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Cardiovascular Research 2007 76(3):409-417; doi:10.1016/j.cardiores.2007.08.006
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Copyright © 2007, European Society of Cardiology

A novel C-terminal truncation SCN5A mutation from a patient with sick sinus syndrome, conduction disorder and ventricular tachycardia

Bi-Hua Tana,1, Pedro Iturralde-Torresb,1, Argelia Medeiros-Domingoc,d,e,f, Santiago Navab, David J. Testerd,e,f, Carmen R. Valdiviaa, Teresa Tusié-Lunac, Michael J. Ackermand,e,f and Jonathan C. Makielskia,*

aDepartment of Medicine, Cardiovascular Section, University of Wisconsin-Madison, 600 Highland Ave H6/349, Madison, WI 53792, United States
bInstituto Nacional de Cardioloia "Ignacio Chàvez", Mexico
cInstituto de Investigaciones Biomédicas, UNAM, Instituto Nacional de Ciencias Médicas y Nutrición, SZ, Mexico
dDepartment of Medicine, Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, United States
eDepartment of Pediatrics, Division of Pediatric Cardiology, Mayo Clinic College of Medicine, Rochester, MN, United States
fDepartment of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic College of Medicine, Rochester, MN, United States

*Corresponding author. Tel.: +1 608 263 9648; fax: +1 608 263 0405. jcm{at}medicine.wisc.edu

Received 22 March 2007; revised 24 July 2007; accepted 15 August 2007


   Abstract
Top
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 Acknowledgments
 References
 
Objectives Individual mutations in the SCN5A-encoding cardiac sodium channel {alpha}-subunit cause single cardiac arrhythmia disorders, but a few cause multiple distinct disorders. Here we report a family harboring an SCN5A mutation (L1821fs/10) causing a truncation of the C-terminus with a marked and complex biophysical phenotype and a corresponding variable and complex clinical phenotype with variable penetrance.

Methods and results A 12-year-old male with congenital sick sinus syndrome (SSS), cardiac conduction disorder (CCD), and recurrent monomorphic ventricular tachycardia (VT) had mutational analysis that identified a 4 base pair deletion (TCTG) at position 5464–5467 in exon 28 of SCN5A. The mutation was also present in six asymptomatic family members only two of which showed mild ECG phenotypes. The deletion caused a frame-shift mutation (L1821fs/10) with truncation of the C-terminus after 10 missense amino acid substitutions. When expressed in HEK-293 cells for patch-clamp study, the current density of L1821fs/10 was reduced by 90% compared with WT. In addition, gating kinetic analysis showed a 5-mV positive shift in activation, a 12-mV negative shift of inactivation and enhanced intermediate inactivation, all of which would tend to reduce peak and early sodium current. Late sodium current, however, was increased in the mutated channels.

Conclusions The L1821fs/10 mutation causes the most severe disruption of SCN5A structure for a naturally occurring mutation that still produces current. It has a marked loss-of-function and unique phenotype of SSS, CCD and VT with incomplete penetrance.

KEYWORDS Genetics; Arrhythmia; Sick sinus syndrome; Conduction disorder; Ventricular tachycardia; SCN5A; Sodium current; Frame-shift mutation; Nav1.5; Inherited arrhythmia

This article is referred to in the Editorial by van Rijen and de Bakker (pages 379–380) in this issue.


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 Acknowledgments
 References
 
SCN5A encodes the voltage-dependent sodium channel {alpha}-subunit protein hNav1.5 [1], found predominantly in human heart muscle. This channel is responsible for large peak inward sodium current (INa) that underlies excitability and conduction in working myocardium (atrial and ventricular cells) and special conduction tissue (Purkinje cells and others), and also for late INa that influences repolarization and refractoriness. Mutations in SCN5A that increase late INa ("gain of function") cause type 3 long QT syndrome (LQT3) [2], and mutations that decrease peak INa ("loss of function") cause several arrhythmogenic syndromes including type 1 Brugada syndrome (BrS1) [3] and isolated cardiac conduction disease (ICCD) [4,5]. More rarely, congenital sick sinus syndrome (SSS) has also been linked to mutations in SCN5A [6,7].

To date, at least 4 mutations in the cardiac sodium channel have been identified whereby the same mutation precipitated multiple different disease phenotypes [7–10]. An insertion of an aspartic acid residue in the C-terminus of SCN5A (1795insD) can result in either BrS1 or LQT3 [8]. The mutation of glycine to arginine (G1406R in the original publication, G1408R by present numbering) in the DIII/S5 to DIII/S6 region resulted in either BrS1 or ICCD in several families [9]. The deletion of a lysine in the III–IV linker of SCN5A ({theta}K1500) is associated with BrS1, LQT3 and ICCD [10]. A replacement of glutamic acid by the basic residue lysine (E161K) in the DI/S2 transmembrane region contributes to SSS, CCD and BrS1 [7]. The mechanisms by which the same or similar biophysical phenotype such as loss-of-function can cause multiple distinct clinical phenotypes are unknown. Discovering and characterizing additional novel mutations in families showing multiple phenotypes may provide further insight.

The sodium channel C-terminal domain (residues 1773–2016) represents a crucial structure implicated in channel inactivation modulation [11]. Intramolecular interactions between Nav1.5 III–IV linker and C-terminal domain have been implicated in stabilization of the inactivated state. Estimated three-dimensional structure predicts that the proximal half contains six helical structures, while the distal half consists of an unstructured peptide. Functional experiments revealed no role of the distal unstructured C-terminal domain. Truncation of the predicted sixth helix of the structured C-terminal region uncouples the C-terminal from the III–IV linker [11]. To date, no deletions in this C-terminal domain have been associated with any heritable arrhythmia syndromes. We present a unique phenotype and functional characterization of a case involving a 4 base deletion (TCTG) in SCN5A at position 5464–5467 in exon 28. This deletion produces a frame-shift mutation (L1821fs/10) that deletes the terminal 195 amino acids. This severe, premature truncation includes amino acids comprising the predicted sixth helix.

Despite a severe disruption of the channel structure, L1821fs/10-SCN5A produced currents, albeit reduced, with predominantly loss-of-function but also an increase in late INa relative to peak. The corresponding clinical phenotype was complex with SSS, CCD and recurrent monomorphic ventricular tachycardia (VT).


   2. Methods
Top
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 Acknowledgments
 References
 
2.1 Mutational analysis of SCN5A
Comprehensive open reading frame/splice site mutational analysis of SCN5A was performed using denaturing high performance liquid chromatography (DHPLC), and direct DNA sequencing as previously described [12,13]. The study was performed according to the terms required by the Research Ethics Committee of the National Institute of Cardiology "Ignacio Chàvez", México City and the Mayo Foundation Institution Review Board written informed consent was obtained from all participants. The investigation also conforms with the principles outlined in the "Declaration of Helsinki" (Cardiovascular Research 1997; 35:2–4).

2.2 Site-directed mutagenesis and heterologous expression
L1821fs/10 was created by site-direct mutagenesis (mutagenesis kit from Stratagene®) using a PCR technique. The appropriate nucleotide changes for L1821fs/10 were engineered into the most common splice variant of human cardiac voltage-dependent Na channel SCN5A/hNav1.5 [lacking a glutamine at position 1077, we note as Q1077del (Genbank accession No. AY148488 [GenBank] )] in the pcDNA3 vector (Invitrogen; Carlsbad, CA). Integrity of the constructs was verified by DNA sequencing. WT and mutant channels were transiently expressed in HEK-293 cells for functional study as described previously [14,15].

2.3 Standard electrophysiological measurements for functional characterization
Macroscopic INa was measured using a standard whole-cell patch-clamp method at a temperature of 22–24 °C. Details have been previously published [15]. The extracellular (bath) solution contained, in mmol/L, NaCl 140, KCl 4, CaCl2 1.8, MgCl2 0.75 and HEPES 5 (pH 7.4 set with NaOH). The pipette solution contained, in mmol/L, CsF 120, CsCl 20, EGTA 2 and HEPES 5 (pH 7.4 set with CsOH). Pipettes had resistances between 1.0 and 2.0 M{Omega} when filled with recording solution. The data were acquired using pClamp 8.2 (Axon Instruments Inc. Union City, CA) and analyzed using Clampfit (Axon Instruments Inc.). The standard voltage clamp protocols are presented with the data and as described in detail previously [16].

2.4 Immunocytochemistry
Forty-eight hours post-transfection, HEK-293 cells transfected with WT and mutant plasmid DNA containing the FLAG epitope, which introduced between S1 and S2 in domain I of hNav1.5 were used for the immunocytochemistry experiments using confocal microscopy. Transfected and nontransfected HEK-293 cells were fixed with a freshly prepared mixture of methanol: acetone (1:1) for 1 min. Other details of the procedure have been previously published [17].

2.5 Statistic analysis
Data are shown as symbols with standard error of the mean (S.E.M.). Determinations of statistical significance were performed using one-way ANOVA for comparisons of two groups. A p value of <0.05 was considered statistically significant. Curve fits are down using pClamp 8.2 (Axon Instruments). Non-linear curve fitting is performed with Origin 6.0 (Microcal Software).


   3. Results
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 Acknowledgments
 References
 
3.1 Clinical case
A 12-year-old male presented with fetal bradycardia and no family history of cardiac disease or sudden death. He was born by C-section without any complication during the prenatal period. At one year of age, right bundle branch block and atrial flutter were documented (Fig. 1A, B). At 3 years, atrial flutter ablation was performed; sinus bradycardia and pauses up to 3.72 s with junctional escapes were observed after the procedure (Fig. 1C). At 5 years of age, monomorphic ventricular tachycardia (VT) was documented (Fig. 1D) and treated with lidocaine in the emergency room converting to a very slow junctional escape rhythm. A DDDR pacemaker was implanted and amiodarone treatment initiated. Two echocardiograms and a CT scan were performed ruling out structural heart disease. Clinical electrophysiological study showed a prolonged H–V interval (100 ms, normal<50 ms) and second-degree 4:3 atrioventricular (AV) conduction during atrial pacing (Fig. 1E). Radiofrequency ablation of a monomorphic VT with RBBB morphology and a cycle length of 350 ms (Fig. 1F) were attempted, without success. A pharmacological test was performed with propafenone (2 mg/kg) to unmask BrS; severe QRS widening was induced without significant changes in repolarization. The patient developed transient asystole with an acute rise in the pacing threshold, reversing spontaneously after a few seconds. The ECG was otherwise negative. The patient was clinically diagnosed as congenital SSS, CCD and recurrent monomorphic VT and LQTS was also considered a possible contributor to the patient's phenotype based on QT prolongation (QTc 550 ms). However, given that torsades de pointes have never been documented, the QT prolongation might be attributed clinically to the combination of amiodarone therapy and the severity of CCD, both of which can cause QT prolongation.


Figure 1
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  		Fig. 1 Electrocardiographic phenotypes. (A) 12-lead surface ECG (10 mm/mV, 25 mm/s, 71 bpm) from proband at 1 year of age showing a prolonged QRS (160 ms) duration with a typical right bundle branch configuration and a prolonged QT interval. (B) 24-h Holter monitoring shows atrial flutter with 3:1 to 6:1 atrioventricular (AV) conduction. (C) Lead II ECG (10 mm/mV, 25 mm/s) shows sinus bradycardia and sinus pause up to 3.72 s and junctional escapes. (D) Lead II ECG (5 mm/mV, 12.5 mm/s) shows monomorphic ventricular tachycardia with a heart rate of 200 bpm. (E) Intracardiac ECG (V1—surface V1 lead, RA and RV—right atrium and ventricular, HBE—His bundle electrogram) shows a second-degree AV block with 4:3 AV conduction during AAI pacing at 80 bpm. (F) Intracardiac ECG shows an induced monomorphic VT (heart rate 171 bpm) and AV dissociation.

 
3.2 Molecular characterization of L1821fs/10
A 4 base pair deletion (TCTG) at position 5464–5467 in exon 28 of SCN5A was elucidated (bottom panel of Fig. 2B). This deletion produced a frame-shift mutation annotated as L1821fs/10 indicating that the final normal amino acid in the protein is the leucine (L) at position 1821 followed by 10 "scrambled" (frame-shifted) amino acids before truncating prematurely. Thus, the gene product from this mutant allele ends at amino acid 1831 resulting in a severe truncation of the C-terminus.


Figure 2
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  		Fig. 2 (A) Topological diagram of SCN5A showing a 4 base pair deletion (TCTG) after codon at no. 1821. The deletion caused a frame shift resulting in additional 10 new amino acids added and a premature truncation of the C-terminus by a stop code (TAA) at no. 1832. (B) Sequence chromatogram for the proband. (C) Family tree showing the mutation carriers and the phenotype assignments (see symbol key). The ages of each family member is displayed above the symbol.

 
The mutation was confirmed in the proband's mother as well (Fig. 2C) who was asymptomatic. One female sibling and one female cousin were genotype positive but had a mild clinical phenotype of bradycardia with intraventricular conduction delay and abnormal repolarization on ECG with 1st degree AV block respectively. Genotype carriers in an aunt, uncle, and grandmother were apparently asymptomatic and without ECG abnormalities. Thus, despite a severe truncation deletion predicted at the molecular/genetic level, L1821fs/10 was associated with incomplete penetrance and variable expressivity.

3.3 Expression of a C-terminal truncation mutant, L1821fs/10
Transfected HEK-293 cells transiently expressing the WT and L1821fs/10 mutant channels were voltage clamped after 24-h and 48-h incubation and showed reduced currents (Fig. 3A and B) for the mutant channel compared to WT. Summary of INa density in 3C showed that after 24 h of incubation, the mutant channel had dramatic reduction of INa density (–4±2 pA/pF, n=14) compared to WT (–302±48 pA/pF, n=21, p value<0.0001). Although the current density of L1821fs/10 was increased after 48 h of incubation (–22±8 pA/pF, n=33), this was still much less than WT levels after 24 h of incubation (p<0.001). Note that among the 47 experiments performed for L1821fs/10, only 5 cells had macroscopic currents after 48 h of incubation sufficiently large to do kinetic analysis. Extending the incubation time to 72 h did not increase the current for L1821fs/10. Incubation with the antiarrhythmic drug (mexiletine 500 µM, quinidine 100 µM and cisapride 10 µM), and other attempts to restore the current density in L1821fs/10 such as incubation at low temperature and co-expression with the β1 and β3 subunits, known to increase INa density of some expression defect mutants, failed to restore the current densities for L1821fs/10 (data not shown). When L1821fs/10 was co-expressed with WT (0.75 µg DNA each, n=10 cells at 24 h) the current amplitude was about 55% of that in WT alone (1.5 µg DNA n=10 cells) consistent with haploinsufficiency in the heterologous system, and no dominant negative effect.


Figure 3
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  		Fig. 3 Comparing the peak or late current of mutant L1821fs/10 and WT in the most common splice variant SCN5A-Q1077del background. (A, B) Whole-cell current traces from representative experiments of L1821fs/10 (A) and WT (B) after 24 h (left panel) and 48 h (right panel) transfection. (C) Summary of INa density in L1821fs/10 and WT after 24 h and 48 h of incubation. The number of experiments is indicated above the bar. N.S. indicates no significant difference. (D) Example of late INa for L1821fs/10 (top panel) and WT (bottom panel) elicited by a test depolarization pulse from –120 mV to –20 mV for 700 ms (here only 200 ms was shown). Late INa was normalized to cell capacitance, and presented in pA/pF. (E) Summary of late INa normalized to peak INa. After leak subtraction, the late INa was measured as the mean between 600 ms and 700 ms after the initiation of the depolarization. The number of experiments is indicated above the bar.

 
Late INa, for L1821fs/10 mutant channels was increased in response to long (700 ms) depolarizing steps to various test potentials from a holding potential of –140 mV (Fig. 3D). After leak subtraction, late INa was measured as the mean between 600 and 700 ms after the initiation of the depolarization and normalized by dividing by the maximum peak amplitude of INa from the current–voltage relationship (Fig. 3E, 2.9%±0.3%, n=5, for L1821fs/10 and 0.8%±0.1%, n=5, for WT, p<0.001). Late INa was confirmed using 1 µM STX (data not shown).

3.4 Voltage-dependent gating properties of L1821fs/10
Table 1 and Fig. 4 summarize voltage-dependent gating for L1821fs/10 and WT channels. The voltage-dependent activation mid-point was significantly positive shifted by 5 mV, and the slope factor was larger for L1821fs/10 compared to WT (Table 1 and Fig. 4A). The steady state inactivation mid-point was significantly negative shifted by 12 mV, and slope factor was larger for L1821fs/10 compared to WT (Table 1 and Fig. 4B). Slower time constants of recovery were observed for L1821fs/10 compared to WT (Table 1 and Fig. 4C). The mutant channel showed enhanced intermediate inactivation compared with WT for prepulse durations longer than 50 ms (Fig. 4D). The voltage dependence of decay of the current traces (Fig. 5) showed that the mutation lost the voltage dependence of decay, with the decay being slower than WT over the range of potentials >–30 mV where inactivation dominates the decay phase relative to deactivation at more negative potentials.


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  		Table 1 Voltage-dependent gating parameters of L1821fs/10 and WT in the Q1077del background

 

Figure 4
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  		Fig. 4 Voltage-dependent gating for L1821fs/10 and WT in the Q1077del splice variant background. (A) Voltage dependence of activation for L1821fs/10 and WT. The line represents a fit to the Boltzmann function where GNa=[1+exp(V1/2–V)/k]–1, where V1/2 and k are the mid-point and the slope factor (as an index of voltage control, all factors were more than 4), respectively, and GNa=INa(norm)/(V–Vrev), where Vrev is the reversal potential and V is the membrane potential. (B) Steady state availability from inactivation for L1821fs/10 and WT. The line represents a fit to the Boltzmann function: INa=INa-max[1+exp(Vc–V1/2)/k]–1, where the V1/2 and k are the mid-point and the slope factor, respectively, and Vc is the membrane potential. (C) Recovery from inactivation for L1821fs/10 and WT with time on a log scale to better show the early time course of recovery. The recovery time course was best fit with two exponentials: normalized INa=[Af exp(–t/{tau}f)]+[As exp(–t/{tau}s)] where t is the recovery time interval, {tau}f and {tau}s are the fast and slow time constant, and Af and As are the fractional amplitude of the fast and slow recovery components respectively. (D) Intermediate inactivation for L1821fs/10 and WT channels with a variant time of the prepulse duration. All data points in this figure are shown as the mean value and the bars represent the standard error of the mean. The N numbers and fit parameters are given in Table 1. *Statistically significant differences for L1821fs/10 vs. WT.

 

Figure 5
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  		Fig. 5 Voltage dependence of time to peak (A), fast time constant (B), slow time constant (C), and fast fractional amplitude of current decay (D). Cells with comparable mean peak current amplitudes were chosen to help control for any effects that might arise from imperfect voltage control. All of the values for L1821fs/10 (opened circle) and WT (filled circle) are plotted against the test potential used to elicit INa. Time to peak is the time from the onset of depolarization to peak INa. To obtain decay rates and components, the portion of the trace from 90% of peak INa to 24 ms was fit with a sum of exponentials (exp): INa (t)=1–[Af exp (–t/{tau}f)+As exp(–t/{tau}s)]+offset, where t is time, and Af and As are fractional amplitudes of fast and slow components, respectively. Symbols represent means, and bars represent the standard error of the mean. *Statistically significant differences for L1821fs/10 vs. WT.

 
The voltage dependence of time to peak amplitude of INa, time constants of INa decay, and fractional amplitude of INa decay were measured at the test potentials of –50, –40, –30, –20, –10, 0, 10, 20, and 30 mV (summary data in Fig. 5). The INa for L1821fs/10 tended to peak earlier than the WT at –50 mV, but tended to peak later at more depolarized potentials (Fig. 5A). Like time to peak, the fast and slow decay time constants were faster at –50 mV for L1821fs/10 but were significantly slower for the depolarization >–20 mV compared with WT channels (Fig. 5B, C). This result of slower inactivation may account for the gain of the late INa for mutated channel.

3.5 Localization of WT and L1821fs/10 mutated sodium channel proteins
Transfected or nontransfected HEK-293 cells were labeled with anti-FLAG antibody (Fig. 6A: in nonpermeabilized cells, and left panel of Fig. 6B: in permeabilized cells) to mark the location of channels. Calnexin is a chaperon protein present in the endoplasmic reticulum and was used as an endoplasmic reticulum marker with anti-calnexin antibody labeling (middle panel of Fig. 6B) to show colocalization of both markers. Forty-eight hours post-transfection, both WT and mutant had a similar peripheral SCN5A localization. Thus L1821fs/10 reached the plasma membrane ruling out a loss-of-function mechanism involving defective trafficking as the sole defect.


Figure 6
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  		Fig. 6 Confocal images of HEK-293 cells expressing the L1821fs/10 (top panel) and WT (bottom panel) with FLAG-tagged sodium channels. (A) Surface staining of nonpermeabilized cells using anti-FLAG antibody. (B) Double staining of permeabilized cells using anti-FLAG (green) and anti-calnexin (red) antibody to show colocalization.

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
Acknowledgments
 References
 
The mutant channel L1821fs/10 exhibited a loss-of-function biophysical phenotype resulting in a mixed clinical syndrome characterized by SSS, CCD and recurrent VT. This discovery provides the fifth SCN5A mutation associated with multiple clinical phenotypes [7–10]. Generally, mutations in SCN5A that cause a decrease in peak INa density appear to be associated with BrS1/CCD [3,5,9]. This can occur by two general mechanisms: a decrease in channel expression or a change in channel kinetics that tends to decrease peak INa.

How does a loss-of-function mutation in some patients cause BrS1, SSS, or CCD, or in some patients, mixtures of these syndromes? It has been proposed [18] that a rightward shift in the voltage dependence of the mutant sodium channel activation curve, as found with L1821fs/10 (Fig. 4A) is a common feature of CCD [5,9,10,19]. The slower time to peak INa (Fig. 5A) in our study indicates that the mutant channels require a more positive membrane potential to fully activate and more time to reach the membrane potential at which the maximum current amplitude occurs than WT channels, which might manifest on the ECG in a widening of the QRS in CCD [5,10,18,19]. However, the mechanisms by which the proband showed SSS and monomorphic VT but not BrS1, are unknown.

The mutation, L1821fs/10, also showed decreased INa with slow decay and a noninactivating component (late INa) in those cells that had measurable macroscopic currents (Figs. 3 and 5Go), similar to the gain-of-functional molecular phenotype of LQT3. This introduces seemingly paradoxical terminology, how can a mutation cause both "loss of function" and "gain of function". The key distinction is timing, "loss of function" generally refers to a loss of peak or early INa, and "gain of function" generally refers to late INa. For L1821fs/10 mutant channels, peak INa is decreased but late INa is increased relative to peak INa.

This combination of molecular phenotypes has been reported previously for {theta}K1500, a deletion of a lysine in the III–IV linker of SCN5A, which is associated with BrS1, LQT3 and CCD [10] and for 1795insD, an insertion of aspartic acid in the C-terminal domain of SCN5A, which causes both LQT3 and BrS1 [8]. In heterologous expression system, L1821/fs10 also has very similar molecular phenotype of both loss-of-function and gain-of-functional sodium channel features with a previously reported mutation of a methionine to a leucine (M1766L) from a patient with LQT3 [20]. When expressed, M1766L showed a profound trafficking defect, but had increased late INa and the expression defect was "rescued" by mexiletine, or, as in the patient, the mutation was rescued when expressed in the context of a sodium channel containing the common polymorphism H558R [14].

In this case, the L1821fs/10 proband did have a prolonged QTc, but it was in the presence of right bundle branch block, and his VT was monomorphic, not torsades. Although this mutation has a biophysical phenotype that could potentially cause LQT3, there is no evidence for LQT3 in the patient. The reduced current expression was not restored with mexiletine, quinidine, or cisapride, drugs previously reported to rescue expression defective SCN5A mutations [17,20–22]. Co-expression with β subunits and low temperature of incubation, which increased some expression levels in M1766L [20], did not increase expression level for L1821fs/10. Further, the cell surface staining with anti-FLAG antibody (Fig. 6A: in nonpermeabilized cells) and co-labeling with anti-Flag antibody and anti-calnexin antibody (Fig. 6B: in permeabilized cells) indicated that the L1821fs/10 channel reached the plasma membrane. From this we conclude that the markedly decreased peak INa of L1821fs/10 was mainly caused by biophysical abnormalities.

Recently, the Nav1.5 C-terminal domain has attracted considerable attention for having a direct structural role in the control of channel inactivation in the studies by Kass and colleagues [11,23–25]. They postulate that the proximal part of the C-terminal domain is a critical structure for stabilizing the inactivated state of the channel during prolonged depolarization. The naturally occurring C-terminal truncation mutation, L1821/fs10 (Q1832 stop) in our study not only showed results similar to the experimental mutation (S1885 stop) designed to test biophysical function of the C-terminus, namely increased late INa resulting from channels failing to inactivate during prolonged depolarization and slows the channel's recovery from inactivation, as well as shifts the steady state inactivation curve in the hyperpolarizing direction [23–25].

It is interesting that selected family members preferentially presented the phenotype with different degrees of severity, the marked clinical phenotype suffered by the proband contrasts sharply with the lack of symptoms in four carriers in the preceding generations and the very mild clinical phenotypes observed in a sister and a cousin. In general, but with one exception, the asymptomatic carriers were females, which agrees with a male predominance for loss-of-function SCN5A mutations causing BrS1. The mechanisms for this variability in this instance and in general are incompletely understood. We previously reported that the two common polymorphisms (H558R and S524Y) caused a profound expression defect in the Q1077 background, but not the Q1077del background [16,26], and that H558R can modify expression of an arrhythmia causing mutation M1766L [14]. These and other polymorphisms were absent in these patients. Loss-of-function for the BrS1 mutation G1406R was more severe in the Q1077 background [17]. Although mRNA for Q1077 and Q1077del is present in equal ratios in different individuals [26], should the protein levels vary this could account for clinical variability. Other unknown genetic, developmental, or acquired abnormalities may also account for clinical variability. For example structural abnormalities such as increased fibrosis have been shown to interact with decreased INa [27] to affect excitability and conduction. Understanding the mechanisms for variability of the clinical phenotype may lead to improved understanding of pathogenesis and of possible therapy.

It is important to emphasize that these studies in heterologous systems, like previous work in the field, may not reflect what occurs in the myocytes, which have additional subunits and interacting proteins. Also these clones do not contain the introns or promoters that might affect expression in the myocytes. These experiments in heterologous systems only suggest a possible biophysical phenotype that may lead to the clinical syndromes, but further studies in more integrated systems are necessary to describe the full pathogenetic pathway.

Time for primary review 22 days


   Acknowledgments
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 Acknowledgments
References
 
This work was supported by an American Heart Association (AHA), Greater Midwest Affiliate Postdoctoral Fellowship to BH.T., AHA Established Investigator Award to M.J.A., and NIH grant HD42569 to M.J.A and HL71092 to J.C.M. We are particularly indebted to family members for their participation in this study.


   Notes
 
1 Contributed equally to this study. Back


   References
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 Acknowledgments
 References
 

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