Objective: To analyze the clinical and genetic characteristics of clinical subtypes of non-obstructive hypertrophic cardiomyopathy (HCM). Methods: It was a cohort study. Patients with non-obstructive HCM admitted to Fuwai Hospital, Chinese Academy of Medical Sciences, from January 1999 to April 2019 were enrolled. According to the characteristics of cardiac morphology and function shown by echocardiography, the patients were divided into common type, dilated type, restricted type and reduced ejection fraction type. The clinical data of the patients were recorded, and 8 sarcomere pathogenic genes were screened by full exon sequencing or panel sequencing. Patienst were followed up and cardiovascular endpoint events were recorded. Results: A total of 815 patients with non-obstructive HCM were enrolled, including 27 (3.3%) restricted type, 51 (6.3%) dilated type, 30 (3.7%) reduced ejection fraction type and 707 (86.7%) common type. A total of 704 out of 815 patients underwent genetic testing. Among them, 299 (42.5%) patients carried at least 1 sarcomere gene mutation. MYBPC3 and MYH7 mutation accounted for 42.1% (126/299) and 35.8% (107/299) respectively. 66.7% (16/24) of the patients with restricted type carried sarcomere gene mutation, which was higher than that in patients with dilated type (36.4% (16/44)) and in common type (41.5% (250/602), P=0.015). Among the patients with reduced ejection fraction, 56.7% (17/30) patients carried sarcomere gene mutations, 23.3% (7/30) carried multiple sarcomere mutations, which was higher than that in restricted type (8.3% (2/24)), in dilated type (9.1% (4/44)) and in common type 4.2% ((24/577), P<0.001). MYH7 and MYBPC3 were the main mutation gene types of all clinical subtypes, and the genotypes were similar among groups (all P>0.05). Seven hundred and three out 815 patients were followed up for 2.9 (1.4, 4.0) years. There were 53(7.5%) cardiovascular death. Cardiovascular death occurred in 5.0% (29/578) patients with common type, 13.0% (3/23) patients with restricted type, 16.3% (7/43) patients with dilated type and 46.7% (14/30) patients with decreased ejection fraction. Univariate Cox proportional hazards model analysis showed that the risk of cardiovascular death in patients with restricted, dilated and reduced ejection fraction type was higher than that in patients with common type (P<0.001). After adjusting for gender, age of onset, body mass index, history of hypertension, coronary heart disease and diabetes, multivariate Cox proportional hazards model analysis showed that the HR of cardiovascular death in patients with restricted, dilated and reduced ejection fraction type were 5.454 (95%CI 1.137-26.157, P=0.034) and 6.597 (95%CI 1.632-26.667, P=0.008) and 9.028 (95%CI 2.201-37.039, P=0.002) respectively, as compared to patients with common type. Conclusions: Most of the patients with non-obstructive HCM are common type, featured by mild clinical manifestations and good prognosis. Although the proportion of restricted type and dilated type is relatively low, and cardiac systolic function is mostly preserved, the clinical phenotype and prognosis of these patients are similarly severe and poor as patients with reduced ejection fraction. The genotypes are similar in different clinical subtypes, but the proportion of patients with sarcomere gene mutation is higher in restricted type, and the proportion of patients with multiple sarcomere gene mutation is higher in decreased ejection fraction type.
Cardiomyopathy, Hypertrophic/genetics* ; Cohort Studies ; Humans ; Mutation ; Phenotype ; Sarcomeres/genetics*

Hypertrophic cardiomyopathy (HCM) is caused by dominant mutations in sarcomere genes. The diagnosis of HCM is usually established by identifying unexplained left ventricular hypertrophy (LVH) on cardiac imaging studies; however, LVH is not an invariable feature of disease. The expression of LVH is highly age-dependent, and LV wall thickness is frequently normal during childhood. Overt development of hypertrophy, and the ability to make a clinical diagnosis, does not typically occur until adolescence or later. Genetic testing allows identification of family members who have inherited the pathogenic sarcomere mutation (G +) before the emergence of clinical manifestations (LVH -). As such, a new and important subset of individuals with preclinical HCM (G+ / LVH-) can be identified early in life, before a clinical diagnosis can be made. Our evaluation of preclinical HCM has indicated that although there are no distinguishing morphologic features of early disease, there is evidence of myocardial dysfunction prior to the development of LVH. Subtle impairment of diastolic function is detectable in otherwise healthy sarcomere mutation carriers and can differentiate these family members from those who did not inherit the mutation. In contrast, systolic function appears relatively preserved in preclinical HCM, but impaired in overt disease. This preliminary finding suggests that both the sarcomere mutation and the characteristic changes in myocardial architecture (LVH, fibrosis and disarray) are required to perturb force generation. By studying this intriguing preclinical cohort, we can better understand the early stages of disease pathogenesis and potentially develop therapy to alter the clinical expression of sarcomere mutations.
Cardiomyopathy, Hypertrophic ; diagnosis ; genetics ; Genotype ; Humans ; Mutation ; Pedigree ; Phenotype ; Sarcomeres ; genetics

Objective: To observe the association between clinical phenotypes of hypertrophic cardiomyopathy (HCM) patients and a rare calcium channel and regulatory gene variation (Ca²⁺ gene variation) and to compare clinical phenotypes of HCM patients with Ca²⁺ gene variation, a single sarcomere gene variation and without gene variation and to explore the influence of rare Ca²⁺ gene variation on the clinical phenotypes of HCM. Methods: Eight hundred forty-two non-related adult HCM patients diagnosed for the first time in Xijing Hospital from 2013 to 2019 were enrolled in this study. All patients underwent exon analyses of 96 hereditary cardiac disease-related genes. Patients with diabetes mellitus, coronary artery disease, post alcohol septal ablation or septal myectomy, and patients who carried sarcomere gene variation of uncertain significance or carried>1 sarcomere gene variation or carried>1 Ca²⁺ gene variation, with HCM pseudophenotype or carrier of ion channel gene variations other than Ca²⁺ based on the genetic test results were excluded. Patients were divided into gene negative group (no sarcomere or Ca²⁺ gene variants), sarcomere gene variation group (only 1 sarcomere gene variant) and Ca²⁺ gene variant group (only 1 Ca²⁺ gene variant). Baseline data, echocardiography and electrocardiogram data were collected for analysis. Results: A total of 346 patients were enrolled, including 170 patients without gene variation (gene negative group), 154 patients with a single sarcomere gene variation (sarcomere gene variation group) and 22 patients with a single rare Ca²⁺ gene variation (Ca²⁺ gene variation group). Compared with gene negative group, patients in Ca²⁺ gene variation group had higher blood pressure and higher percentage of family history of HCM and sudden cardiac death (P<0.05); echocardiographic results showed that patients in Ca²⁺ gene variation group had thicker ventricular septum ((23.5±5.8) mm vs. (22.3±5.7) mm, P<0.05); electrocardiographic results showed that patients in Ca²⁺ gene variation group had prolonged QT interval ((416.6±23.1) ms vs. (400.6±47.2) ms, P<0.05) and higher RV5+SV1 ((4.51±2.26) mv vs. (3.50±1.65) mv, P<0.05). Compared with sarcomere gene variation group, patients in Ca²⁺ gene variation group had later onset age and higher blood pressure (P<0.05); echocardiographic results showed that there was no significant difference in ventricular septal thickness between two groups; patients in Ca²⁺ gene variation group had lower percentage of left ventricular outflow tract pressure gradient>30 mmHg (1 mmHg=0.133 kPa, 22.8% vs. 48.1%, P<0.05) and the lower early diastolic peak velocity of the mitral valve inflow/early diastolic peak velocity of the mitral valve annulus (E/e') ratio ((13.0±2.5) vs. (15.9±4.2), P<0.05); patients in Ca²⁺ gene variation group had prolonged QT interval ((416.6±23.1) ms vs. (399.0±43.0) ms, P<0.05) and lower percentage of ST segment depression (9.1% vs. 40.3%, P<0.05). Conclusion: Compared with gene negative group, the clinical phenotype of HCM is more severe in patients with rare Ca²⁺ gene variation; compared with patients with sarcomere gene variation, the clinical phenotype of HCM is milder in patients with rare Ca²⁺ gene variation.
Humans ; Cardiac Surgical Procedures/methods* ; Cardiomyopathy, Hypertrophic/genetics* ; Echocardiography ; Electrocardiography ; Phenotype ; Sarcomeres/genetics* ; Adult

Titin, the largest known protein in the body expressed in three isoforms (N2A, N2BA and N2B), is essential for muscle structure, force generation, conduction and regulation. Since the 1950s, muscle contraction mechanisms have been explained by the sliding filament theory involving thin and thick muscle filaments, while the contribution of cytoskeleton in force generation and conduction was ignored. With the discovery of insoluble protein residues and large molecular weight proteins in muscle fibers, the third myofilament, titin, has been identified and attracted a lot of interests. The development of single molecule mechanics and gene sequencing technology further contributed to the extensive studies on the arrangement, structure, elastic properties and components of titin in sarcomere. Therefore, this paper reviews the structure, isforms classification, elastic function and regulatory factors of titin, to provide better understanding of titin.
Connectin/genetics* ; Muscle Proteins/metabolism* ; Protein Isoforms/genetics* ; Sarcomeres/metabolism* ; Muscle Fibers, Skeletal/metabolism*

Since the pathology of hypertrophic cardiomyopathy was first described by French pathologists in the mid 19th century, many research papers and extensive reviews for the diverse clinical, pathological and genetics related findings have been published. The common term of hypertrophic cardiomyopathy was suggested to be used by the recommendation of the world health organization in 1980. The characteristic findings have been inappropriate myocardial hypertrophy occurring in the absence of any obvious cause such as aortic stenosis or systemic hypertension, which predominantly involved the interventricular septum in the hyperdynamic and nondilated left ventricle. Hypertrophic cardiomyopathy, initially thought to be rare, is now proved to be an important cause of morbidity and mortality across all ages. It occurs in 1 in 500 live births, and in approximately half of these cases is transmitted as an autosomal dominant trait thus becoming the most common cause of sudden death during exercise in young people. Recently, molecular genetic studies have revealed that it is a heterogeneous disease of the sarcomere in which more than 150 different mutations across 10 sarcomeric proteins are involved, and that the phenotypic manifestation and prognosis varies markedly depending on variations in genetic mutations. Consequently, genetic diagnosis is expected to be available within a few years and able to be used for early diagnosis, prevention and treatment of hypertrophic cardiomyopathy in addition to the currently available morphological and functional diagnosis by two-dimensional and Doppler echocardiography.
Aortic Valve Stenosis ; Cardiomyopathy, Hypertrophic* ; Death, Sudden ; Diagnosis ; Early Diagnosis ; Echocardiography ; Echocardiography, Doppler ; Genetics ; Heart Ventricles ; Hypertension ; Hypertrophy ; Live Birth ; Molecular Biology ; Mortality ; Pathology ; Prognosis ; Sarcomeres ; World Health Organization