A new SCN5A-related cardiac syndrome, MEPPC, was identified. The SCN5A mutation leads to a gain of function of the sodium channel responsible for hyperexcitability of the fascicular-Purkinje system. The MEPPC syndrome is responsive to hydroquinidine.

T he cardiac action potential (AP) is initiated by the Na + channel Na V 1.5, an established key element for cardiac excitability and impulse propagation. The importance of Na V 1.5 is exemplified by the myriad of cardiac disorders caused by hundreds of mutations identified in SCN5A, the gene coding for Na V 1.5.1 For some SCN5A mutation carriers, cardiac conduction slowing or block, secondary to reduced Na + channel function, predisposes them to ventricular arrhythmias and sudden cardiac death. Editorial see p 132 Clinical Perspective on p 160The cardiac Na + channel is composed of a 220-kDa α-subunit, Na V 1.5, constituting the pore of the channel, which is known to associate with four ≈30-kDa β-subunits. Recent studies have demonstrated that many proteins interact with and regulate Na V 1.5. 2 The physiological relevance of these interactions, however, is poorly understood, mainly due to a lack of in vivo studies. Many protein-protein interaction motifs for these regulatory proteins are located at the C-terminus of Na V 1.5. 2 In particular, we have previously demonstrated that Na V 1.5 associates with the dystrophinsyntrophin multiprotein complex (DMC) in cardiac cells.3 InBackground-Sodium channel Na V 1.5 underlies cardiac excitability and conduction. The last 3 residues of Na V 1.5 (Ser-IleVal) constitute a PDZ domain-binding motif that interacts with PDZ proteins such as syntrophins and SAP97 at different locations within the cardiomyocyte, thus defining distinct pools of Na V 1.5 multiprotein complexes. Here, we explored the in vivo and clinical impact of this motif through characterization of mutant mice and genetic screening of patients. Methods and Results-To investigate in vivo the regulatory role of this motif, we generated knock-in mice lacking the SIV domain (∆SIV). ∆SIV mice displayed reduced Na V 1.5 expression and sodium current (I Na ), specifically at the lateral myocyte membrane, whereas Na V 1.5 expression and I Na at the intercalated disks were unaffected. Optical mapping of ∆SIV hearts revealed that ventricular conduction velocity was preferentially decreased in the transversal direction to myocardial fiber orientation, leading to increased anisotropy of ventricular conduction. Internalization of wild-type and ΔSIV channels was unchanged in HEK293 cells. However, the proteasome inhibitor MG132 rescued ΔSIV I Na , suggesting that the SIV motif is important for regulation of Na V 1.5 degradation. A missense mutation within the SIV motif (p.V2016M) was identified in a patient with Brugada syndrome. The mutation decreased Na V 1.5 cell surface expression and I Na when expressed in HEK293 cells. Conclusions-Our results demonstrate the in vivo significance of the PDZ domain-binding motif in the correct expression of Na V 1.5 at the lateral cardiomyocyte membrane and underline the functional role of lateral Na V 1.5 in ventricular conduction. Recherche 1087, L'Institut du Thorax, Nantes, France (R.R.); Centre National de la Recherche Scientifique Unité Mixte de Recherche 6291, Nantes, France...