Discovery and characterization of a monogenetic insult, caveolin-3-V37L, that precipitated oligo-proteomic perturbations governing repolarization reserve

Background: Caveolin-3 (Cav-3) is an essential scaffolding protein for caveolae formation in cardiomyocytes and targets multiple long QT syndrome (LQTS)-associated ion channels. Mutations in CAV3 have caused an LQT3-like accentuation in late sodium current, I_Na (Nav1.5). Here, we characterize a novel CAV3-V37L variant and determine whether it is the substrate for the patient's LQTS. Methods: The proband was a 39-year-old female with drug-induced, sudden cardiac arrest (SCA) with profound QT prolongation (QTc > 600 ms). Genetic testing revealed a rare CAV3-V37L variant of uncertain significance (VUS). Whole-cell patch clamp technique was used to measure I_Ks, I_Kr, I_Na, and I_{Ca, L} currents co-expressed with either CAV3-WT or CAV3-V37L in TSA201 cells and to measure the action potential duration (APD) in control human induced pluripotent stem cells-derived cardiomyocytes (hiPSC-CMs) overexpressed with CAV3-WT or CAV3-V37L. Results: CAV3-V37L did not affect Nav1.5 late current. Instead, CAV3-V37L resulted in 1) I_{Ca, L} with slower inactivation, a 1.5 fold increase in peak I_{Ca, L} current density and a 1.1 fold increase in I_{Ca, L} persistent current, 2) dramatically reduced I_Ks peak current density by 74.9%, 3) significantly reduced I_Kr peak current density by 31.1%, and 4) significantly prolonged the APD in hiPSC-CMs. Conclusions: These functional validation assays enabled the promotion of CAV3-V37L from VUS status to a likely pathogenic variant. Although Nav1.5 was spared, this monogenetic insult precipitated an oligo-proteomic impact with a concomitant gain-of-function of I_{Ca, L} and loss-of-function of both I_Ks and I_Kr culminating in a marked prolongation of the cardiomyocyte's action potential duration.