Mutations in the gene encoding the phosphoinositide 3-phosphatase myotubularin (MTM1) are responsible for a pediatric disease of skeletal muscle named myotubular myopathy (XLMTM). Muscle fibers from MTM1-deficient mice present defects in excitation-contraction (EC) coupling likely responsible for the disease-associated fatal muscle weakness. However, the mechanism leading to EC coupling failure remains unclear. During normal skeletal muscle EC coupling, transverse (t) tubule depolarization triggers sarcoplasmic reticulum (SR) Ca 2+ release through ryanodine receptor channels gated by conformational coupling with the t-tubule voltage-sensing dihydropyridine receptors. We report that MTM1 deficiency is associated with a 60% depression of global SR Ca 2+ release over the full range of voltage sensitivity of EC coupling. SR Ca 2+ release in the diseased fibers is also slower than in normal fibers, or delayed following voltage activation, consistent with the contribution of Ca 2+ -gated ryanodine receptors to EC coupling. In addition, we found that SR Ca 2+ release is spatially heterogeneous within myotubularin-deficient muscle fibers, with focally defective areas recapitulating the global alterations. Importantly, we found that pharmacological inhibition of phosphatidylinositol 3-kinase (PtdIns 3-kinase) activity rescues the Ca 2+ release defects in isolated muscle fibers and increases the lifespan and mobility of XLMTM mice, providing proof of concept for the use of PtdIns 3-kinase inhibitors in myotubular myopathy and suggesting that unbalanced PtdIns 3-kinase activity plays a critical role in the pathological process.skeletal muscle | excitation-contraction coupling | ryanodine receptor | sarcoplasmic reticulum Ca 2+ release | myotubularin I mpaired skeletal muscle excitation-contraction (EC) coupling is believed to be a main cause of the severe muscle weakness associated with myotubular myopathy (1). EC coupling operates through interactions between the voltage-sensing CAV1.1 Ca 2+ channel (also known as the dihydropyridine receptor) in the transverse (t) tubule membrane and the type 1 ryanodine receptor (RYR1) Ca 2+ release channel in the junctional sarcoplasmic reticulum (SR) membrane: Opening of RYR1 channels under the control of the CAV1.1 voltage-sensing activity is responsible for the Ca 2+ flux that raises cytosolic Ca 2+ to trigger contraction (2, 3). Myotubular myopathy is due to genetic deficiency in the phosphoinositide (phosphatidylinositol, PtdInsP) phosphatase MTM1, which dephosphorylates PtdIns(3,5)P 2 and PtdIns(3)P at the D3 position of the inositol ring (4, 5). How MTM1 deficiency is responsible for defective EC coupling remains unclear, and this issue is highly relevant to understanding the mechanisms of the disease but also to gaining insights into the interactions between phosphoinositides and Ca 2+ signaling in muscle (see ref. 6). The Mtm1-KO mouse model reproduces the main symptomatic features of the human disease: Mutant mice develop a progressive myopathy that starts at about 3-4 wk of ...