The adult cTn complexes were generated from recombinant human adult troponin subunits (expressed from TNNC1, TNNI3, and TNNT2). Reconstituted thin filaments were generated by mixing each cTn complex with human alpha-tropomyosin (TPM1) as well as native actin extracted from rabbit skeletal muscle, which has a 99.2% sequence identity with human cardiac actin (Dewar et al., 2017). See Supplementary Table S1 for the complete list of the constructs utilized in generating the hcRTF.

All steady-state fluorescence measurements were performed using a Cary Eclipse fluorescence spectrophotometer (Agilent) at 15 ± 0.1°C as described (Dewar et al., 2017). In brief, IAANS fluorescence was excited at 330 nm and monitored at the peak of the emission of 450 nm. Microliter amounts of CaCl₂ were added to 2 ml of each labeled hcRTF in a titration buffer containing the following (in millimolars): 200 MOPS, 150 KCl, 3 MgCl₂, and 1 DTT at pH 7.0. At least five to eight datasets were collected for each construct, and the data were fit with a sigmoidal fit (based on the Hill equation) in Origin 8.5 (Microcal Software, Northampton, MA). The Ca²⁺ sensitivity for each hcRTF was represented by the dissociation constant K _d (±SEM) defined as the Ca²⁺ concentration at the half-maximal fluorescence change. Two means were considered to be significantly different when p ≤ 0.05.

Ca²⁺ dissociation rates [k _off(Ca ²⁺ ₎] from each hcRTF were characterized using a Chirascan stopped-flow apparatus (Applied Photophysics, Surrey, United Kingdom) with a dead time of 1.1 ms at 15.0 ± 0.1°C. IAANS fluorescence was excited at 300 nm and monitored through a 510-nm broad band-pass interference filter (Semrock, Rochester, NY). Each trace was obtained as the solution containing hcRTF saturated with 200 μM CaCl₂ was rapidly mixed with 10 mM EGTA solution in the stopped-flow buffer containing the following(in millimolars): 10 MOPS, 150 KCl, 3 MgCl₂, and 1 DTT at pH 7.0. Each k _off(Ca ²⁺ ₎ value represents an average of at least five traces fit with a single exponential equation and repeated more than 15 times. Two means were considered to be significantly different when p ≤ 0.05.

Human iPSC lines (iPS IMR90-1) were obtained from the Wicell Research Institute (https://www.wicell.org/). Differentiation of hiPSCs to cardiomyocytes (hiPSC-CMs) employed a protocol published previously (Dewar et al., 2017). In brief, hiPSCs were maintained on Corning Matrigel (0.5 mg/six-well plate, dissolved in DMEM/F-12 medium) cultured in mTeSR1 medium (StemCell Technologies, Vancouver, BC). Cells were passaged every 4 days using Versene solution (Thermo Fisher, Waltham, MA) and were then seeded on a six-well Matrigel-coated plate at a density of 100,000 cells cm⁻² in mTeSR1 medium. The medium was changed daily, and after 3–4 days, when the monolayer of cells reached >90% confluency, the mTeSR1 medium was replaced with Roswell Park Memorial Institute (RPMI) 1640 basal medium (Thermo Fisher, Waltham, MA) plus B27 without insulin supplement (Thermo Fisher) containing 12 µM CHIR99021 (R&D Systems) for 24 h, followed by 5 mM IWP4 (Tocris) for 2 days without medium change. The medium was changed to RPMI 1640 plus B27 complete supplement, and then subsequently, the medium was changed every 2–3 days. Robust spontaneous beating of the monolayer was observed by day 12.

Single-guide RNAs (sgRNA) were designed to target the region close to I79 TNNT2 using online CRISPR tools including CRISPRko Tool from the Broad Institute (Nivala et al., 2012a), the CRISPR Finder from Wellcome Trust Sanger Institute (Nivala et al., 2015), and Benchling (Mahajan et al., 2008). The sgRNA sequences used in the study are shown in Supplementary Table S2. The sgRNAs were cloned into a pCCC vector, which is based on the pSpCas9(BB)-2A-GFP vector (PX458, Addgene plasmid # 48,138) as detailed previously (Marston and Zamora, 2020; Menon et al., 2008). The pCCC vector contains the complete U6 promoter for enhanced expression in hiPSCs. The 127-bp asymmetric single-stranded donor nucleotides (ssODNs) (Marston and Zamora, 2020; Menon et al., 2008; Pasquale et al., 2012) were designed (Supplementary Table S2) to include the transition (T → A) that is seen in I79N, as well as a silent mutation at the PAM site to prevent the continuous cutting and improve the efficiency of the HDR repair (Pasquale et al., 2012).

Human iPSCs were co-transfected with a PX458 plasmid and ssODN using Lipofectamine 3000 (Thermo Fisher). Briefly, 2 × 10⁵ hiPSCs were transfected with 500 ng sgRNA and 10 pmol of ssODN. Since the vector contained GFP as a reporter, the GFP⁺ hiPSCs were sorted as single cells using fluorescence-activated cell sorting (FACS) 48–72 h post-transfection and were plated on Matrigel-coated plates in mTeSR1 (Dewar et al., 2017). More than 100 single-cell colonies were assayed. To screen for on-target single mutation, genomic DNA was extracted and used for PCR amplification of the CRISPR target sites. These amplicons were sequenced to confirm the single-nucleotide mutation at the I79 TNNT2 site using the primers described in Supplementary Table S2. Genome-edited hiPSC lines were retested for pluripotency and genome integrity as described.

Prior to imaging, a monolayer of hiPSC-CM was perfused with IMDM supplemented with a physiological solution (final concentrations in millimolars): 140 NaCl, 3.6 KCl, 1.2 CaCl₂, 1 MgCl₂, 10 HEPES, and 5.5 D-glucose for optical mapping as described (Varnava et al., 2001; Baudenbacher et al., 2008; Dewar et al., 2017). In brief, the cells were incubated with 15 μM of the potentiometric dye RH-237 (Molecular Probes, Eugene, OR) for 45 min. After incubating the hiPSC-CMs with RH-237, 5 μM of the Ca²⁺-sensitive dye Rhod-2AM (Molecular Probes) and 20 μM blebbistatin [a myosin ATPase inhibitor (Sigma-Aldrich)] were added to the culture dish. Blebbistatin inhibits contraction and reduces motion artifact with no detectable effect on electrophysiological properties (Rust et al., 1999). For imaging, the hiPSC-CMs were excited by 532-nm LEDs. RH-237 and Rhod-2 emissions were monitored using a >710-nm long-pass and 565–600-nm band-pass filters, respectively, at 100 fps at 37°C. The spectral properties allow both dyes to be fluoresced using 532 nm and their respective emissions to be separated by dichroic mirrors. Both signals were captured with a single Hamamatsu ORCA-Flash4 digital CMOS camera by incorporating an optical image splitter. Electrical field stimulation was applied using stainless steel electrodes. The electrodes were ∼1 cm apart, which were placed in the imaging chamber. The hiPSC-CMs harboring the TNNT2 heterozygous mutation I79N^+/− and wild type (WT) were stimulated for 20 s each at four stimulation frequencies (55, 65, 75, and 100 beats/min). Data were analyzed using a custom-built software in IDL (Exelis Visual Information Solutions, McLean, VA) (Varnava et al., 2001; Baudenbacher et al., 2008; Dewar et al., 2017).

Computer simulations were carried out to investigate the mechanisms of alternans promoted by the I79Nvariant. We used a ventricular cell model developed previously (Nivala et al., 2012b), consisting of a three-dimension network of 20,000 (100  ×  20  ×  10) coupled Ca²⁺ release units (CRUs). The model has been used to investigate spatiotemporal Ca²⁺ cycling and action potential dynamics in ventricular myocytes, including the genesis of Ca²⁺ waves and Ca²⁺ alternans (Nivala et al., 2012a; Nivala et al., 2015). Details of the model have been published previously (Nivala et al., 2012b), and the parameters were the same except for the K _D of SERCA, which was changed from 1.0 to 0.25 μM. In addition, troponin C buffers were added to the model. The formulation is listed below, which is adopted from our previous model (Mahajan et al., 2008): J t r p n = k o n ( B t − [ C a T ] i ) [ C a 2 + ] i − k o f f [ C a T ] i where k o n = 0.0327 ( μ M m s ) − 1 and k o f f = 0.5 m s − 1 . To simulate the effects of the I79N^+/− variant on Ca²⁺ alternans, the dissociation rate (k _off) of Ca²⁺ from troponin C was reduced to 0.1 ms⁻¹.

Quantitative real-time PCR: Total RNA was extracted from hiPCS-CM using TRIzol followed by RNeasy kit (Qiagen, Mississauga, ON), according to the manufacturer’s instructions. The concentration and purity of the RNA was determined using a NanoDrop ND-1000 spectrophotometer (Thermo Fisher Scientific). The cDNA was synthesized using Qiagen Quantitect Reverse Transcription kit, according to the manufacturer’s instructions. Real-time qRT-PCR analysis was performed on a Bio-Rad CFX96 Touch Real-Time PCR System (Bio-Rad, Mississauga, ON). Primers were designed using Primer3 and OligoAnalyzer 3.1. Analysis was performed according to the ΔΔCt method using the geometric mean of housekeeping genes β-actin and GAPDH to normalize the qRT-PCR data.

Multiplexed mRNA profiling was conducted using a custom codeset containing 251 gene probes synthesized by NanoString Technologies Inc. and the NanoString nCounter® SPRINT Profiler28 (see Supplementary Table S3 for a list of all transcripts included in the codeset). A total of 50 ng of purified RNA per sample was hybridized overnight (16 h) to the custom capture and reporter probes. Hybridized samples were loaded into each channel of the nCounter® SPRINT cartridge. Raw mRNA counts were collected, and the results were normalized to seven housekeeping genes (PIK3CA, ATP5F1, IPO8, PPIA, SPCS1, AKT, and RPS13). Analysis was performed on the nSolver analysis software and the Advanced Analysis module (NanoString Technologies Inc.).

Data were presented as mean ± SEM unless noted otherwise. Statistical analysis and data visualization of hcRTF Ca²⁺ kinetics, optical mapping, and NanoString data were conducted using R version 3.6.1. Unpaired Student’s t tests were conducted to compare two groups (WT vs I79N^+/− TNNT2 hiPSC-CMs) in all analysis except for the differential expression of genes (DEG) analysis of the NanoString data. For DEG, the fold-change of each gene was compared between the WT and I79N^+/− TNNT2 hiPSC-CMs using Welch’s t-test and was corrected for multiple comparisons using the Benjamini–Yekutieli method to calculate the false discovery rate (FDR). A p value <0.05 was considered statistically significant with the following notation: *p < 0.05, **p < 0.01, and ***p < 0.001.

Supplementary Figure S1 compares human TNNT2 from residues 1 to 109, which are homologous sequences from mammals to teleosts. The conservation of the isoleucine at residue 79 represents the fact that is preserved for more than 400 million years of evolution.

Steady-state fluorescence measurements were carried out on WT and variant hcRTFs, and Ca²⁺-dependent IAANS fluorescence increase was observed for all hcRTF constructs. The I79N variant shows a statistically significant increase of Ca²⁺ sensitivity by∼2.3-fold (p ≤ 0.05) (Figure 1A).

Stopped-flow fluorescence spectroscopy was used to determine the Ca²⁺ dissociation rates from the hcRTF constructs. Upon the addition of EGTA, the Ca²⁺ rapidly dissociated from cTnC, inducing a cTnC conformational change in which the fluorescence change was recorded. As Ca²⁺ was stripped from cTnC by EGTA, a decrease in IAANS fluorescence was observed for all hcRTF constructs. The hcRTF harboring the I79N TnT variant show a significant decrease of k _off compared to WT, increasing the Ca²⁺ sensitivity by ∼1.4-fold (p ≤ 0.05) (Figure 1B). This explains, at least in part, the increase of Ca²⁺ sensitivity conferred by the hcRTF harboring this TNNT2 variant in the steady-state experiments.

The NanoString data showed that the expression differences in the TNNI3/TNNI1 ratio were not significantly different between I79N^+/− and WT lines (Supplementary Figure S3).

To understand how the I79N^+/− TNNT2 variant impacts cardiomyocyte function, genome-edited I79N^+/− TNNT2 hiPSCs were generated and differentiated to cardiomyocytes. The heterozygous 179N^+/− TNNT2 hiPSC colonies were identified by Sanger sequencing (Supplementary Figure S2). The I79N^+/− TNNT2 hiPSCs did not have any off-target mutations for the 10 most homologous sites predicted by the Broad Institute algorithm (Nivala et al., 2012a).

We next investigated the effect of various stimulation frequencies in WT and I79N^+/− hiPSC-CMs. Membrane voltage (V _m) and cytosolic Ca²⁺ transients were determined from the fluorescence emitted by RH-237 and Rhod-2, respectively. Figure 2 shows the duration of the V _m transients from hiPSC-CM monolayers stimulated at 55, 65, and 75 bpm. Figure 2A shows the action potential duration at 30% repolarization (APD₃₀), and Figure 2B shows the APD₈₀ as a function of stimulation frequency. Figure 3A shows the Ca²⁺ transient duration at 30% recovery (CaTD₃₀), and Figure 3B depicts the CaTD₈₀ as a function of frequency. The V _m and Ca²⁺ transients from both WT and I79N^+/− hiPSC-CMs entrained normally to 55, 65, and 75 bpm stimulation frequencies. These frequencies were chosen because 55 bpm was higher than the intrinsic beating rate of all hiPSC-CMs and 75 bpm was below frequencies that induced any observable form of arrhythmia. The action potential morphology showed significant triangulation [(APD₈₀ − APD₃₀) / APD₈₀] in I79N^+/− compared to WT hiPSC-CMs at 55 but not at 65 and 75 bpm (data not shown).

Figure 4 shows the same data as in Figures 2 and 3 but allows for a direct comparison of each parameter across the spectrum of frequencies. While WT hiPSC-CMs show a significant reduction of APD₃₀ and APD₈₀ as the frequency is increased from 55 to 75 bpm, the same does not hold true for I79N^+/− hiPSC-CMs. In contrast, the Ca²⁺ transient duration decreases significantly in both groups with increased stimulation frequency.

Representative optical mapping traces of V _m (red) and Ca²⁺ transients (black) at stimulation frequencies of 55, 65, and 100 bpm are shown in Figure 5. Both WT and I79N^+/− hiPSC-CMs entrained well to frequencies up to 75 bpm. However, at stimulation frequencies greater than 75 bpm, the arrhythmogenicity of the I79N^+/− lines is clearly demonstrated with an alternans pattern seen for both voltage and Ca²⁺ transients. In stark contrast, WT hiPSC-CMs could be entrained normally to stimulation frequencies >150 bpm (data not shown).

The computer simulation results for the control (k _off = 0.5 ms⁻¹) and slowed (k _off = 0.1 ms⁻¹) Ca²⁺ off rate constants are shown in Figure 6. This figure shows the simulated traces for voltage (Figure 6A), cytosolic Ca²⁺ concentration (Figure 6B), and sarcoplasmic reticulum (SR) Ca²⁺ concentration (Figure 6C) for paced cycle length (PCL) = 400 ms. The modeling shows no alternans for the control dissociation rate (black traces), but alternans occurred for the reduced off rate (red traces). In Figure 6D, we plot the peak Ca²⁺ concentration versus PCL. For the control experimental conditions (k _off = 0.5 ms⁻¹), no alternans was present for PCLs from 300 to 700 ms (black dots in Figure 6D) or 86–200 bpm. However, for the reduced k _off(Ca ²⁺ ₎, alternans occurred when the PCL was shorter than 500 ms (>120 bpm) (red dots in Figure 6D).

To characterize further the effects of the I79N^+/− TNNT2 variant, we profiled the gene expression of the variant in comparison to WT using a custom NanoString codeset. Out of the 251 genes in the codeset (Supplementary Table S3), 236 genes were detected above the threshold as determined by the digital counts of the negative controls of the nCounter assay. The unsupervised hierarchical clustering analysis displayed the unbiased similarity profile between the hiPSC-CM samples, namely, the clear segregation between I79N^+/− TNNT2 and WT TNNT2 hiPSC-CMs (Supplementary Figure S4A, B). The heatmap showed clear patterns of dysregulation in a series of genes between I79N^+/− and WT samples. This difference in profile was further reflected in the unsupervised principal component analysis (PCA) showing a strong clustering to TNNT2 genotype. In PCA, the hiPSC-CM samples were clustered according to the TNNT2 genotype with samples possessing the I79N^+/− or WT TNNT2 being strongly associated to samples of the same TNNT2 genotype. The principal component 1 (PC1) and PC2 accounted for 73% and 16% of the total variance, respectively. The high variance observed in PC1 demonstrated that the TNNT2 mutation variability (i.e., I79N^+/− and WT) is the largest driver of the difference at the gene expression level.

DEG analysis, illustrated via the volcano plot, revealed 68 genes differentially expressed (adjusted p-value ˂0.05 with no fold change cut-offs) between the I79N^+/− variant and WT hiPSC-CMs (Figure 7A). In the volcano plot, data are presented as the change in the magnitude of gene expression in I79N vs WT, which is shown on the abscissa and probability of the differences being significantly shown on the ordinate. We observed 45 significantly upregulated transcripts and 23 downregulated transcripts in I79N^+/−, which were respectively shown in red and blue data points of Figure 7A. Highlighted in the volcano plot among the transcripts significantly upregulated in I79N^+/− vs. WT are NPPA (18.6-fold), which encodes for atrial natriuretic peptide, and NPPB (5.9-fold), which encodes for brain natriuretic peptide. In addition, Notch signaling components (NOTCH1, 3, and 4; JAG1; and HEY1) were significantly (p < 0.001) upregulated in I79N^+/− compared to WT. Transcripts encoding for the components of collagen (COL1A1, COL3A1, and COL9A2) were also dramatically upregulated in I79N^+/− hiPSC-CMs. Significantly downregulated transcripts included SOX2 and cardiac developmental marker BMP4. The ratio of TNNI3/TNNI1, which is used as an index of hiPSC-CM maturation, was 6.1 and 5.6 in I79N^+/− and WT, respectively, and was not significantly different between the groups.

We conducted a gene pathway analysis using the Enrichr tool (Chen et al., 2013; Kuleshov et al., 2016) by inputting the list of DEGs between the I79N^+/− and WT samples. The top five functional pathways that were found to be significantly dysregulated (adjusted p-value ˂0.05) across six gene set libraries are highlighted in Supplementary Figure S5A, B. The most affected pathways in I79N^+/− include Notch signaling, both canonical and non-canonical, which includes the maturation precursor as well as the Notch receptor-ligand signaling (Supplementary Figure S5A). The pathways involved in NFAT signaling in cardiac hypertrophy, calcium signaling, heart development, cardiac progenitor differentiation, and cardiac conduction were found to be dysregulated by the mutation as well (Supplementary Figure S5B). Furthermore, the top five enriched Gene Ontology (GO) terms across six GO libraries revealed several mutation-related Notch diseases known to cause congenital heart defects along with atrial fibrillation (AF) and cardiac conduction system to be most significantly (adjusted p-value <0.05) associated to 45 upregulated DEGs in I79N^+/− (Supplementary Figure S5C). Whereas, 23 downregulated transcripts in I79N^+/− were significantly (adjusted p-value <0.05) enriched in terms associated with the regulation of cardiac muscle cell membrane repolarization (Supplementary Figure S5D).

TNNT2 variants that cause HCM have been studied in transgenic mice, which have different electrophysiological properties compared to humans (Knollmann et al., 2003). To study TNNT2 variants in a human model, we used genome editing (CRISPR/Cas9) to generate heterozygous I79N^+/− TNNT2 hiPSCs. This technique enabled us to compare I79N^+/− TNNT2 hiPSCs with its isogenic control hiPSCs instead of comparing with control hiPSCs that have different genetic and epigenetic backgrounds. It has been shown that I79N-related HCM cases are characterized by mild hypertrophy (Watkins et al., 1995). The I79N^+/− TNNT2 hiPSC-CMs expressed some of the hypertrophic transcription factors (Supplementary Figure S6), which is consistent with clinical findings in patients with troponin T mutations (Varnava et al., 2001). We also examined the effect of I79N^+/− TNNT2 variants on voltage and Ca²⁺ transients at different stimulation frequencies (Figures 2 and 3). We found that I79N^+/− TNNT2 hiPSC-CMs exhibited altered Ca²⁺ handling (Figure 2) and shortened early repolarization (Figure 4) and resulted in AP triangulation (Figure 5). In our study, AP triangulation refers to the repolarization time from APD₃₀ relative to APD₈₀, which is shortened in the TNNT2 I79N^+/− variant (Figures 2 and 3) but only at the lowest stimulation frequencies. TNNT2 I79N-induced AP triangulation was also observed in a transgenic mouse model by the Knollmann group (Baudenbacher et al., 2008). Here, we demonstrate that this HCM-associated TNNT2 variant is pro-arrhythmic by altering the action potential and Ca²⁺ transient decay rate in human iPSC-CMs, which are consistent with the clinical features of this variant. Although the mechanism of arrhythmogenesis is not clear, alterations in Ca²⁺-handling properties are likely involved.

The expression of mutant TnT protein in myofilaments results in structural and functional changes in cardiac cells (Rust et al., 1999). Unlike the transgenic mice model, myofibril disarray was observed in the I79N^+/− TNNT2 hiPSC-CM model, which is important for understanding the underlying mechanism of TnT-linked HCM (Wang et al., 2018). The rapid heart rate in HCM patients carrying TNNT2 mutations can be arrhythmogenic. In a study on HCM patients who were recipients of implantable cardiac defibrillators (ICDs), the rapid heart rate resulted in atrial fibrillation or sinus tachycardia in over 90% of the arrhythmic episodes (Cha et al., 2007). In another study in children with HCM who were treated to reduce their heart rates, sinus tachycardia was observed in 90% of ventricular fibrillation episodes (Pablo Kaski et al., 2007). The results of these studies are consistent with the high incidence of ventricular tachycardia and sudden cardiac death possibly linked to high Ca²⁺ sensitivity due to TNNT2 variants (Watkins et al., 1995; Knollmann and Potter, 2001; Van Driest et al., 2003). Our data from I79N^+/− TNNT2 hiPSC-CMs demonstrated that fast stimulating rates can be arrhythmogenic, compared to WT TNNT2 hiPSC-CM (Figure 3).

Previous studies found that TNNT2-linked HCM variants increased Ca²⁺ sensitivity in the cardiac skinned fibers and slowed the Ca²⁺ dissociation rate [k _{off (Ca} ²⁺ ₎] from troponin C during diastole (Baudenbacher et al., 2008; Schober et al., 2012; Gomes et al., 2002; Miller et al., 2001) in the murine heart. However, the total number of Ca²⁺-binding sites did not change in TNNT2 variants. Therefore, increased Ca²⁺ sensitivity due to TNNT2 variants increases cytosolic Ca²⁺ buffering because the troponin complex accounts for a substantial portion of cytosolic Ca²⁺ buffering (Miller et al., 2001; Bers, 2000). As expected, increased Ca²⁺ buffering and sensitivity caused a reduction in Ca²⁺ transient peak in I79N^+/− TNNT2 hiPSC-CMs (Wang et al., 2018) at physiological heart rates but, surprisingly, did not change the Ca²⁺ transient amplitude in the transgenic mouse model (Schober et al., 2012). During diastole, increased Ca²⁺ sensitivity results in prolongation of Ca²⁺ transient and slower Ca²⁺ decay rate. Unlike transgenic mice expressing I79N TNNT2, but consistent with a previous human model (Wang et al., 2018), we also did not observe prolonged Ca²⁺ transients in I79N^+/− TNNT2 hiPSC-CM (Figure 5). However, our data demonstrated a slower Ca²⁺ decay rate in I79N^+/− TNNT2 hiPSC-CMs compared to WT TNNT2 hiPSC-CMs (Knollmann et al., 2003) (Figure 2).

It has been reported that the Ca²⁺ sensitization of myofilaments causes action potential remodeling and triangulation, which, in turn, result in induction of arrhythmia in I79N transgenic mice (Knollmann et al., 2003). Previous studies on transgenic mice indicate that the increased Ca²⁺ sensitivity due to I79N variant reduces (Ca²⁺)_free during systole and leads to a shorter plateau phase in APD. Moreover, the downregulation of the inward rectifier current (I _k1) in I79N transgenic mice contributes to the shortening of the APD (Knollmann et al., 2003). Our findings also demonstrated this fact in I79N^+/− TNNT2 hiPSC-CM. However, one cannot measure the I _k1 current in an optical mapping assay (Figure 5). One possible explanation for AP triangulation due to increased Ca²⁺ sensitivity is NCX activity (Pott et al., 2007; Bögeholz et al., 2015; Wang et al., 2018). The primary activity of the NCX is during the plateau phase of AP by exchanging the Na⁺ ions with one Ca²⁺ ion, which produces an inward current during phases 2 and 3 of AP. Since the (Ca²⁺)_free during systole was reduced due to increased Ca²⁺ sensitivity, the activity of the NCX decreased, resulting in a smaller NCX current and a shorter plateau phase (Pott et al., 2007; Bögeholz et al., 2015). The role of NCX in modulating the AP plateau phase due to Ca²⁺-handling alteration is observed in mouse, rat, and human cardiomyocytes (Knollmann et al., 2003; duBell et al., 1991). However, it is important to note that the NCX activity is different among various species, and APD is less dependent on NCX in higher mammals, which limit the application of this potential mechanism (duBell et al., 1991; London, 2001). The AP remodeling and triangulation in I79N^+/− TNNT2 hiPSC-CMs are considered arrhythmogenic (Wang et al., 2018) and can cause re-entrant ventricular tachycardia in mouse and rabbit models (Boersma et al., 2002). However, in this study, while AP triangulation occurred in AP hiPSC-CMs at the lowest stimulation frequency (55 bpm), it was not apparent at higher frequencies. The arrhythmias, however, were only detectable at the higher stimulation frequencies (>75 bpm), indicating that AP triangulation was not, per se, the cause of the arrhythmia. The combination of decreased I _k1 ¹², slower Ca²⁺ decay rate, and increased cytosolic (Ca²⁺) during fast pacing may lead to arrhythmogenic events.

In previous studies (Nishikimi et al., 2006; Rovetti et al., 2010), we developed a theory for the mechanism of cytosolic Ca²⁺ alternans. It was called it the “3R” theory since Ca²⁺ alternans is promoted by the interactions of random firing of the Ca²⁺ sparks, recruitment of neighboring Ca²⁺ CRUs for firing (spark-induced sparks), and refractoriness of the CRUs. The recruitment is determined by the coupling strength between CRUs, and Ca²⁺ buffering is one of the parameters affecting recruitment (Nivala et al., 2012a). In this mechanism, Ca²⁺ alternans is promoted by enhancement of the recruitment (Rovetti et al., 2010). This theory can provide a plausible mechanism for alternans promoted by the I79N variant observed in the experiments. Since the slowing of the dissociation of Ca²⁺ from the myofilament by the mutants increases the Ca²⁺–troponin C complex, this reduces Ca²⁺ and troponin C binding. In other words, slowing the dissociation rate of Ca²⁺ from the myofilaments effectively reduces the Ca²⁺ buffering effect and thus enhances the recruitment. The enhancement of recruitment then promotes Ca alternans based on the “3R” theory. Note that in the computer simulations shown in Figure 6, reducing the k _off(Ca ²⁺ ₎ increases the cytosolic Ca²⁺ transient but reduces the SR Ca²⁺ load, indicating that slowing the Ca²⁺ dissociation rate caused more CRUs to fire due to the enhanced recruitment.

We assessed the impact of the I79N^+/− TNNT2 variant on the transcriptome profile demonstrating increased signaling of a hypertrophic state, profibrotic extracellular matrix (ECM) gene network, and the dysregulation of cardiac developmental pathways. The significant consequence of the I79N^+/− variant on the transcriptome profile requires further investigation. Every precaution was taken to ensure, to the best of our ability, that the WT and I79N^+/− TNNT2 variant hiPSC-CMs were as similar as possible except for the point mutation. Both lines were exposed to the CRISPR/Cas9 genome-editing protocol with the I79N^+/− line undergoing a double-strand break and then homology-directed repair while the WT remain unchanged. The 10 most likely off-target mutation sites were all sequenced to determine that this was not a contributing factor. Both lines were then subjected to identical differentiation protocols in parallel, and RNA was isolated at the same time. Thus, the most likely explanations for the striking observation are the functional consequences of the variant of biophysical aspects of the contractile process and the alterations in hiPSC-CM Ca²⁺ handling due to the decrease in the Ca²⁺ off-rate constant from the myofibrils.

The significant increase in the expression of the transcripts for atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) is indicative of a remodeling taking place that likely reflects a hypertrophic response (Nishikimi et al., 2006). Mechanical stress is an important trigger for ANP and BNP production and release from cardiomyocytes (Nishikimi et al., 2006). In a potentially hypertrophic state induced by HCM-associated variants such as I79N, there is a reappearance of ventricular ANP expression in the developing cardiomyocytes, which is recognized as a marker for the induction of the embryonic gene program seen mainly in ventricular hypertrophy (Razeghi et al., 2001; Gardner, 2003). This shift causes a massive fold increase in ANP and BNP mRNA quantities as seen in the I79N cells and is likely reflecting early indicators of a hypertrophic process (Kerkelä et al., 2015).

Critical components of the Notch signaling pathway (Notch1, Notch3, Notch4, Jag1, and Hey1) were all significantly upregulated in I79N^+/− hiPSC-CMs. The Notch signaling pathway plays an important role during development and maintaining homeostasis by regulating cellular apoptosis, proliferation, and differentiation as well as playing an important role in intercellular communication (Zhou and Liu, 2014). Several studies have shown that Notch signaling is involved in counteracting fibrotic remodeling (D'Amato et al., 2016; MacGrogan et al., 2018; Nistri et al., 2017). Upregulation of the Notch 1, 3, and 4 was also observed in hiPSC-CMs cultured on a stiff substrate, which recapitulates a fibrotic condition as shown by Heras-Bautista et al. (2019). Again, the Notch signaling transcriptomic changes likely reflect a change in the biophysical properties of the hiPSC-CMs harboring the I79N^+/− TNNT2 variant. This striking upregulation in Notch-related transcripts is particularly significant because of the novelty and likely significance of the finding. For example, Notch signaling pathways have been shown to change in response to ischemia and myocardial infarction (Nistri et al., 2017). A major component of HCM progression involves altered microcirculation and the microenvironment of the cardiomyocytes, which could be causal for the Notch transcriptional upregulation (MacGrogan et al., 2018). A study by Øie et al. (2010) investigated the alterations in Notch signaling in rats with HF after induction of myocardial infarction and in humans with heart failure. The isolated cardiomyocytes from both rats and humans showed a significant increase in the relative expression levels of Notch receptors in failing vs. non-failing myocardium (Øie et al., 2010). Another major study by Qiao et al. (2017) investigating sick sinus syndrome showed that the persistent activation of Notch alters gene expression of related ion channels and cellular electrophysiology. This shift predisposes the cardiomyocytes to an arrhythmogenic substrate (Qiao et al., 2017). This could be one possible link between Notch signaling and the arrhythmic phenotype seen in HCM patients with the I79Nvariant. This means that there is a future opportunity for treatment by modulating the Notch pathway to ameliorate the HCM phenotype.

The modification of transcripts associated with collagen was also striking and indicative of a remodeling process. Collagen is the main structural protein of the cardiac ECM, which consists of approximately 85% type I collagen, which is responsible for building thick fibers and is important for strength, and 11% type III collagen, which assembles as thin fibers and plays an important role in ECM elasticity. The ECM also includes collagen types IV, V, and VI; fibronectin; laminin; elastin and fibrillin; proteoglycans; and glycoproteins (Exposito et al., 2010). Collagen type I consists of two chains of collagen type I alpha 1 (COL1A1) (which was significantly upregulated in I79N^+/− hiPSC-CMs) and one chain of collagen type I alpha 2 (COL1A2). The COL3A1 gene, which encodes for the collagen alpha-1 (III) chain, known as the alpha 1 chain of type III collagen, and was increased significantly in this study. Since the ECM network transmits mechanical signals to cardiomyocytes, disruption or excess production and accumulation of the ECM proteins observed in cardiac fibrosis can significantly affect contraction and relaxation as well as the architecture and function of the heart (Ho et al., 2010). Although the functional consequences of these transcriptomic changes are not fully understood, clearly, the HCM-associated TNNT2 variant I79N^+/− induces a broad spectrum of adaptations.

In conclusion, we generated I79N^+/− TNNT2 hiPSC-CMs using CRISPR/Cas9 and optically mapped their physiological features including voltage and Ca²⁺ transients. Our findings indicate that the alteration of AP and Ca²⁺ handling in I79N^+/− TNNT2 hiPSC-CMs is proarrhythmic at higher stimulation frequencies. Remarkably, the transcriptome was dramatically impacted by the insertion of a point mutation in one allele of troponin T and likely has profound consequences in a disease phenotype. The hiPSC-CMs along with the genome-editing tools demonstrate the utility of this technology for modeling sarcomeric mutations linked with HCM, identifying the arrhythmogenic factors and, potentially, developing therapeutic agents for the treatment of HCM.