Dilated Cardiomyopathy Due to BLC2-Associated Athanogene 3 (BAG3) Mutations

Abstract

Background: The BAG3 (BLC2-associated athanogene 3) gene codes for an antiapoptotic protein located on the sarcomere Z-disc. Mutations in BAG3 are associated with dilated cardiomyopathy (DCM), but only a small number of cases have been reported to date, and the natural history of BAG3 cardiomyopathy is poorly understood.

Objectives: This study sought to describe the phenotype and prognosis of BAG3 mutations in a large multicenter DCM cohort.

Methods: The study cohort comprised 129 individuals with a BAG3 mutation (62% males, 35.1 ± 15.0 years of age) followed at 18 European centers. Localization of BAG3 in cardiac tissue was analyzed in patients with truncating BAG3 mutations using immunohistochemistry.

Results: At first evaluation, 57.4% of patients had DCM. After a median follow-up of 38 months (interquartile range: 7 to 95 months), 68.4% of patients had DCM and 26.1% who were initially phenotype-negative developed DCM. Disease penetrance in individuals >40 years of age was 80% at last evaluation, and there was a trend towards an earlier onset of DCM in men (age 34.6 ± 13.2 years vs. 40.7 ± 12.2 years; p = 0.053). The incidence of adverse cardiac events (death, left ventricular assist device, heart transplantation, and sustained ventricular arrhythmia) was 5.1% per year among individuals with DCM. Male sex, decreased left ventricular ejection fraction. and increased left ventricular end-diastolic diameter were associated with adverse cardiac events. Myocardial tissue from patients with a BAG3 mutation showed myofibril disarray and a relocation of BAG3 protein in the sarcomeric Z-disc.

Conclusions: DCM caused by mutations in BAG3 is characterized by high penetrance in carriers >40 years of age and a high risk of progressive heart failure. Male sex, decreased left ventricular ejection fraction, and enlarged left ventricular end-diastolic diameter are associated with adverse outcomes in patients with BAG3 mutations.

Keywords: BAG3; dilated cardiomyopathy; genetics; prognosis.

Graphical abstract

Figure 1

Flowchart of Patients Included in the Study *1 patient was still on LVAD at last evaluation. BAG3 = BLC2-associated athanogene 3; DCM = dilated cardiomyopathy; FU = follow-up; HF = heart failure; HTx = heart transplantation; IQR = interquartile range; LVAD = left ventricular assist device; SCD = sudden cardiac death.

Figure 2

Clinical Events During Follow-Up of Individuals With BAG3 Mutation SVT/FV = sustained ventricular tachycardia/ventricular fibrillation; other abbreviations as in Figure 1.

Figure 3

Survival Analysis in BAG3 DCM (A) Global survival free of the primary composite endpoint (heart transplantation, left ventricular assist device, cardiac death, aborted SCD and appropriate ICD shock). Analysis from date of first evaluation until last follow-up or event. (B) Male sex as risk factor for clinical events. ICD = implantable cardioverter-defibrillator; other abbreviations as in Figure 1.

Central Illustration

Clinical Outlook and Outcomes of 129 Patients With BAG3 Mutations BAG3 = BLC2-associated athanogene 3; DCM = dilated cardiomyopathy; ECG = electrocardiogram; HF = heart failure; ICD = implantable cardioverter defibrillator; LVAD = left ventricular assist device; SCD = sudden cardiac death; SVT = sustained ventricular tachycardia.

Figure 4

BAG3 Localization in Explanted Hearts Samples fluorescently labeled for actinin (green) and BAG3 (red). Scale bar: 50 μm. (Left column) The first row belongs to a patient without mutations. The second row to a patient with a mutation in Lamin, and the third and fourth rows to patients with truncating mutations in TTN. Samples labeled with actinin and BAG3 show normal localization of the proteins on Z-discs on all the patients. (Right column) The first row belongs to a patient without mutations. Subsequent rows belong to patients with BAG3 truncating mutations. In patients with BAG3 mutations, BAG3 is present at Z-discs but appears disorganized. Myofibrillar disarray can also be observed. BAG3 = BLC2-associated athanogene 3.