High prevalence of ventricular repolarization abnormalities in people carrying TGFßR2 mutations.

Mutations in the TGFßR2 gene have been associated with a life threatening risk of aortic dissection but no arrhythmic death has been previously reported. Two young females carrying a TGFßR2 mutation, initially diagnosed as Marfan syndrome or Loeys Dietz syndrome, presented sudden death with autopsy ruling out dissection. The ECGs of the 2 Sudden Cardiac Deaths revealed profound ventricular repolarization abnormalities with a sinusoidal T-U morphology associated with normal left ventricular ejection fraction. These data strongly suggest sudden cardiac arrhythmic deaths and prompted us to systematically study the repolarization pattern in the patients with TGFßR2 mutations. ECG findings from 58 mutation carriers patients (TGFßR2 group) were compared with those of 46 non-affected first degree relatives (control group). TGFßR2 mutation was associated with ventricular repolarization abnormalities in 47% of patients (p < 0.001 vs. controls), including a 19.6 ms (95%CI 8.7; 30.5) QTc interval prolongation compared to the non-affected first degree relatives (p < 0.001), higher prevalence of abnormal U waves (16% vs. 2%), and sinusoidal T-U morphology (10% vs. 0%). TGFßR2 mutations can be associated with abnormal ventricular repolarization pattern, longer QT interval than non-carrier relatives and an increased risk for sudden death.

Pregnancy and newborn outcomes in arrhythmogenic right ventricular cardiomyopathy/dysplasia.

INTRODUCTION: The prognosis of pregnancy in patients with Arrhythmogenic Right Ventricular Cardiomyopathy/dysplasia (ARVC/D) is poorly documented. The aim of this study is to assess the cardiac risks during pregnancy and the impact of ARVC/D on fetuses/neonates/children. METHODS: We included all ARVC/D women with a history of pregnancy from the ARVC/D Pitié-Salpêtrière registry. Cardiac and obstetrical events having occurred during pregnancy/delivery/post-partum periods and neonatal data/follow-up were collected. RESULTS: Sixty pregnancies in twenty-three patients were identified between 1968 and 2016. Only two major non-fatal cardiac events (one sustained non-documented tachycardia and one ventricular tachycardia) were recorded during pregnancy in two different mothers (3% of pregnancies, 9% of mothers). None occurred during delivery or in the postpartum period. No mother developed heart failure. Beta-blocker therapy during pregnancy (n=15) was associated with lower birthweight (2730 vs 3400g, p=0.004). Only two preterm deliveries occurred, unrelated to cardiac condition. Caesarean section was performed in 13% of cases. Premature sudden-death occurred in 10% (n=5) of children before 25years-old including two in the first year of life. CONCLUSION: ARVC/D is associated with a low rate of major cardiac events during pregnancy and vaginal delivery appears safe. The risk of sustained ventricular arrhythmia seems poorly predictable and supports the continuation of beta-blockers during pregnancy. Major cardiac events were frequent in childhood, justifying close cardiac monitoring.

Plakophilin 2A is the dominant isoform in human heart tissue: consequences for the genetic screening of arrhythmogenic right ventricular cardiomyopathy.

BACKGROUND: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited heart disease in which mutations affecting Plakophilin-2 (PKP2) are the most frequently detected. However, pathogenicity of variants is not always fully determined. PKP2 encodes two isoforms, the longest (PKP2b) includes the alternatively spliced exon 6, which is routinely screened for molecular diagnosis, despite the absence of data on cardiac expression of PKP2 isoforms. OBJECTIVE: To examine the pathogenicity of PKP2 exon 6 mutations by focusing on a missense variant located in this exon. METHODS AND RESULTS: The PKP2 heterozygous p.Arg490Trp variant was identified in two unrelated ARVC probands (absent from 470 controls). In silico analysis suggested that PKP2 exon 6 is an Alu-derived sequence with very low expression level. PKP2a mRNA, which does not include the sequence encoded by exon 6, was the dominant isoform transcribed; at western blot analysis PKP2A was the only clearly detectable isoform in all human heart samples analysed (from six different controls and the proband). Moreover, in the proband's sample, p.Arg490Trp was not associated with aberrant exon 6 splicing or mutant mRNA downregulation. Finally, a heterozygous missense variant (p.Glu2343Lys) in Desmoplakin was identified in this proband and is likely to be the disease-causing mutation. CONCLUSION: PKP2A was shown to be the major isoform expressed in human heart tissue and PKP2B protein was undetectable. The results strongly suggest that p.Arg490Trp and other variants located in PKP2 exon 6 may not be disease causing. Variant splicing also has important consequences for the interpretation of mutation analysis and genetic counselling in ARVC and other hereditary cardiac diseases.

[Genetics of inherited cardiomyopathies]. / Génétique des cardiomyopathies héréditaires.

Hereditary cardiomyopathy is a primitive disorder in which the heart muscle is structurally and functionally abnormal in the absence of any other cause of cardiomyopathy. They are separated into four phenotypic groups, hypertrophic cardiomyopathy, dilated cardiomyopathy, restrictive cardiomyopathy and arrhythmogenic cardiomyopathy of the right ventricle. Hypertrophic cardiomyopathy was the first identified at the molecular level and then the first to benefit of molecular testing. The molecular analyses were then extended the following years to the dilated cardiomyopathy and restrictive cardiomyopathy. The arrhythmogenic right ventricular cardiomyopathy was the latest to be analyzed at the molecular level because the identification of genes involved in that phenotype was published only in 2002 to 2006. The genetics analysis of these diseases has developed over the past decade and, although still complex, is now available in current hospital practice. The objectives of these tests are to confirm a diagnosis difficult to achieve by classic clinical approach and to perform predictive and presymptomatic diagnosis in families when the mutation was identified. This allows for appropriate care of patients at risk, and may respond to a request for prenatal diagnosis in particularly serious forms. These tests are framed in the context of genetic counselling consultation and patients are the subjects of a multidisciplinary care in reference centres.

[Neonatal forms of congenital long QT syndrome]. / Formes néonatales du syndrome de QT long congénital.

UNLABELLED: The neonatal congenital long QT syndrome (LQTS) is rare and of bad prognosis due to the presence of severe ventricular arrhythmia and conduction abnormalities. METHODS: we included 24 propositus newborns from our population with LQTS. Genetic study was possible in 19 cases. RESULTS: the diagnosis of LQTS was made according to a QT prolongation associated with a sinusal neonatal bradycardia (n=9) or a 2/1 AV block (n=15). The onset presentation consisted of syncope (n=2), torsades de pointes (n=7), cardiovascular collapse (n=5), cardiac arrest (n=1). The mean QTc was at 550+60 ms. During the neonatal period the treatment consisted of beta-blocking agents in all cases, associated with a definitive pacemaker implantation in 10 cases with 2/1 AV block. Three newborns with a 2/1 AV block died during the first month of life (one case due to a septecemia after implantation of a pacemaker, and two who were waiting for that implantation). All survivors remained asymptomatic during a follow-up period of 7 years. In all cases with a 2/1 AV block we identified mutations in HERG (n=8). Newborns with isolated sinusal bradycardia presented all a mutation in KCNQ1 (n=9). CONCLUSION: the LTQS with 2/1 AV block is preferably associated with mutation in HERO with a bad initial prognosis.

Consequences of treatment with dexamethasone in rats on the susceptibility of total plasma and isolated lipoprotein fractions to copper oxidation.

According to the oxidative hypothesis of atherosclerosis, a hyperoxidizability of lipoproteins could favor the development of the atherosclerotic process. Besides, it has been recently reported that models of elevated very-low-density-lipoprotein (VLDL) levels in rats resulted in an increased susceptibility of these VLDL to oxidation. Treatment with dexamethasone classically induces an increase in plasma VLDL concentration. The aim of our study was thus to assess the effects of a treatment with dexamethasone in rats on the susceptibility to copper oxidation, both on total plasma and on isolated lipoproteins. Male Sprague-Dawley rats aged three months were treated with a daily intraperitoneal injection of dexamethasone (1.5 mg per kg) for five days (DEX group), whereas control rats were fed ad libitum (AL group). In order to take into account the decrease of food intake induced by dexamethasone treatment, a group of pair-fed rats was constituted (PF group). These rats had the same food intake as rats of the DEX group and were treated with a daily isovolumic intraperitoneal injection of NaCl for 5 d. After 5 d treatment, rats were fasted overnight, then killed, and blood was collected on EDTA. Low-density lipoproteins (VLDL + LDL) and high-density lipoproteins (HDL) were isolated by ultracentrifugation. A copper oxidation was conducted both on total plasma and on isolated lipoproteins. As expected, after treatment with dexamethasone, plasma exhibited increased triglyceride and glucose levels. Similarly, VLDL + LDL of rats from the DEX group were enriched with triglycerides, when compared with VLDL + LDL of the other two groups of rats. Our major finding was a marked increase in the susceptibility of total plasma of the DEX group to copper oxidation, in comparison with the other two groups of rats. This oxidizability was assessed by the maximal level of oxidation products absorbing at 234 nm and classically considered to be conjugated dienes (7.46+/-0.70 micromol L(-1) in the DEX group vs. 3.36+/-0.40 and 2.05+/-0.60 micromol L(-1) in the AL and PF groups, respectively). Nevertheless, this higher oxidizability was not observed in the isolated lipoprotein fractions, as shown by the formation of lipid peroxidation products such as conjugated dienes, thiobarbituric-acid reactive substances, hydroperoxides, 7-ketocholesterol, and dienals. This is not in agreement with other models of hypertriglyceridemia that have been reported to induce a hyperoxidizability of lipoproteins in rats. Our results led us to hypothesize that other plasma components such as proteins could be involved in this susceptibility to oxidation. Indeed, the severe protein catabolism induced by dexamethasone treatment could support this hypothesis, by forming protein components that are more susceptible to oxidation, as shown by an increased carbonyl formation upon plasma copper oxidation.

Copper and cell-oxidized low-density lipoprotein induces activator protein 1 in fibroblasts, endothelial and smooth muscle cells.

The effect of cupric ion- or endothelial cell-oxidized low-density lipoproteins (LDL) on transcription factor AP1 activation was investigated by electrophoretic mobility shift assay. Both oxidized LDL induced AP1 activation in fibroblasts, endothelial and smooth muscle cells. This phenomenon was also observed in the presence of cycloheximide. alpha-Tocopherol, a lipophilic free radical scavenger, and N-acetylcysteine, an hydrophilic antioxidant, partially inhibited the stimulatory effect of Cu2+-oxidized LDL. LDL modified by the mixture of the oxygen radicals OH. and O2.-, which generated lipid peroxidation products, also initiated AP1 activation, whereas LDL modified by OH. alone, which did not lead to marked LDL lipid peroxidation, was ineffective. Thus, lipid peroxidation products seem at least partially involved in the activation mechanism. Since AP1 activity is essential for the regulation of genes involved in cell growth and differentiation, our study suggests that the oxidative stress induced by oxidized LDL might be related to the fibroproliferative response observed in the atherosclerotic plaque.

Hydroxyl radical attack of low density lipoprotein decreases its cellular catabolism in the absence of significant lipid peroxidation.

Low density lipoprotein (LDL) has been submitted to oxidative modification induced by gamma radiolysis of water under conditions generating either hydroxyl radical (OH.) alone, or a mixture of superoxide anion and OH.. Treatment of LDL with hydroxyl radical alone did not lead to significant lipid peroxidation as assessed by thiobarbituric acid reactive substances (TBARS) and hydroperoxide measurement and induced only very small change in the electrophoretic mobility of the particle. In contrast, superoxide and hydroxyl radical mixture induced a dose-dependent increase in lipid peroxidation, with a marked elevation of the negative net charge of the LDL. However, in both cases, a similar reduction of the uptake and degradation of modified LDL by the apo B/E receptor pathway of human fibroblasts was observed. This suggests that factors other than lipid peroxidation could play a role in LDL modification and influence their cellular metabolism.