BACKGROUND: Sudden unexpected death in epilepsy (SUDEP) is a fatal complication experienced by otherwise healthy epilepsy patients. Dravet syndrome (DS) is an inherited epileptic disorder resulting from loss of function of the voltage-gated sodium channel, NaV 1.1, and is associated with particularly high SUDEP risk. Evidence is mounting that NaVs abundant in the brain also occur in the heart, suggesting that the very molecular mechanisms underlying epilepsy could also precipitate cardiac arrhythmias and sudden death. Despite marked reduction of NaV 1.1 functional expression in DS, pathogenic late sodium current (INa,L) is paradoxically increased in DS hearts. However, the mechanisms by which DS directly impacts the heart to promote sudden death remain unclear. OBJECTIVES: In this study, the authors sought to provide evidence implicating remodeling of Na+ - and Ca2+ -handling machinery, including NaV 1.6 and Na+/Ca2+exchanger (NCX) within transverse (T)-tubules in DS-associated arrhythmias. METHODS: The authors undertook scanning ion conductance microscopy (SICM)-guided patch clamp, super-resolution microscopy, confocal Ca2+ imaging, and in vivo electrocardiography studies in Scn1a haploinsufficient murine model of DS. RESULTS: DS promotes INa,L in T-tubular nanodomains, but not in other subcellular regions. Consistent with increased NaV activity in these regions, super-resolution microscopy revealed increased NaV 1.6 density near Ca2+release channels, the ryanodine receptors (RyR2) and NCX in DS relative to WT hearts. The resulting INa,L in these regions promoted aberrant Ca2+ release, leading to ventricular arrhythmias in vivo. Cardiac-specific deletion of NaV 1.6 protects adult DS mice from increased T-tubular late NaV activity and the resulting arrhythmias, as well as sudden death. CONCLUSIONS: These data demonstrate that NaV 1.6 undergoes remodeling within T-tubules of adult DS hearts serving as a substrate for Ca2+ -mediated cardiac arrhythmias and may be a druggable target for the prevention of SUDEP in adult DS subjects.

The Frick Center for Heart Failure and Arrhythmia Dorothy M Davis Heart and Lung Research Institute College of Medicine The Ohio State University Wexner Medical Center Columbus Ohio USA; Department of Biomedical Engineering College of Engineering The Ohio State University Columbus Ohio USA

The Frick Center for Heart Failure and Arrhythmia Dorothy M Davis Heart and Lung Research Institute College of Medicine The Ohio State University Wexner Medical Center Columbus Ohio USA; Department of Biomedical Engineering College of Engineering The Ohio State University Columbus Ohio USA; Department of Internal Medicine Division of Cardiovascular Medicine College of Medicine The Ohio State University Columbus Ohio USA

The Frick Center for Heart Failure and Arrhythmia Dorothy M Davis Heart and Lung Research Institute College of Medicine The Ohio State University Wexner Medical Center Columbus Ohio USA; Department of Neuroscience College of Medicine The Ohio State University Columbus Ohio USA

The Frick Center for Heart Failure and Arrhythmia Dorothy M Davis Heart and Lung Research Institute College of Medicine The Ohio State University Wexner Medical Center Columbus Ohio USA; Division of Outcomes and Translational Sciences College of Pharmacy The Ohio State University Columbus Ohio USA

The Frick Center for Heart Failure and Arrhythmia Dorothy M Davis Heart and Lung Research Institute College of Medicine The Ohio State University Wexner Medical Center Columbus Ohio USA; Division of Outcomes and Translational Sciences College of Pharmacy The Ohio State University Columbus Ohio USA; Department of Pharmacology and Toxicology Faculty of Pharmacy Charles University Akademika Heyrovského Hradec Králové Czech Republic

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