AAV-Mediated Delivery of Plakophilin-2a Arrests Progression of Arrhythmogenic Right Ventricular Cardiomyopathy in Murine Hearts: Preclinical Evidence Supporting Gene Therapy in Humans

Overview

Journal Circ Genom Precis Med

Specialties Cardiology & Vascular Diseases
Genetics

Date 2024 Jan 30

PMID 38288614

Authors

Chantal J M van Opbergen

Bitha Narayanan

Chester B Sacramento

Katie M Stiles

Vartika Mishra

Esther Frenk

David Ricks

Grace Chen

Mingliang Zhang

Paul Yarabe

Jonathan Schwartz

Mario Delmar

Chris D Herzog

Marina Cerrone

Affiliations

Soon will be listed here.

Abstract

Background: Pathogenic variants in PKP2 (plakophilin-2) cause arrhythmogenic right ventricular cardiomyopathy, a disease characterized by life-threatening arrhythmias and progressive cardiomyopathy leading to heart failure. No effective medical therapy is available to prevent or arrest the disease. We tested the hypothesis that adeno-associated virus vector-mediated delivery of the human gene to an adult mammalian heart deficient in PKP2 can arrest disease progression and significantly prolong survival.

Methods: Experiments were performed using a PKP2-cKO (cardiac-specific, tamoxifen-activated PKP2 knockout murine model). The potential therapeutic, adeno-associated virus vector of serotype rh.74 (AAVrh.74)-PKP2a (PKP2 variant A; RP-A601) is a recombinant AAVrh.74 gene therapy viral vector encoding the human PKP2 variant A. AAVrh.74-PKP2a was delivered to adult mice by a single tail vein injection either before or after tamoxifen-activated PKP2-cKO. PKP2 expression was confirmed by molecular and histopathologic analyses. Cardiac function and disease progression were monitored by survival analyses, echocardiography, and electrocardiography.

Results: Consistent with prior findings, loss of PKP2 expression caused 100% mortality within 50 days after tamoxifen injection. In contrast, AAVrh.74-PKP2a-mediated PKP2a expression resulted in 100% survival for >5 months (at study termination). Echocardiographic analysis revealed that AAVrh.74-PKP2a prevented right ventricle dilation, arrested left ventricle functional decline, and mitigated arrhythmia burden. Molecular and histological analyses showed AAVrh.74-PKP2a-mediated transgene mRNA and protein expression and appropriate PKP2 localization at the cardiomyocyte intercalated disc. Importantly, the therapeutic benefit was shown in mice receiving AAVrh.74-PKP2a after disease onset.

Conclusions: These preclinical data demonstrate the potential for AAVrh.74-PKP2a (RP-A601) as a therapeutic for PKP2-related arrhythmogenic right ventricular cardiomyopathy in both early and more advanced stages of the disease.

Citing Articles

Targeting Ventricular Arrhythmias in Non-Ischemic Patients: Advances in Diagnosis and Treatment.

Stanciulescu L, Dorobantu M, Vatasescu R Diagnostics (Basel). 2025; 15(4).

PMID: 40002571 PMC: 11854509. DOI: 10.3390/diagnostics15040420.

Genetics in arrhythmogenic cardiomyopathies: where are we now and where are we heading to?.

Mazzanti A, Kukavica D, Trancuccio A, Scilabra G, Coppini L, Pergola V Eur Heart J Suppl. 2025; 27(Suppl 1):i98-i102.

PMID: 39980788 PMC: 11836680. DOI: 10.1093/eurheartjsupp/suae114.

Ion channel traffic jams: the significance of trafficking deficiency in long QT syndrome.

Mondejar-Parreno G, Moreno-Manuel A, Ruiz-Robles J, Jalife J Cell Discov. 2025; 11(1):3.

PMID: 39788950 PMC: 11717978. DOI: 10.1038/s41421-024-00738-0.

Unveiling the Future of Cardiac Care: A Review of Gene Therapy in Cardiomyopathies.

Venturiello D, Tiberi P, Perulli F, Nardoianni G, Guida L, Barsali C Int J Mol Sci. 2024; 25(23).

PMID: 39684857 PMC: 11642060. DOI: 10.3390/ijms252313147.

Patient Perceptions of Emerging Gene Therapies for Arrhythmogenic Right Ventricular Cardiomyopathy.

Schopp E, Okwara L, Tichnell C, Turriff A, Murray B, Barth A Circ Genom Precis Med. 2024; 17(6):e004759.

PMID: 39611272 PMC: 11651351. DOI: 10.1161/CIRCGEN.124.004759.

References

Donahue J, Heldman A, Fraser H, McDonald A, Miller J, Rade J . Focal modification of electrical conduction in the heart by viral gene transfer. Nat Med. 2000; 6(12):1395-8. DOI: 10.1038/82214. View

Yuan P, Cheedipudi S, Rouhi L, Fan S, Simon L, Zhao Z . Single-Cell RNA Sequencing Uncovers Paracrine Functions of the Epicardial-Derived Cells in Arrhythmogenic Cardiomyopathy. Circulation. 2021; 143(22):2169-2187. PMC: 8169643. DOI: 10.1161/CIRCULATIONAHA.120.052928. View

Carrick R, Te Riele A, Gasperetti A, Bosman L, Muller S, Pendleton C . Longitudinal Prediction of Ventricular Arrhythmic Risk in Patients With Arrhythmogenic Right Ventricular Cardiomyopathy. Circ Arrhythm Electrophysiol. 2022; 15(11):e011207. PMC: 9669260. DOI: 10.1161/CIRCEP.122.011207. View

Bhonsale A, Groeneweg J, James C, Dooijes D, Tichnell C, Jongbloed J . Impact of genotype on clinical course in arrhythmogenic right ventricular dysplasia/cardiomyopathy-associated mutation carriers. Eur Heart J. 2015; 36(14):847-55. DOI: 10.1093/eurheartj/ehu509. View

Leor J, Quinones M, Patterson M, Kedes L, Kloner R . Adenovirus-mediated gene transfer into infarcted myocardium: feasibility, timing, and location of expression. J Mol Cell Cardiol. 1996; 28(10):2057-67. DOI: 10.1006/jmcc.1996.0199. View

van Opbergen C, Bagwan N, Maurya S, Kim J, Smith A, Blackwell D . Exercise Causes Arrhythmogenic Remodeling of Intracellular Calcium Dynamics in Plakophilin-2-Deficient Hearts. Circulation. 2022; 145(19):1480-1496. PMC: 9086182. DOI: 10.1161/CIRCULATIONAHA.121.057757. View

Towbin J, McKenna W, Abrams D, Ackerman M, Calkins H, Darrieux F . 2019 HRS expert consensus statement on evaluation, risk stratification, and management of arrhythmogenic cardiomyopathy. Heart Rhythm. 2019; 16(11):e301-e372. DOI: 10.1016/j.hrthm.2019.05.007. View

Goedeker N, Dharia S, Griffin D, Coy J, Truesdale T, Parikh R . Evaluation of rAAVrh74 gene therapy vector seroprevalence by measurement of total binding antibodies in patients with Duchenne muscular dystrophy. Ther Adv Neurol Disord. 2023; 16:17562864221149781. PMC: 9880577. DOI: 10.1177/17562864221149781. View

van Opbergen C, Noorman M, Pfenniger A, Copier J, Vermij S, Li Z . Plakophilin-2 Haploinsufficiency Causes Calcium Handling Deficits and Modulates the Cardiac Response Towards Stress. Int J Mol Sci. 2019; 20(17). PMC: 6747156. DOI: 10.3390/ijms20174076. View

10.

Tsui H, van Kampen S, Han S, Meraviglia V, van Ham W, Casini S . Desmosomal protein degradation as an underlying cause of arrhythmogenic cardiomyopathy. Sci Transl Med. 2023; 15(688):eadd4248. DOI: 10.1126/scitranslmed.add4248. View

11.

Nielsen M, van Opbergen C, van Veen T, Delmar M . The intercalated disc: a unique organelle for electromechanical synchrony in cardiomyocytes. Physiol Rev. 2023; 103(3):2271-2319. PMC: 10191137. DOI: 10.1152/physrev.00021.2022. View

12.

Gasperetti A, Carrick R, Costa S, Compagnucci P, Bosman L, Chivulescu M . Programmed Ventricular Stimulation as an Additional Primary Prevention Risk Stratification Tool in Arrhythmogenic Right Ventricular Cardiomyopathy: A Multinational Study. Circulation. 2022; 146(19):1434-1443. PMC: 9640278. DOI: 10.1161/CIRCULATIONAHA.122.060866. View

13.

Pozsgai E, Griffin D, Heller K, Mendell J, Rodino-Klapac L . Systemic AAV-Mediated β-Sarcoglycan Delivery Targeting Cardiac and Skeletal Muscle Ameliorates Histological and Functional Deficits in LGMD2E Mice. Mol Ther. 2017; 25(4):855-869. PMC: 5383645. DOI: 10.1016/j.ymthe.2017.02.013. View

14.

Dries A, Kirillova A, Reuter C, Garcia J, Zouk H, Hawley M . The genetic architecture of Plakophilin 2 cardiomyopathy. Genet Med. 2021; 23(10):1961-1968. PMC: 8486657. DOI: 10.1038/s41436-021-01233-7. View

15.

Chelko S, Asimaki A, Lowenthal J, Bueno-Beti C, Bedja D, Scalco A . Therapeutic Modulation of the Immune Response in Arrhythmogenic Cardiomyopathy. Circulation. 2019; 140(18):1491-1505. PMC: 6817418. DOI: 10.1161/CIRCULATIONAHA.119.040676. View

16.

Cruz F, Sanz-Rosa D, Roche-Molina M, Garcia-Prieto J, Garcia-Ruiz J, Pizarro G . Exercise triggers ARVC phenotype in mice expressing a disease-causing mutated version of human plakophilin-2. J Am Coll Cardiol. 2015; 65(14):1438-50. DOI: 10.1016/j.jacc.2015.01.045. View

17.

Bongianino R, Denegri M, Mazzanti A, Lodola F, Vollero A, Boncompagni S . Allele-Specific Silencing of Mutant mRNA Rescues Ultrastructural and Arrhythmic Phenotype in Mice Carriers of the R4496C Mutation in the Ryanodine Receptor Gene (). Circ Res. 2017; 121(5):525-536. DOI: 10.1161/CIRCRESAHA.117.310882. View

18.

Krahn A, Wilde A, Calkins H, La Gerche A, Cadrin-Tourigny J, Roberts J . Arrhythmogenic Right Ventricular Cardiomyopathy. JACC Clin Electrophysiol. 2022; 8(4):533-553. DOI: 10.1016/j.jacep.2021.12.002. View

19.

NORTH A, Bardsley W, Hyam J, Bornslaeger E, Cordingley H, Trinnaman B . Molecular map of the desmosomal plaque. J Cell Sci. 1999; 112 ( Pt 23):4325-36. DOI: 10.1242/jcs.112.23.4325. View

20.

Cerrone M, Montnach J, Lin X, Zhao Y, Zhang M, Agullo-Pascual E . Plakophilin-2 is required for transcription of genes that control calcium cycling and cardiac rhythm. Nat Commun. 2017; 8(1):106. PMC: 5524637. DOI: 10.1038/s41467-017-00127-0. View