Demetrio Julián Santiago

Cardiac Calsequestrin (CASQ2) polymerizes within the junctional sarcoplasmic reticulum to buffer Ca ²⁺ and regulate ryanodine receptor 2 (RyR2) gating, yet the molecular mechanism governing this process remains poorly understood. Using an integrated set of complementary approaches spanning single-particle biophysics, bulk solution measurements, and polymer chemistry, we demonstrate that CASQ2 is an intrinsic dimer at nanomolar concentrations and under physiological ionic conditions, independently of CaCa ²⁺ . In addition, CaCa ²⁺ -dependent polymerization operates as a highly cooperative switch between a stable oligomeric phase and a high-order polymeric state. Physiological amounts of KCa ⁺ ions modulate this switch through a biphasic electrostatic mechanism, supporting polymerization at low concentrations and inhibiting it beyond charge neutralization (≈194 mM). These findings redefine CASQ2 as an intrinsic dimer with polymerization-switch properties, and provide a mechanistic framework for understanding how catecholaminergic polymorphic ventricular tachycardia type 2 mutations, distributed evenly across the CASQ2 surface, cause disease through two distinct pathological trajectories.

While calcium (Ca²⁺) is a universal cellular messenger, the ionic properties of magnesium (Mg²⁺) make it less suited for rapid signaling and more for structural integrity. Still, besides being a passive player, Mg²⁺ is the only active Ca²⁺ antagonist, essential for tuning the efficacy of Ca²⁺-dependent cardiac excitation–contraction coupling (ECC) and for ensuring cardiac function robustness and stability. This review aims to provide a comprehensive framework to link the structural and molecular mechanisms of Mg²⁺/Ca²⁺ antagonistic binding across key proteins of the cardiac ECC machinery to their physiopathological relevance. The pervasive “dampening” effect of Mg²⁺ on ECC activity is exerted across various players and mechanisms, and lies in the ions’ physiological competition for multiple, flexible binding protein motifs across multiple compartments. Mg²⁺ profoundly modulates the cardiac action potential waveform by inhibiting the L-type Ca²⁺ channel Cav1.2, i.e., the key trigger of cardiac ryanodine receptor (RyR2) opening. Cytosolic Mg²⁺ favors RyR2 closed or inactive conformations not only through physical binding at specific sites, but also indirectly through modulation of RyR2 phosphorylation by Camk2d and PKA. RyR2 is also potently inhibited by luminal Mg²⁺, a vital mechanism in the cardiac setting for preventing excessive Ca²⁺ release during diastole. This mechanism, able to distinguish between Ca²⁺ and Mg²⁺, is mediated by luminal partners Calsequestrin 2 (CASQ2) and Triadin (TRDN). In addition, Mg²⁺ favors a rearrangement of the RyR2 cluster configuration that is associated with lower Ca²⁺ spark frequencies.

Timothy syndrome 1 (TS1) is a multi-organ form of long QT syndrome associated with life-threatening cardiac arrhythmias, the organ-level dynamics of which remain unclear. In this study, we developed and characterized a novel porcine model of TS1 carrying the causative p.Gly406Arg mutation in CACNA1C, known to impair Ca_V1.2 channel inactivation. Our model fully recapitulated the human disease with prolonged QT interval and arrhythmic mortality. Electroanatomical mapping revealed the presence of a functional substrate vulnerable to reentry, stemming from an unforeseen constitutional slowing of cardiac activation. This signature substrate of TS1 was reliably identified using the reentry vulnerability index, which, we further demonstrate, can be used as a benchmark for assessing treatment efficacy, as shown by testing of multiple clinical and preclinical anti-arrhythmic compounds. Notably, in vitro experiments showed that TS1 cardiomyocytes display Ca²⁺ overload and decreased peak I_Na current, providing a rationale for the arrhythmogenic slowing of impulse propagation in vivo.

Calsequestrin (CASQ) is a key intra-sarcoplasmic reticulum Ca²⁺-handling protein that plays a pivotal role in the contraction of cardiac and skeletal muscles. Its Ca²⁺-dependent polymerization dynamics shape the translation of electric excitation signals to the Ca²⁺-induced contraction of the actin-myosin architecture. Mutations in CASQ are linked to life-threatening pathological conditions, including tubular aggregate myopathy, malignant hyperthermia, and Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT). The variability in the penetrance of these phenotypes and the lack of a clear understanding of the disease mechanisms associated with CASQ mutations pose a major challenge to the development of effective therapeutic strategies. In vitro studies have mainly focused on the polymerization and Ca²⁺-buffering properties of CASQ but have provided little insight into the complex interplay of structural and functional changes that underlie disease. In this review, the biochemical and structural natures of CASQ are explored in-depth, while emphasizing their direct and indirect consequences for muscle Ca²⁺ physiology. We propose a novel functional classification of CASQ pathological missense mutations based on the structural stability of the monomer, dimer, or linear polymer conformation. We also highlight emerging similarities between polymeric CASQ and polyelectrolyte systems, emphasizing the potential for the use of this paradigm to guide further research.

This editorial refers to ‘Loss-of-function mutations in cardiac ryanodine receptor channel cause various types of arrhythmias including long QT syndrome’ by S. Hirose et al., pp. 497–510. Hirose et al. ¹ propose a novel conceptual frame in which loss-of-function (LOF) mutations of the cardiac ryanodine receptor (RyR2) have the potential to be stratified in two kinds, moderate and severe, depending on how drastically they depress the Ca²⁺-dependent activity of RyR2s. Moderate mutations cause affected channels to operate with lower activity than wild-type (WT) channels, whereas severe mutations render RyR2s that barely activate, in separate in vitro tests. From this molecular stratification of LOF severity, Hirose et al. present the clinical cases of four heterozygous LOF carriers to further show that, counter-intuitively, in vitro experiments and electrocardiographic data indicate an association between severe mutations and milder arrhythmogenic phenotypes. Conversely, moderate LOF mutations were associated with more complex, life-threatening arrhythmias. These findings highlight that the in vivo effects of RyR2 LOF mutations may be more complex than anticipated, stressing that LOF severity, while evaluated from a molecular standpoint of view (today’s gold standard), should also be defined in terms of patient’s phenotypes.

Cells sense the presence of more than one version of mtDNA and select the variant according to its impact on function.

Key points: Ventricular arrhythmias are a major complication after myocardial infarction (MI), associated with sympathetic activation. The structurally heterogeneous peri‐infarct zone is a known substrate, but the functional role of the myocytes is less well known. Recordings of monophasic action potentials in vivo reveal that the peri‐infarct zone is a source of delayed afterdepolarizations (DADs) and has a high beat‐to‐beat variability of repolarization (BVR) during adrenergic stimulation (isoproterenol, ISO). Myocytes isolated from the peri‐infarct region have more DADs and spontaneous action potentials, with spontaneous Ca²⁺ release, under ISO. These myocytes also have reduced repolarization reserve and increased BVR. Other properties of post‐MI remodelling are present in both peri‐infarct and remote myocytes. These data highlight the importance of altered myocyte adrenergic responses in the peri‐infarct region as source and substrate of post‐MI arrhythmias. Ventricular arrhythmias are a major early complication after myocardial infarction (MI). The heterogeneous peri‐infarct zone forms a substrate for re‐entry while arrhythmia initiation is often associated with sympathetic activation. We studied the mechanisms triggering these post‐MI arrhythmias in vivo and their relation to regional myocyte remodelling. In pigs with chronic MI (6 weeks), in vivo monophasic action potentials were simultaneously recorded in the peri‐infarct and remote regions during adrenergic stimulation with isoproterenol (isoprenaline; ISO). Sham animals served as controls. During infusion of ISO in vivo, the incidence of delayed afterdepolarizations (DADs) and beat‐to‐beat variability of repolarization (BVR) was higher in the peri‐infarct than in the remote region. Myocytes isolated from the peri‐infarct region, in comparison to myocytes from the remote region, had more DADs, associated with spontaneous Ca²⁺ release, and a higher incidence of spontaneous action potentials (APs) when exposed to ISO (9.99 ± 4.2 vs. 0.16 ± 0.05 APs/min, p = 0.004); these were suppressed by CaMKII inhibition. Peri‐infarct myocytes also had reduced repolarization reserve and increased BVR (26 ± 10 ms vs. 9 ± 7 ms, P < 0.001), correlating with DAD activity. In contrast to these regional distinctions under ISO, alterations in Ca²⁺ handling at baseline and myocyte hypertrophy were present throughout the left ventricle (LV). Expression of some of the related genes was, however, different between the regions. In conclusion, altered myocyte adrenergic responses in the peri‐infarct but not the remote region provide a source of triggered activity in vivo and of repolarization instability amplifying the substrate for re‐entry. These findings stimulate further exploration of region‐specific therapies targeting myocytes and autonomic modulation.