Congenital long-QT syndrome (LQTS) may present during fetal development and can be life-threatening. The molecular mechanism for the unusual early onset of LQTS during fetal development is unknown.
We sought to elucidate the molecular basis for severe fetal LQTS presenting at 19-weeks gestation, the earliest known presentation of this disease.
Fetal magnetocardiography was used to demonstrated torsade de pointes and a prolonged rate-corrected QT interval. In vitro electrophysiological studies were performed to determine functional consequences of a novel SCN5A mutation found in the fetus.
The fetus presented with episodes of ventricular ectopy progressing to incessant ventricular tachycardia and hydrops fetalis. Genetic analysis disclosed a novel, de novo heterozygous mutation in SCN5A (L409P) and a homozygous common variant (R558). In vitro electrophysiological studies demonstrated that the mutation in combination with R558 caused significant depolarized shifts in voltage-dependence of inactivation and activation, faster recovery from inactivation and a 7-fold greater level of persistent current. When the mutation was engineered in a fetal-expressed SCN5A splice isoform, channel dysfunction was markedly potentiated. Also, R558 alone in the fetal splice isoform evoked a large persistent current, hence both alleles were dysfunctional.
We report the earliest confirmed diagnosis of symptomatic LQTS, and present evidence that mutant cardiac sodium channel dysfunction is potentiated by a developmentally regulated alternative splicing event in SCN5A. Our findings provide a plausible mechanism for the unusual severity and early onset of cardiac arrhythmia in fetal LQTS.
Keywords: arrhythmia, sodium channel, SCN5A, sudden death, long-QT syndrome, magnetocardiography, alternative splicing