Ca ²⁺ -CaM Dependent Inactivation of RyR2 Underlies Ca ²⁺ Alternans in Intact Heart

Rationale: Ca 2+ alternans plays an essential role in cardiac alternans that can lead to ventricular fibrillation, but the mechanism underlying Ca 2+ alternans remains undefined. Increasing evidence suggests that Ca 2+ alternans results from alternations in the inactivation of cardiac RyR2 (ryanodine receptor 2). However, what inactivates RyR2 and how RyR2 inactivation leads to Ca 2+ alternans are unknown. Objective: To determine the role of CaM (calmodulin) on Ca 2+ alternans in intact working mouse hearts. Methods and Results: We used an in vivo local gene delivery approach to alter CaM function by directly injecting adenoviruses expressing CaM-wild type, a loss-of-function CaM mutation, CaM (1–4), and a gain-of-function mutation, CaM-M37Q, into the anterior wall of the left ventricle of RyR2 wild type or mutant mouse hearts. We monitored Ca 2+ transients in ventricular myocytes near the adenovirus-injection sites in Langendorff-perfused intact working hearts using confocal Ca 2+ imaging. We found that CaM-wild type and CaM-M37Q promoted Ca 2+ alternans and prolonged Ca 2+ transient recovery in intact RyR2 wild type and mutant hearts, whereas CaM (1–4) exerted opposite effects. Altered CaM function also affected the recovery from inactivation of the L-type Ca 2+ current but had no significant impact on sarcoplasmic reticulum Ca 2+ content. Furthermore, we developed a novel numerical myocyte model of Ca 2+ alternans that incorporates Ca 2+ -CaM-dependent regulation of RyR2 and the L-type Ca 2+ channel. Remarkably, the new model recapitulates the impact on Ca 2+ alternans of altered CaM and RyR2 functions under 9 different experimental conditions. Our simulations reveal that diastolic cytosolic Ca 2+ elevation as a result of rapid pacing triggers Ca 2+ -CaM dependent inactivation of RyR2. The resultant RyR2 inactivation diminishes sarcoplasmic reticulum Ca 2+ release, which, in turn, reduces diastolic cytosolic Ca 2+ , leading to alternations in diastolic cytosolic Ca 2+ , RyR2 inactivation, and sarcoplasmic reticulum Ca 2+ release (ie, Ca 2+ alternans). Conclusions: Our results demonstrate that inactivation of RyR2 by Ca 2+ -CaM is a major determinant of Ca 2+ alternans, making Ca 2+ -CaM dependent regulation of RyR2 an important therapeutic target for cardiac alternans.