peptide-conjugated PMO. The results show that the DMD pigs developed here can be an appropriate large animal model for evaluating in vivo exon skipping efficacy.

334 Hereditary transthyretin amyloidosis: main features and profiles of different clinical phenotypes

Aims Hereditary transthyretin-related amyloidosis (h-ATTR) is a systemic infiltrative disease caused by a single amino acid mutation on the transthyretin (TTR) gene, which destabilizes the protein and can determine its deposition on multiple organs, including heart and peripheral nervous system. We aimed to characterize and compare clinical, instrumental, and prognostic features of patients affected by h-ATTR by dividing the population into the disease’s main phenotypes (unaffected carriers, cardiac, neurological or mixed phenotype). Methods and results Two hundred and eighty-five subjects of a single-centre cohort with a recognized pathogenic mutation on TTR gene were retrospectively included in the analysis. Phenotypes of disease were defined at baseline. Neurological phenotype (NP) was defined according to sensorimotor and/or autonomic dysfunction, while cardiac phenotype (CP) was defined in the presence of unexplained maximum wall thickness >12 mm and other typical echocardiographic findings. Unaffected carriers (UC) and mixed phenotypes (MP) presented none or both of the above-mentioned features, respectively. Two hundred and ten patients showed clinical signs of the disease, 37 (13%) with CP, 65 (23%) with NP and 108 (38%) with MP, while 75 subjects (26%) were UC. Ile68Leu was the most represented mutation (96 subjects, 34%), followed by Val30Met (21%) and Glu89Gln (13%). NP patients (mostly Val30Met) had mPND score >1 in 45% of patients, were younger at diagnosis (mean 47 years, P < 0.001 vs. CP/MP), and sex was equally distributed. In contrast, CP patients were older at diagnosis (mean 70 years, P < 0.001 vs. CP/MP), predominantly male (as well as in MP) with a higher incidence of tunnel carpal syndrome and a shorter time interval between onset of symptoms and diagnosis (mean 17 months, P < 0.001 vs. CP/MP). NYHA class, ECG findings, left ventricular wall thickness, and ejection fraction did not significantly differ between CP and MP. After a mean follow-up of 59 months, 98 (34%) patients died. On a Kaplan–Meier survival analysis, mean survival times were 208, 123, 150, and 95 months for UC, CP, NP, and MP, respectively, with a statistically significant difference in affected patients between NP and MP (P = 0.012). Conclusions H-ATTR is a rare systemic disorder whose natural history, including age of onset, clinical characteristics, and instrumental findings, is strongly influenced by primary phenotypes, ranging from the excellent prognosis of unaffected carriers to the inauspicious outcome of mixed phenotypes.

Changes in Thyroid Hormone Signaling Mediate Cardiac Dysfunction in the Tg197 Mouse Model of Arthritis: Potential Therapeutic Implications

Background Rheumatoid Arthritis (RA) patients show a higher risk of heart failure. The present study investigated possible causes of cardiac dysfunction related to thyroid hormone (TH) signaling in a RA mouse model. Methods A TNF-driven mouse model of RA[TghuTNF (Tg197)] was used. Cardiac function was evaluated by echocardiography. SERCA2a and phospholamban protein levels in left ventricle (LV) tissue, thyroid hormone levels in serum, TH receptors in LV and TH-related kinase signaling pathways were measured. T3 hormone was administered in female Tg197 mice. Results We show LV and atrial dilatation with systolic dysfunction in Tg197 animals, accompanied by downregulated SERCA2a. We suggest an interaction of pro-inflammatory and thyroid hormone signaling indicated by increased p38 MAPK and downregulation of TRβ1 receptor in Tg197 hearts. Interestingly, female Tg197 mice showed a worse cardiac phenotype related to reduced T3 levels and Akt activation. T3 supplementation increased Akt activation, restored SERCA2a expression and improved cardiac function in female Tg197 mice. Conclusions TNF overexpression of Tg197 mice results in cardiac dysfunction via p38 MAPK activation and downregulation of TRβ1. Gender-specific reduction in T3 levels could cause the worse cardiac phenotype observed in female mice, while T3 administration improves cardiac function and calcium handling via modified Akt activation.

GRINL1A Complex Transcription Unit Containing GCOM1, MYZAP, and POLR2M Genes Associates with Fully Penetrant Recessive Dilated Cardiomyopathy

Background: Familial dilated cardiomyopathy (DCM) is a monogenic disorder typically inherited in an autosomal dominant pattern. We have identified two Finnish families with familial cardiomyopathy that is not explained by a variant in any previously known cardiomyopathy gene. We describe the cardiac phenotype related to homozygous truncating GCOM1 variants.Methods and Results: This study included two probands and their relatives. All the participants are of Finnish ethnicity. Whole-exome sequencing was used to test the probands; bi-directional Sanger sequencing was used to identify the GCOM1 variants in probands’ family members. Clinical evaluation was performed, medical records and death certificates were obtained. Immunohistochemical analysis of myocardial samples was conducted. A homozygous GCOM1 variant was identified altogether in six individuals, all considered to be affected. None of the nine heterozygous family members fulfilled any cardiomyopathy criteria. Heart failure was the leading clinical feature, and the patients may have had a tendency for atrial arrhythmias.Conclusions: This study demonstrates the significance of GCOM1 variants as a cause of human cardiomyopathy and highlights the importance of searching for new candidate genes when targeted gene panels do not yield a positive outcome.

Variant location is a novel risk factor for individuals with arrhythmogenic cardiomyopathy due to a desmoplakin (DSP) truncating variant

Background: Truncating variants in desmoplakin (DSPtv) are an important cause of arrhythmogenic cardiomyopathy (ACM), however the genetic architecture and genotype-specific risk factors are incompletely understood. We evaluated phenotype, risk factors for ventricular arrhythmias, and underlying genetics of DSPtv cardiomyopathy. Methods: Individuals with DSPtv and any cardiac phenotype, and their gene-positive family members were included from multiple international centers. Clinical data and family history information were collected. Event-free survival from ventricular arrhythmia was assessed. Variant location was compared between cases and controls, and literature review of reported DSPtv performed. Results: There were 98 probands and 72 family members (mean age at diagnosis 43 +/- 18 years, 59% female) with a DSPtv, of which 146 were considered clinically affected. Ventricular arrhythmia (sudden cardiac arrest, sustained ventricular tachycardia, appropriate implantable cardioverter defibrillator therapy) occurred in 56 (33%) individuals. DSPtv location and proband status were independent risk factors for ventricular arrhythmia, while prior risk factors showed no association. Further, gene region was important with variants in cases (cohort n=98, Clinvar n=168) more likely to occur in the regions resulting in nonsense mediated decay of both major DSP isoforms, compared to n=124 gnomAD control variants (148 [83.6%] versus 29 [16.4%], p<0.0001). Conclusions: In the largest series of individuals with DSPtv, we demonstrate variant location is a novel risk factor for ventricular arrhythmia, can inform variant interpretation, and provide critical insights to allow precision-based clinical management.

EFHD1 ablation reduces cardiac mitoflash activation and protects cardiomyocytes from ischemia.

Altered levels of intracellular calcium (Ca2+) are a highly prevalent feature in different forms of cardiac injury, producing changes in contractility, arrhythmias, and mitochondrial dysfunction. In cardiac ischemia-reperfusion injury, mitochondrial Ca2+ overload leads to pathological production of reactive oxygen species (ROS), activates the permeability transition, and cardiomyocyte death. Here we investigated the cardiac phenotype caused by deletion of EF-hand domain-containing protein D1 (Efhd1-/-), a Ca2+-binding mitochondrial protein whose function is poorly understood. Efhd1-/- mice are viable and have no adverse cardiac phenotypes. They feature reductions in basal ROS levels and mitoflash events, both important precursors for mitochondrial injury, though cardiac mitochondria have normal susceptibility to Ca2+ overload. Notably, we also find that Efhd1-/- mice and their cardiomyocytes are resistant to hypoxic injury.

Combined deletion of PR-domain containing 16 (Prdm16) in cardiomyocyte and non-cardiomyocyte lineages results in spontaneous early-onset lethality and progressive left ventricular dysfunction in mice

Introduction PR-domain containing 16 (Prdm16) has an asymmetric expression pattern in the developing cardiovascular system, including ventricular myocardium, endocardium and arterial endothelial and smooth muscle cell (SMC) layers. Heterozygous PRDM16 mutations in humans have been linked with early-onset cardiomyopathy resulting in heart failure. Myocardial PRDM16-deficiency has been suggested as the culprit for this cardiomyopathy, however embryonic Prdm16 deletion in cardiomyocytes or their progenitors in mice only results in symptomatic cardiac defects upon metabolic stress or ageing. This suggests that Prdm16 loss in other cell types has an important co-contribution in the early heart phenotype seen in patients with causal PRDM16 variants. Purpose To investigate the adjuvant role of non-cardiomyocytes to the heart phenotype caused by Prdm16 deficiency, we used a conditional mouse model in which deletion of Prdm16 occurs in all cells expressing an Sm22-driven Cre recombinase which has a combined activity in cardiomyocyte and non-cardiomyocyte lineages in the heart, including SMCs and pericytes. Methods Mice carrying two Prdm16 alleles with a floxed exon 9 (Prdm16fl/fl) were intercrossed with the Sm22-Cre driver line. Offspring of Sm22Cre+; Prdm16fl/fl and Sm22Cre−; Prdm16fl/fl breeding pairs was monitored for Mendelian inheritance and for signs of (progressive) cardiac dysfunction by echocardiography at 5 and 16 weeks of age. Hearts were isolated and analyzed for RNA expression levels of cardiac stress markers Atrial and Brain Natriuretic Peptide (ANP and BNP) via quantitative RT-PCR and histologically for the appearance of fibrosis through Sirius red-staining. Results Genotyping at 5 weeks of age showed a loss of 60.4% of Sm22Cre+; Prdm16fl/fl offspring. Mice surviving at 5 weeks spontaneously developed signs of left ventricular diastolic and systolic dysfunction, the latter shown by a significantly reduced ejection fraction (EF; 37±3% vs. 61±3% in control Sm22Cre−; Prdm16fl/fl littermates). Cardiac expression levels of ANP and BNP were significantly increased (728-fold and 36-fold, respectively) in Sm22Cre+; Prdm16fl/fl mice which also showed perivascular fibrosis compared to control littermates. At 16 weeks of age, this aberrant cardiac phenotype further progressed (EF: 32±3% vs. 57±4%; ANP: 2,541-fold increase; BNP: 129-fold increase) and in addition to perivascular fibrosis, hearts also showed interstitial fibrosis (Sirius red+ area: 17±2% vs. 3.0±0.4% in control littermates). Conclusion Unlike recently reported mice with a Prdm16 deficiency in cardiomyocytes or their (precursor) lineages, mice with a combined loss of Prdm16 in the cardiomyocytes and certain non-cardiomyocyte lineages feature early mortality and (progressive) signs of severe heart failure. Therefore, Prdm16 expressed by non-cardiomyocytes is indispensable for proper cardiac function and its loss in these cell types co-determines the aberrant cardiac phenotype. FUNDunding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Fonds voor Wetenschappelijk Onderzoek Strategic Basic Research pre-doctoral fellowship (1S25817N)KU Leuven Research Coordination grant (C14/19/095)