Children and Adolescent Patients with the Variants in the ATP1A3-encoded Sodium-Potassium ATPase Alpha-3 Subunit Demonstrate Impaired QT Response to Bradycardia and Predisposition to Sinus Node Dysfunction

BackgroundAlternating hemiplegia of childhood (AHC) is a rare disorder with both neurologic and cardiac manifestations. The ATP1A3-D801N variant is associated with a pathologically short QT interval and risk of ventricular arrhythmia following bradycardia; however, the mechanism of this remains unknown. We investigated the relationship between heart rate (HR), QT, and QTc, hypothesizing that individuals with ATP1A3-D801N have abnormal, impaired shortening of QT and QTc at lower HR leading to arrhythmia predisposition. MethodsWe performed a retrospective observational study of individuals who underwent clinical evaluation, Holter monitoring, and genetic testing for AHC at Duke University Hospitals. We also compiled a group of healthy individuals as a control cohort. A larger, worldwide cohort of individuals with ATP1A3-related phenotypes was compiled to investigate sinus node dysfunction. Linear regression analysis was then performed. ResultsThe cohort consisted of 44 individuals with ATP1A3-related phenotypes with 81 Holter recordings (52.27% female; mean age at first Holter 8.04 years, range 0.58 - 33 years), compared to 36 healthy individuals with 57 Holter recordings (52.78% female; mean age at first Holter 9.84 years, range 0.08 - 38 years). Individuals with ATP1A3-D801N had reduced prolongation of QT at lower HR, manifest as a significantly lower slope for HR vs QT compared to healthy (P<0.0001). This resulted in a significantly higher slope of the relationship for HR vs QTc compared to healthy (P<0.0001). Individuals with ATP1A3-related phenotypes and baseline QTc <350 milliseconds (ms) had increased shortening of QT and QTc at lower HR compared to those with normal QTc (P=0.003; P=0.001). Among worldwide cases, 3 out of 131 individuals with ATP1A3-related phenotypes required device implantation and/or had sinus pauses >4 seconds. ConclusionsIndividuals with the ATP1A3-D801N variant exhibit paradoxical shortening of QT and QTc at lower HR, which contributes to an increased risk of arrhythmias during bradycardia. This is exacerbated by an underlying risk of sinus node dysfunction. Clinical PerspectiveWhat is Known: O_LIIndividuals with ATP1A3-D801N have a short baseline QTc. C_LIO_LITwo individuals with AHC experienced ventricular fibrillation following bradycardia. C_LI What the Study Adds: O_LIThe QT and QTc shorten to a greater extent at lower heart rate in individuals with ATP1A3-D801N than in healthy individuals. C_LIO_LIIndividuals with ATP1A3-related phenotypes and QTc <350ms show greater impairment of QT and QTc dynamics than those with normal QTc. C_LIO_LIThere is low prevalence of device implantation and significant sinus pauses in individuals with ATP1A3-related phenotypes, with a relatively greater prevalence in those with ATP1A3-D801N. C_LI