title: A Precision Medicine Approach to the Rescue of Function on Malignant Calmodulinopathic Long-QT Syndrome.
abstract: BACKGROUND
  Calmodulinopathies comprise a new category of potentially life-threatening genetic arrhythmia syndromes capable of producing severe long-QT syndrome (LQTS) with mutations involving CALM1, CALM2, or CALM3. The underlying basis of this form of LQTS is a disruption of Ca2+/calmodulin (CaM)-dependent inactivation of L-type Ca2+channels.
  
  
  OBJECTIVE
  To gain insight into the mechanistic underpinnings of calmodulinopathies and devise new therapeutic strategies for the treatment of this form of LQTS.
  
  
  RESULTS
  We generated and characterized the functional properties of induced pluripotent stem cell-derived cardiomyocytes from a patient with D130G-CALM2-mediated LQTS, thus creating a platform with which to devise and test novel therapeutic strategies. The patient-derived induced pluripotent stem cell-derived cardiomyocytes display (1) significantly prolonged action potentials, (2) disrupted Ca2+cycling properties, and (3) diminished Ca2+/CaM-dependent inactivation of L-type Ca2+channels. Next, taking advantage of the fact that calmodulinopathy patients harbor a mutation in only 1 of 6 redundant CaM-encoding alleles, we devised a strategy using CRISPR interference to selectively suppress the mutant gene while sparing the wild-type counterparts. Indeed, suppression of CALM2 expression produced a functional rescue in induced pluripotent stem cell-derived cardiomyocytes with D130G-CALM2, as shown by the normalization of action potential duration and Ca2+/CaM-dependent inactivation after treatment. Moreover, CRISPR interference can be designed to achieve selective knockdown of any of the 3 CALM genes, making it a generalizable therapeutic strategy for any calmodulinopathy.
  
  
  CONCLUSIONS
  Overall, this therapeutic strategy holds great promise for calmodulinopathy patients as it represents a generalizable intervention capable of specifically altering CaM expression and potentially attenuating LQTS-triggered cardiac events, thus initiating a path toward precision medicine.
authors.affiliation: From the Calcium Signals Laboratory, Department of Biomedical Engineering (W.B.L., I.E.D., W.Y., M.H.C., J.B., D.T.Y.) and Division of Cardiology, Department of Medicine (P.L., D.D., G.F.T.), The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Physiology, The University of Maryland School of Medicine, Baltimore (I.E.D.); Division of Heart Rhythm Services, Department of Cardiovascular Diseases (D.J.T., N.J.B., M.J.A.), Division of Pediatric Cardiology, Department of Pediatrics (D.J.T., N.J.B., M.J.A.), and Windland Smith Rice Sudden Death Genomics Laboratory, Department of Molecular Pharmacology and Experimental Therapeutics (D.J.T., N.J.B., M.J.A.), Mayo Clinic, Rochester, MN; and Division of Cardiology, Nicklaus Children's Hospital, Miami, FL (R.J.K.).
authors.forename: Worawan B
authors.initials: WB
authors.lastname: Limpitikul
authors.affiliation: From the Calcium Signals Laboratory, Department of Biomedical Engineering (W.B.L., I.E.D., W.Y., M.H.C., J.B., D.T.Y.) and Division of Cardiology, Department of Medicine (P.L., D.D., G.F.T.), The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Physiology, The University of Maryland School of Medicine, Baltimore (I.E.D.); Division of Heart Rhythm Services, Department of Cardiovascular Diseases (D.J.T., N.J.B., M.J.A.), Division of Pediatric Cardiology, Department of Pediatrics (D.J.T., N.J.B., M.J.A.), and Windland Smith Rice Sudden Death Genomics Laboratory, Department of Molecular Pharmacology and Experimental Therapeutics (D.J.T., N.J.B., M.J.A.), Mayo Clinic, Rochester, MN; and Division of Cardiology, Nicklaus Children's Hospital, Miami, FL (R.J.K.).
authors.forename: Ivy E
authors.initials: IE
authors.lastname: Dick
authors.affiliation: From the Calcium Signals Laboratory, Department of Biomedical Engineering (W.B.L., I.E.D., W.Y., M.H.C., J.B., D.T.Y.) and Division of Cardiology, Department of Medicine (P.L., D.D., G.F.T.), The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Physiology, The University of Maryland School of Medicine, Baltimore (I.E.D.); Division of Heart Rhythm Services, Department of Cardiovascular Diseases (D.J.T., N.J.B., M.J.A.), Division of Pediatric Cardiology, Department of Pediatrics (D.J.T., N.J.B., M.J.A.), and Windland Smith Rice Sudden Death Genomics Laboratory, Department of Molecular Pharmacology and Experimental Therapeutics (D.J.T., N.J.B., M.J.A.), Mayo Clinic, Rochester, MN; and Division of Cardiology, Nicklaus Children's Hospital, Miami, FL (R.J.K.).
authors.forename: David J
authors.initials: DJ
authors.lastname: Tester
authors.affiliation: From the Calcium Signals Laboratory, Department of Biomedical Engineering (W.B.L., I.E.D., W.Y., M.H.C., J.B., D.T.Y.) and Division of Cardiology, Department of Medicine (P.L., D.D., G.F.T.), The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Physiology, The University of Maryland School of Medicine, Baltimore (I.E.D.); Division of Heart Rhythm Services, Department of Cardiovascular Diseases (D.J.T., N.J.B., M.J.A.), Division of Pediatric Cardiology, Department of Pediatrics (D.J.T., N.J.B., M.J.A.), and Windland Smith Rice Sudden Death Genomics Laboratory, Department of Molecular Pharmacology and Experimental Therapeutics (D.J.T., N.J.B., M.J.A.), Mayo Clinic, Rochester, MN; and Division of Cardiology, Nicklaus Children's Hospital, Miami, FL (R.J.K.).
authors.forename: Nicole J
authors.initials: NJ
authors.lastname: Boczek
authors.affiliation: From the Calcium Signals Laboratory, Department of Biomedical Engineering (W.B.L., I.E.D., W.Y., M.H.C., J.B., D.T.Y.) and Division of Cardiology, Department of Medicine (P.L., D.D., G.F.T.), The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Physiology, The University of Maryland School of Medicine, Baltimore (I.E.D.); Division of Heart Rhythm Services, Department of Cardiovascular Diseases (D.J.T., N.J.B., M.J.A.), Division of Pediatric Cardiology, Department of Pediatrics (D.J.T., N.J.B., M.J.A.), and Windland Smith Rice Sudden Death Genomics Laboratory, Department of Molecular Pharmacology and Experimental Therapeutics (D.J.T., N.J.B., M.J.A.), Mayo Clinic, Rochester, MN; and Division of Cardiology, Nicklaus Children's Hospital, Miami, FL (R.J.K.).
authors.forename: Pattraranee
authors.initials: P
authors.lastname: Limphong
authors.affiliation: From the Calcium Signals Laboratory, Department of Biomedical Engineering (W.B.L., I.E.D., W.Y., M.H.C., J.B., D.T.Y.) and Division of Cardiology, Department of Medicine (P.L., D.D., G.F.T.), The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Physiology, The University of Maryland School of Medicine, Baltimore (I.E.D.); Division of Heart Rhythm Services, Department of Cardiovascular Diseases (D.J.T., N.J.B., M.J.A.), Division of Pediatric Cardiology, Department of Pediatrics (D.J.T., N.J.B., M.J.A.), and Windland Smith Rice Sudden Death Genomics Laboratory, Department of Molecular Pharmacology and Experimental Therapeutics (D.J.T., N.J.B., M.J.A.), Mayo Clinic, Rochester, MN; and Division of Cardiology, Nicklaus Children's Hospital, Miami, FL (R.J.K.).
authors.forename: Wanjun
authors.initials: W
authors.lastname: Yang
authors.affiliation: From the Calcium Signals Laboratory, Department of Biomedical Engineering (W.B.L., I.E.D., W.Y., M.H.C., J.B., D.T.Y.) and Division of Cardiology, Department of Medicine (P.L., D.D., G.F.T.), The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Physiology, The University of Maryland School of Medicine, Baltimore (I.E.D.); Division of Heart Rhythm Services, Department of Cardiovascular Diseases (D.J.T., N.J.B., M.J.A.), Division of Pediatric Cardiology, Department of Pediatrics (D.J.T., N.J.B., M.J.A.), and Windland Smith Rice Sudden Death Genomics Laboratory, Department of Molecular Pharmacology and Experimental Therapeutics (D.J.T., N.J.B., M.J.A.), Mayo Clinic, Rochester, MN; and Division of Cardiology, Nicklaus Children's Hospital, Miami, FL (R.J.K.).
authors.forename: Myoung Hyun
authors.initials: MH
authors.lastname: Choi
authors.affiliation: From the Calcium Signals Laboratory, Department of Biomedical Engineering (W.B.L., I.E.D., W.Y., M.H.C., J.B., D.T.Y.) and Division of Cardiology, Department of Medicine (P.L., D.D., G.F.T.), The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Physiology, The University of Maryland School of Medicine, Baltimore (I.E.D.); Division of Heart Rhythm Services, Department of Cardiovascular Diseases (D.J.T., N.J.B., M.J.A.), Division of Pediatric Cardiology, Department of Pediatrics (D.J.T., N.J.B., M.J.A.), and Windland Smith Rice Sudden Death Genomics Laboratory, Department of Molecular Pharmacology and Experimental Therapeutics (D.J.T., N.J.B., M.J.A.), Mayo Clinic, Rochester, MN; and Division of Cardiology, Nicklaus Children's Hospital, Miami, FL (R.J.K.).
authors.forename: Jennifer
authors.initials: J
authors.lastname: Babich
authors.affiliation: From the Calcium Signals Laboratory, Department of Biomedical Engineering (W.B.L., I.E.D., W.Y., M.H.C., J.B., D.T.Y.) and Division of Cardiology, Department of Medicine (P.L., D.D., G.F.T.), The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Physiology, The University of Maryland School of Medicine, Baltimore (I.E.D.); Division of Heart Rhythm Services, Department of Cardiovascular Diseases (D.J.T., N.J.B., M.J.A.), Division of Pediatric Cardiology, Department of Pediatrics (D.J.T., N.J.B., M.J.A.), and Windland Smith Rice Sudden Death Genomics Laboratory, Department of Molecular Pharmacology and Experimental Therapeutics (D.J.T., N.J.B., M.J.A.), Mayo Clinic, Rochester, MN; and Division of Cardiology, Nicklaus Children's Hospital, Miami, FL (R.J.K.).
authors.forename: Deborah
authors.initials: D
authors.lastname: DiSilvestre
authors.affiliation: From the Calcium Signals Laboratory, Department of Biomedical Engineering (W.B.L., I.E.D., W.Y., M.H.C., J.B., D.T.Y.) and Division of Cardiology, Department of Medicine (P.L., D.D., G.F.T.), The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Physiology, The University of Maryland School of Medicine, Baltimore (I.E.D.); Division of Heart Rhythm Services, Department of Cardiovascular Diseases (D.J.T., N.J.B., M.J.A.), Division of Pediatric Cardiology, Department of Pediatrics (D.J.T., N.J.B., M.J.A.), and Windland Smith Rice Sudden Death Genomics Laboratory, Department of Molecular Pharmacology and Experimental Therapeutics (D.J.T., N.J.B., M.J.A.), Mayo Clinic, Rochester, MN; and Division of Cardiology, Nicklaus Children's Hospital, Miami, FL (R.J.K.).
authors.forename: Ronald J
authors.initials: RJ
authors.lastname: Kanter
authors.affiliation: From the Calcium Signals Laboratory, Department of Biomedical Engineering (W.B.L., I.E.D., W.Y., M.H.C., J.B., D.T.Y.) and Division of Cardiology, Department of Medicine (P.L., D.D., G.F.T.), The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Physiology, The University of Maryland School of Medicine, Baltimore (I.E.D.); Division of Heart Rhythm Services, Department of Cardiovascular Diseases (D.J.T., N.J.B., M.J.A.), Division of Pediatric Cardiology, Department of Pediatrics (D.J.T., N.J.B., M.J.A.), and Windland Smith Rice Sudden Death Genomics Laboratory, Department of Molecular Pharmacology and Experimental Therapeutics (D.J.T., N.J.B., M.J.A.), Mayo Clinic, Rochester, MN; and Division of Cardiology, Nicklaus Children's Hospital, Miami, FL (R.J.K.). gtomasel@jhmi.edu ackerman.michael@mayo.edu.
authors.forename: Gordon F
authors.initials: GF
authors.lastname: Tomaselli
authors.affiliation: From the Calcium Signals Laboratory, Department of Biomedical Engineering (W.B.L., I.E.D., W.Y., M.H.C., J.B., D.T.Y.) and Division of Cardiology, Department of Medicine (P.L., D.D., G.F.T.), The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Physiology, The University of Maryland School of Medicine, Baltimore (I.E.D.); Division of Heart Rhythm Services, Department of Cardiovascular Diseases (D.J.T., N.J.B., M.J.A.), Division of Pediatric Cardiology, Department of Pediatrics (D.J.T., N.J.B., M.J.A.), and Windland Smith Rice Sudden Death Genomics Laboratory, Department of Molecular Pharmacology and Experimental Therapeutics (D.J.T., N.J.B., M.J.A.), Mayo Clinic, Rochester, MN; and Division of Cardiology, Nicklaus Children's Hospital, Miami, FL (R.J.K.).
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Ackerman
authors.affiliation: From the Calcium Signals Laboratory, Department of Biomedical Engineering (W.B.L., I.E.D., W.Y., M.H.C., J.B., D.T.Y.) and Division of Cardiology, Department of Medicine (P.L., D.D., G.F.T.), The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Physiology, The University of Maryland School of Medicine, Baltimore (I.E.D.); Division of Heart Rhythm Services, Department of Cardiovascular Diseases (D.J.T., N.J.B., M.J.A.), Division of Pediatric Cardiology, Department of Pediatrics (D.J.T., N.J.B., M.J.A.), and Windland Smith Rice Sudden Death Genomics Laboratory, Department of Molecular Pharmacology and Experimental Therapeutics (D.J.T., N.J.B., M.J.A.), Mayo Clinic, Rochester, MN; and Division of Cardiology, Nicklaus Children's Hospital, Miami, FL (R.J.K.).
authors.forename: David T
authors.initials: DT
authors.lastname: Yue
mesh_terms: D002147:Calmodulin / Q000235:genetics*; D002478:Cells, Cultured; D064112:Clustered Regularly Interspaced Short Palindromic Repeats / Q000235:genetics; D005260:Female; D006801:Humans; D057026:Induced Pluripotent Stem Cells / Q000502:physiology* / Q000637:transplantation; D008133:Long QT Syndrome / Q000175:diagnosis / Q000235:genetics* / Q000628:therapy*; D020125:Mutation, Missense / Q000235:genetics; D057285:Precision Medicine / Q000379:methods*
chemical_list: D002147:Calmodulin
keywords: L-type calcium channels; action potential; calmodulin; induced pluripotent stem cells; long-QT syndrome; nucleotides