Hypoplastic left heart syndrome (HLHS) is a clinically and anatomically severe form of congenital heart disease; however, its etiology remains largely unknown. We previously demonstrated that genetic variants in the MYH6 gene are significantly associated with HLHS. Additionally, induced pluripotent stem cell-derived cardiomyocytes (iPSC-CMs) from an HLHS-affected family trio (affected parent, unaffected parent, affected proband) carrying an MYH6-R443P head domain variant demonstrated dysmorphic sarcomere structure and increased compensatory MYH7 expression. Analysis of iPSC-CMs derived from the HLHS trio revealed that only beta myosin heavy chain expression was observed in CMs carrying the MYH6-R443P variant after differentiation day 15 (D15). Functional assessments performed between D20-D23 revealed that MYH6-R443P variant CMs contracted more slowly (40 ± 2 vs. 47 ± 2 contractions/min, P < 0.05), shortened less (5.6 ± 0.5 vs. 8.1 ± 0.7% of cell length, P < 0.05), and exhibited slower shortening rates (19.9 ± 1.7 vs. 28.1 ± 2.5 µm/s, P < 0.05) and relaxation rates (11.0 ± 0.9 vs. 19.7 ± 2.0 µm/s, P < 0.05). Treatment with isoproterenol had no effect on iPSC-CM mechanics. Using CRISPR/Cas9 gene editing technology, introduction of the R443P variant into the unaffected parent's iPSCs recapitulated the phenotype of the proband's iPSC-CMs, and conversely, correction of the R443P variant in the proband's iPSCs rescued the cardiomyogenic differentiation, sarcomere organization, slower contraction (P < 0.05) and decreased velocity phenotypes (P < 0.0001). This is the first report to identify that cardiac tissues from HLHS patients with MYH6 variants can exhibit sarcomere disorganization in atrial but not ventricular tissues. This new discovery was not unexpected, since MYH6 is expressed predominantly in the postnatal atria in humans. These findings demonstrate the feasibility of employing patient-derived

Background: Ebstein's anomaly (EA) is a rare congenital heart disease of the tricuspid valve and right ventricle. Patients with EA often manifest with left ventricular noncompaction (LVNC), a cardiomyopathy. Despite implication of cardiac sarcomere genes in some cases, very little is understood regarding the genetic etiology of EA/LVNC. Our study describes a multigenerational family with at least 10 of 17 members affected by EA/LVNC. Methods: We performed echocardiography on all family members and conducted exome sequencing of six individuals. After identifying candidate variants using two different bioinformatic strategies, we confirmed segregation with phenotype using Sanger sequencing. We investigated structural implications of candidate variants using protein prediction models. Results: Exome sequencing analysis of four affected and two unaffected members identified a novel, rare, and damaging coding variant in the Kelch-like family member 26 (KLHL26) gene located on chromosome 19 at position 237 of the protein (GRCh37). This variant region was confirmed by Sanger sequencing in the remaining family members. KLHL26 (c.709C > T p.R237C) segregates only with EA/ 2 of 9 | SAMUDRALA et AL.

Traditional definitions of Ebstein’s anomaly (EA) and left ventricular noncompaction (LVNC), two rare congenital heart defects (CHDs), confine disease to either the right or left heart, respectively. Around 15–29% of patients with EA, which has a prevalence of 1 in 20,000 live births, commonly manifest with LVNC. While individual EA or LVNC literature is extensive, relatively little discussion is devoted to the joint appearance of EA and LVNC (EA/LVNC), which poses a higher risk of poor clinical outcomes. We queried PubMed, Medline, and Web of Science for all peer-reviewed publications from inception to February 2022 that discuss EA/LVNC and found 58 unique articles written in English. Here, we summarize and extrapolate commonalities in clinical and genetic understanding of EA/LVNC to date. We additionally postulate involvement of shared developmental pathways that may lead to this combined disease. Anatomical variation in EA/LVNC encompasses characteristics of both CHDs, including tricuspid valve displacement, right heart dilatation, and left ventricular trabeculation, and dictates clinical presentation in both age and severity. Disease treatment is non-specific, ranging from symptomatic management to invasive surgery. Apart from a few variant associations, mainly in sarcomeric genes MYH7 and TPM1, the genetic etiology and pathogenesis of EA/LVNC remain largely unknown.

The inside cover image is based on the Original Article Novel KLHL26 variant associated with a familial case of Ebsteinșs anomaly and left ventricular noncompaction by Sai Suma K. Samudrala et al., https://doi.org/10.1002/mgg3.1152.

Hypoplastic left heart syndrome (HLHS) is a complex form of congenital heart disease (CHD) characterized by hypoplasia of the left ventricle and proximal aorta, as well as stenosis or atresia of the mitral and aortic valves. Our lab previously identified that rare, predicted-damaging variants in the gene encoding for α-myosin heavy chain ( MYH6, α-MHC), a key contractile protein in the heart, are enriched in HLHS. It has been shown that pathological variants in the MHC head domain directly alter force generation, but mechanisms by which tail domain variants cause contractile defects are less clear.In double-blind analyses, patient-specific induced pluripotent stem cell-derived cardiomyocytes (iPSC-CMs) carrying the MYH6 E1584K tail domain variant (VAR) showed significant structural and functional deficits compared to wild-type (WT). Consistent with our previously reported findings in atrial tissue from a patient carrying MYH6 E1584K, VAR iPSC-CMs exhibited sarcomere disarray (p<0.001) and altered sarcomeric gene expression (p<0.05). VAR iPSC-CMs display a hypercontractile phenotype compared to WT, with increased amplitude (2.16μm VAR, 1.32μm WT; p<0.05) and duration (233 msec VAR, 173 msec WT; p<0.05) of contraction and elongated relaxation times (270 msec VAR, 190 msec WT; p<0.01). Hypercontractility was also observed in bulk culture, where VAR iPSC-CMs demonstrated increased amplitude (1413.4 a.u. VAR, 993.6 a.u. WT, p<0.05) and velocity of contraction (1493.7 a.u./msec VAR, 982.2 a.u./msec WT, p<0.05). Notably, this is different than our previous reports of iPSC-CMs carrying the head domain variant MYH6 R443P, which exhibited decreased contraction velocity.Our data demonstrate the mechanism of MYH6 pathogenicity is distinct between variants, emphasizing the importance of mechanistic studies to inform clinical decision-making. Furthermore, this work will direct future investigations into the genetic etiology and physiology of CHD and provide a framework upon which personalized treatment strategies can be developed. Future studies will examine the effect of myosin modulators omecamtiv mecarbil (OM) and mavacamten on MYH6 variant iPSC-CMs. Advancing a Healthier Wisconsin Endowment This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.