RRAD mutation causes electrical and cytoskeletal defects in cardiomyocytes derived from a familial case of Brugada syndrome

Introduction The Brugada syndrome (BrS) is an inherited cardiac disorder predisposing to ventricular arrhythmias and sudden death. In the present day, only 30% of BrS cases have known genetic causes. Using whole-exome sequencing in a large pedigree with affected members, we identified a rare variant (p.R211H) in RRAD, the gene encoding Rad GTPase. Objective The aim of this work was to elucidate the mechanisms by which the RRAD p.R211H variant leads to BrS. Methods The study was performed in two cell models, i.e., cardiomyocytes derived from induced pluripotent stem cells (iPSC-CM) reprogrammed from the proband carrying the familial mutation and his healthy brother (non-carrier) and neonatal mouse cardiomyocytes (NMC) infected with adenoviruses encoding wildtype human RAD (ad_WT-RAD) or GFP (ad_GFP), and knock-in mouse mo del carrying the equivalent p.R210H Rad mutation (KI mice). Results iPSC-CMs from the proband displayed a severe decrease of INa and a moderate decrease of ICaL. Overexpression of WT-RAD in NMC triggered similar impact on both currents. The iPSC-CMs carrying the variant exhibited reduced action potential upstroke velocity, prolonged action potentials and increased incidence of early afterdepolarizations. Combined with the electrical phenotype, these cells showed cortical distribution of actin, cell rounding and reduced focal adhesion count. In mice, Rad was predominantly expressed in the right ventricle outflow tract compared to the other cardiac compartments. This pattern of expression was not altered by the variant. KI mice displayed ventricular conduction disorders under ajmaline challenge and histological anomalies, including fibrosis development, in the right ventricular wall. Conclusion Mutation in the RAD GTPase recapitulate the typical electrophysiological signature of Brugada syndrome coupled with cytoskeleton disturbances in cardiomyocytes derived from the patient. KI mice showed both cardiac electrical and structural disturbances.