Multiparametric Assessment of TNNI3 Variant Phenotypes in Human iPSC-Cardiomyocytes Correlates with Disease Severity in Patients.

Background: The routine genetic testing of cardiomyopathy patients has significantly accelerated the identification of causative cardiomyopathy variants. However, translating these genetic insights into effective patient management poses significant challenges, since the impact of gene variants on physiological function and clinical outcomes is not yet fully understood. Therefore, there is an urgent need for large-scale methods to assess the effects of genetic variants on cardiomyocyte physiology and to establish correlations between functional phenotypes and clinical severity. Methods: We developed a high throughput imaging platform to measure force generation and calcium handling throughout the cardiac cycle of human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs). By expressing variants of a sarcomeric protein [cardiac Troponin-I (TNNI3)] in a healthy genetic background, we were able to assess sarcomeric calcium sensitivity as well as systolic and diastolic function. Analysis of these parameters distinguished subgroups of variants, and permitted the correlation of in vitro physiological effects with a measure of disease severity in a single-center cardiomyopathy cohort. Results: Combining contractile force and calcium cycling measurements accurately distinguished known pathogenic from non-pathogenic TNNI3 variants and also revealed pathogenicity of two variants of unknown significance (VUS) that occurred in two families, suggesting the ability to prospectively discern pathogenicity. Clustering of TNNI3 variants based on quantitative physiological phenotypes identified subgroups that correlated with age of disease onset across a well-characterized cardiomyopathy patient cohort, showing clinical relevance of the in vitro phenotypes. Interestingly, normalized measures of in vitro diastolic function correlated with age of onset (R2 = 0.6), but calcium sensitivity, which accurately predicted pathogenicity, did not translate into disease severity. Conclusions: A high throughput in vitro platform that measures multidimensional cardiomyocyte function can link subgroups of human genetic variants in TNNI3 with differential patient outcomes. Comprehensive determination of variant effects on disease-relevant cardiomyocyte function will help classify variants into different pathogenic mechanisms leading to variable disease severity, and potentially lead to class-targeted ameliorative strategies.