Catecholaminergic polymorphic ventricular tachycardia (CPVT) is linked to mutations in the cardiac ryanodine receptor (RyR2) or calsequestrin. We recently found that the drug flecainide inhibits RyR2 channels and prevents CPVT in mice and humans. Here we compared the effects of flecainide and tetracaine, a known RyR2 inhibitor ineffective in CPVT myocytes, on arrhythmogenic Ca 2+ waves and elementary sarcoplasmic reticulum (SR) Ca 2+ release events, Ca 2+ sparks. In ventricular myocytes isolated from a CPVT mouse model, flecainide significantly reduced spark amplitude and spark width, resulting in a 40% reduction in spark mass. Surprisingly, flecainide significantly increased spark frequency. As a result, flecainide had no significant effect on spark-mediated SR Ca 2+ leak or SR Ca 2+ content. In contrast, tetracaine decreased spark frequency and spark-mediated SR Ca 2+ leak, resulting in a significantly increased SR Ca 2+ content. Measurements in permeabilized rat ventricular myocytes confirmed the different effects of flecainide and tetracaine on spark frequency and Ca 2+ waves. In lipid bilayers, flecainide inhibited RyR2 channels by open state block, whereas tetracaine primarily prolonged RyR2 closed times. The differential effects of flecainide and tetracaine on sparks and RyR2 gating can explain why flecainide, unlike tetracaine, does not change the balance of SR Ca 2+ fluxes. We suggest that the smaller spark mass contributes to flecainide's antiarrhythmic action by reducing the probability of saltatory wave propagation between adjacent Ca 2+ release units. Our results indicate that inhibition of the RyR2 open state provides a new therapeutic strategy to prevent diastolic Ca 2+ waves resulting in triggered arrhythmias, such as CPVT.

Experience results in long-lasting changes in dendritic spine size, yet how the molecular architecture of the synapse responds to plasticity remains poorly understood. Here, a combined approach of multi-color stimulated emission depletion microscopy (STED) and confocal imaging demonstrates that structural plasticity is linked to the addition of unitary synaptic nanomodules to spines. Spine synapses in vivo and in vitro contain discrete and aligned sub-diffraction modules of pre- and post-synaptic proteins whose number scales linearly with spine volume. Live-cell time-lapse super-resolution imaging reveals that N-methyl-D-aspartate receptor (NMDAR)-dependent increases in spine size are accompanied both by enhanced mobility of pre- and post-synaptic modules that remain aligned with each other and by the coordinated addition of new nanomodules. These findings suggest a simplified model for experience-dependent structural plasticity relying on an unexpectedly modular nano-molecular architecture of synaptic proteins.

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