SCN5A-L256del and L1621F exhibit loss-of-function properties related to autosomal recessive congenital cardiac disorders presenting as sick sinus syndrome, dilated cardiomyopathy, and sudden cardiac death

Pathogenic mutations in SCN5A could result in dysfunctions of Na_v1.5 and consequently lead to a wide range of inherited cardiac diseases. However, the presence of numerous SCN5A-related variants with unknown significance (VUS) and the comprehensive genotype-phenotype relationship pose challenges to precise diagnosis and genetic counseling for affected families. Here, we functionally identified two novel compound heterozygous variants (L256del and L1621F) in SCN5A in a Chinese family exhibiting complex congenital cardiac phenotypes from sudden cardiac death to overlapping syndromes including sick sinus syndrome and dilated cardiomyopathy in an autosomal recessive pattern. In silico tools predicted decreased stability and hydrophobicity of the two mutated proteins due to conformational changes. Patch-clamp electrophysiology revealed slightly decreased sodium currents, accelerated inactivation, and reduced sodium window current in the Na_v1.5-L1621F channels as well as no sodium currents in the Na_v1.5-L256del channels. Western blotting analysis demonstrated decreased expression levels of mutated Na_v1.5 on the plasma membrane, despite enhanced compensatory expression of the total Na_v1.5 expression levels. Immunofluorescence imaging showed abnormal condensed spots of the mutated channels within the cytoplasm instead of normal membrane distribution, indicating impaired trafficking. Overall, we identified the loss-of-function characteristics exhibited by the two variants, thereby providing further evidence for their pathogenic nature. Our findings not only extended the variation and phenotype spectrums of SCN5A, but also shed light on the crucial role of patch-clamp electrophysiology in the functional analysis of VUS in SCN5A, which have significant implications for the clinical diagnosis, management, and genetic counseling in affected individuals with complex cardiac phenotypes.