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BACKGROUND:
Catecholaminergic polymorphic ventricular tachycardia (CPVT), an inherited cardiac arrhythmia characterized by adrenergically triggered arrhythmias, is inadequately treated by current standard of care. Ca2+/calmodulin-dependent protein kinase II (CaMKII), an adrenergically activated kinase that contributes to arrhythmogenesis in heart disease models, is a candidate therapeutic target in CPVT. However, translation of CaMKII inhibition has been limited by the need for selective CaMKII inhibition in cardiomyocytes. Here we tested the hypothesis that CaMKII inhibition using a cardiomyocyte-targeted gene therapy strategy would suppress arrhythmia in CPVT mouse models.

METHODS:
We developed AAV9-GFP-AIP, an adeno-associated viral vector in which a potent CaMKII inhibitory peptide (AIP), is fused to GFP and expressed from a cardiomyocyte selective promoter. The vector was delivered systemically. Arrhythmia burden was evaluated using invasive electrophysiology testing in adult mice. AIP was also tested on induced pluripotent stem cells (iPSC) derived from CPVT patients with different disease-causing mutations to determine the effectiveness of our proposed therapy on human iPSC-derived cardiomyocytes (iPSC-CMs) and different pathogenic genotypes.

RESULTS:
AAV9-GFP-AIP was robustly expressed in the heart without significant expression in extra-cardiac tissues, including the brain. Administration of AAV9-GFP-AIP to neonatal mice with a known CPVT mutation ( RYR2R176Q/+) effectively suppressed ventricular arrhythmias induced by either β-adrenergic stimulation or programmed ventricular pacing, without significant proarrhythmic effect. Intravascular delivery of AAV9-GFP-AIP to adolescent mice transduced ~50% of cardiomyocytes and was effective in suppressing arrhythmia in CPVT mice. iPSC-CMs derived from two different CPVT patients with different pathogenic mutations demonstrated increased frequency of abnormal calcium release events, which was suppressed by a cell-permeable form of AIP.

CONCLUSIONS:
This proof-of-concept study showed that AAV-mediated delivery of a CaMKII peptide inhibitor to the heart was effective in suppressing arrhythmias in a murine model of CPVT. CaMKII inhibition also reversed the arrhythmia phenotype in human CPVT iPSC-CMs models with different pathogenic mutations.