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Filamin C Cardiomyopathy Variants Cause Protein and Lysosome Accumulation

Originally published Research. 2021;129:751–766



Dominant heterozygous variants in filamin C (FLNC) cause diverse cardiomyopathies, although the underlying molecular mechanisms remain poorly understood.


We aimed to define the molecular mechanisms by which FLNC variants altered human cardiomyocyte gene and protein expression, sarcomere structure, and contractile performance.

Methods and Results:

Using CRISPR/Cas9, we introduced FLNC variants into human induced pluripotent stem cell–derived cardiomyocytes (hiPSC-CMs). We compared isogenic hiPSC-CMs with normal (wild-type), ablated expression (FLNC−/−), or haploinsufficiency (FLNC+/−) that causes dilated cardiomyopathy. We also studied a heterozygous in-frame deletion (FLNC+/Δ7aa) which did not affect FLNC expression but caused aggregate formation, similar to FLNC variants associated with hypertrophic cardiomyopathy. FLNC−/− hiPSC-CMs demonstrated profound sarcomere misassembly and reduced contractility. Although sarcomere formation and function were unaffected in FLNC+/ and FLNC+/Δ7aa hiPSC-CMs, these heterozygous variants caused increases in lysosome content, enhancement of autophagic flux, and accumulation of FLNC-binding partners and Z-disc proteins.


FLNC expression is required for sarcomere organization and physiological function. Variants that produce misfolded FLNC proteins cause the accumulation of FLNC and FLNC-binding partners which leads to increased lysosome expression and activation of autophagic pathways. Surprisingly, similar pathways were activated in FLNC haploinsufficient hiPSC-CMs, likely initiated by the loss of stoichiometric FLNC protein interactions and impaired turnover of proteins at the Z-disc. These results indicate that both FLNC haploinsufficient variants and variants that produce misfolded FLNC protein cause disease by similar proteotoxic mechanisms and indicate the therapeutic potential for augmenting protein degradative pathways to treat a wide range of FLNC-related cardiomyopathies.


Meet the First Author, see p 701

Cardiomyopathy, characterized by pathological cardiac enlargement and contractile dysfunction, is a leading cause of heart failure. Among patients with nonischemic cardiomyopathy, a cause is identified in over 20%, including damaging variants (loss of function, in-frame deletions/insertions, and deleterious missense) in over 40 genes with diverse functions in cardiomyocyte biology.1,2 These variants cause diverse forms of cardiac remodeling which are clinically subclassified into hypertrophic cardiomyopathy (HCM), dilated cardiomyopathy (DCM), and restrictive cardiomyopathies, among others. A critical next step to improve the understanding of human heart failure is to define shared and distinct mechanisms by which these variants cause disease.

Variants in FLNC, encoding filamin C, have emerged as a more common cause of cardiomyopathy.3–6FLNC truncating variants are found in ≈3% to 4% of patients with DCM which presents in early-to-mid adulthood and is associated with a high rate of ventricular arrhythmias and sudden cardiac death.6–9FLNC missense variants are more commonly associated with HCM and can cause pathological FLNC protein aggregation.9 However, there is considerable overlap between the cardiomyopathy phenotypes caused by distinct classes of FLNC variants, with missense, splice site, and in-frame indels reported in DCM, HCM, and restrictive cardiomyopathy.3,9,10

Filamins (FLNA, FLNB, FLNC) are dimeric proteins, consisting of 270 to 290 kDa subunits, that crosslink filamentous (F−) actin.11,12 FLNs contain an N-terminal ABD (actin-binding domain) followed by 24 immunoglobulin-like repeats, the last of which mediates protein dimerization.13,14 FLNC (Figure 1) is uniquely and highly expressed in cardiac and skeletal muscle15,16 and has an immunoglobulin-like domain insertion that enables sarcomere binding at Z-discs, where it crosslinks actin to anchor thin filaments.16 FLNC is less abundantly found at costameres (specialized focal adhesion complexes that connect sarcomeres to the sarcolemma) and at intercalated discs.12,17,18 At these locations and at Z-discs, the C-terminal immunoglobulin domains (immunoglobulin 16–24) of FLNC interact with a large number of proteins with diverse structural and signaling roles, including the dystrophin-glycoprotein-complex, SGCG (γ-sarcoglycan),12 ITGB1 (β1-integrin tail),17 SORBS1 (costamere-associated protein),19 FBLIM1 (migfilin),20 PGM5 (aciculin),21 XIRPs (xin proteins; XIRP1, XIRP2),21 SYNPO2 (synaptopodin 2),22 MYOT (myotilin),16 MYOZs (myozenins; MYOZ1, MYOZ2),23 TTN (titin),24 and HSP (heat shock proteins; HSPB1,18 HSPB725).

Figure 1.

Figure 1. Sarcomere structure and FLNC (filamin C) localization in human induced pluripotent stem cell–derived cardiomyocytes. Schematic representation of the cardiac sarcomere, a highly-organized structure consisting of parallel arrays of thick and thin filaments. Myosin-rich (blue) thick filaments are anchored at the M-band and actin-rich (pink) thin filaments are anchored at Z-discs. FLNC (red) localizes primarily to Z-discs, where it crosslinks actin contained in thin filaments. Smaller amounts of FLNC also localize to costameres (light green oval), and intercalated discs (not shown). TTN (Titin) spans half of the sarcomere length extending from the Z-disc (N-terminus) to the M-band (C-terminus). ECM indicates extracellular matrix.

Homozygous ablation of Flnc in mice, flies, and fish produces abnormal Z-disc morphology, compromised sarcomere integrity, and striated muscle dysfunction.24,26–28 However, heterozygous FLNC variants in these model systems do not show overt striated muscle phenotypes, and thus their utility in understanding human cardiomyopathy pathogenesis has remained limited. A related disease, myofibrillar myopathy (MFM), is also caused by truncating FLNC variants and shows large protein aggregates composed of FLNC and its binding partners in skeletal muscle.29,30 Although some patients with MFM also have DCM the converse is not true—the vast majority of DCM patients with pathogenic FLNC variants lack skeletal muscle involvement. Moreover, large protein aggregates are not reported in cardiac biopsies from FLNC-DCM patients.7,10 As such, the relatedness of pathogenic mechanisms involved in FLNC myofibrillar myopathy and FLNC cardiomyopathy remains unclear.

Here, we explored the mechanism of FLNC cardiomyopathy by employing CRISPR/Cas9 methodologies to produce and study a series of damaging FLNC variants in human induced pluripotent stem cell–derived cardiomyocytes (hiPSC-CMs). Unexpectedly, our studies reveal that homozygous and heterozygous FLNC variants have largely distinct consequences. From analyses of transcriptomic, proteomic, and live-cell imaging, we define a critical role for FLNC expression in sarcomere assembly and demonstrate proteopathic effects that ensue from heterozygous FLNC variants.


Data Availability

The authors declare that all supporting data are available within the article (and its Data Supplement). Please see the Major Resources Table in the Data Supplement.

Culture and Maintenance of hiPSCs

PGP1 hiPSCs (derived from PGP1 donor from the Personal Genome Project) with an endogenous green florescent protein (GFP) tag on the sarcomere gene TTN31 were grown in Matrigel-coated 6-well tissue culture dishes, maintained in stem cell maintenance media (mTESR1, STEMCELL Technologies), and passaged every 2 to 3 days (passage range, 55–70) in the presence of 5 μM ROCK (Rho kinase) inhibitor Y-27632 (125410; R&D Systems).

CRISPR/Cas9-Mediated Gene Editing of hiPSCs

The Benchling design tool was used for guideRNA and homology-directed repair arm design. Adherent hiPSCs were dissociated into single cells from the tissue culture plate using accutase, and nucleofected with 2 μg of Cas9 plasmid (pSpCas9[BB]-2A-Puro [PX459] V2.0, no. 62988; Addgene Plasmid), 4 μg of guideRNA pCR-BluntII-TOPO plasmid, and 4 μg of homology-directed repair arm using a Lonza nucleofector, as previously described.32 Edited colonies were subcloned and resequenced by MiSeq to confirm editing and population clonality.

Differentiation of hiPSC-CMs

hiPSCs seeded in Matrigel-coated 6-well culture plates were grown to 90% confluency for hiPSC-CM differentiation.33 hiPSC-CMs were enriched by glucose deprivation at differentiation day 11 to 17. Unless indicated, all hiPSC-CMs were studied on or after day 30 to maximize cardiomyocyte maturity (eg, MYH7/MYH6 [myosin heavy chain] proteins=0.97±0.02).34

Replating hiPSC-CMs for Imaging

hiPSC-CMs were dissociated and replated onto Matrigel-coated glass-bottom imaging-optimized 12-well plates (Mat-Tek) as described.35

Contractility Analysis of hiPSC-CMs

Replated hiPSC-CMs were imaged as described35 using a ×100 objective of a fluorescence microscope (Keyence BZ X-710) at an acquisition rate of 30 frames per second; sarcomere lengths and percent of sarcomere contraction were quantified using SarcTrack software.36

Immunofluorescent Analyses of iPSC-CMs

Replated hiPSC-CMs were fixed, permeabilized, and stained with an F-actin molecular probe, FLNC (1:100, abcam Rb mAb, ab180941), TFEB (1:500, Cell Signaling Technology [CST], Rb mAb 37785), or NucBlue before imaging with a ×100 oil objective. For all immunofluorescent analyses, secondary antibody-only controls (abcam Rb [rabbit] monoclonalantibody ab150113, ab150116, ab150077, ab150080) were used to distinguish genuine target staining from background. Sarcomere content, anisotropy, and sarcomere persistence were quantified using custom MatLab algorithms (Extended Methods in the Data Supplement).

Patterning of hiPSC-CMs and Quantification of Sarcomere Striation

hiPSC-CMs were replated onto 2000 μm2 fibronectin-coated rectangular polydimethylsiloxane micropatterns.37 At 2 and 8 days after patterning, hiPSC-CMs were fixed, permeabilized, and stained with NucBlue and paxillin (610569, 1:100 dilution; BD Biosciences), and imaged using a ×100 oil objective.

Live Imaging of Lysosomes in hiPSC-CMs

hiPSC-CMs were stained using 75 nM LysoTracker probe (LysoTracker Red DND-99, Thermo Fisher Scientific L7528) in RPMI B27 plus insulin media. Videos were acquired in an incubation chamber (37 °C, 5% CO2) using a widefield fluorescence microscope (Keyence BZ X-710; ×100 objective, 30 frames/s). Lysosomes were also imaged using a ×100 objective of a spinning disk confocal microscope. Image data were processed using Fiji software.

Flow Cytometry of eGFP-TTN Expression in hiPSC-CMs

hiPSC-CMs were dissociated, strained through a 100 µm cell strainer, and eGFP signal was quantified with a FACSCanto flow cytometer. hiPSC-CMs without the eGFP-TTN tag were analyzed to set appropriate gates for the identification of GFP-TTN hiPSC-CMs. The resultant GFP (FITC-A) intensity frequency distributions were plotted using FlowJo software.

RNA Sequencing of hiPSC-CMs

Cells were lysed in Trizol Reagent (Life Technologies) for RNA extraction and stored at −80 °C until RNA was extracted. All RNA quality (RIN) and quantity were assessed on the TapeStation 2200 (Agilent) and all samples had an RNA integrity number (RIN) of >8. Library preparation was conducted using the Nextera library preparation method (Nextera XT DNA Library Preparation Kit, Illumina) and sequenced (Illumina NextSeq500 platform). All data were combined into a single fastq file. Samples typically had 30M to 50M reads each. Seventy-five base pair-end reads were aligned to the human reference genome hg38 using Spliced Transcripts Alignment to a Reference. Raw reads were normalized to the total number of reads per kilobase of transcript per million.

Protein Isolation From Cell Lysates

hiPSC-CMs were washed and lysed with cold RIPA buffer containing protease and phosphatase inhibitors (Sigma-Aldrich 11873580001, Sigma-Aldrich 4906837001). To ensure lysis of nuclei, the lysate was passed 20× through a 21G needle, then shaken gently on ice for 15 minutes, and centrifuged (14 000g for 15 minutes). The supernatant was transferred to a fresh tube and protein concentration was quantified using the bicinchoninic assay kit (Pierce 23227).

Western Blotting

For each sample, 12.5 μg (or 20 μg for soluble/insoluble experiments) of protein lysate was loaded and resolved under denaturing conditions on a NuPAGE 3% to 8% Tris-Acetate Protein Gel (or 4%–20% Tris-Glycine Gel for soluble/insoluble and autophagic flux experiments). Proteins were wet transferred to a polyvinylidene fluoride (PVDF) membrane overnight at 40 mA at 4 °C or 70 V for 3 hours. Membrane was blocked for 1 hour at room temperature in 5% skim milk in TBST buffer, before addition of primary and secondary antibodies (Expanded Methods), and then imaged on an LI-COR Biosciences Odyssey CLx (infrared) or ChemiDoc BioRad imaging system.

Tandem-Mass-Tag Proteomics of hiPSC-CMs

Equal amounts of protein (≈100 μg) from each sample were digested into peptides for tandem-mass-tag quantitative proteome profiling as described.38 Peptides were tagged with unique, sample-specific isobaric chemical labels (tandem-mass-tags) for multiplexing, and data were collected on an Orbitrap Fusion mass spectrometer in line with a Proxeon NanolC-1200 UHPLC. Database searching and reporter-ion quantification was performed using an in-house SEQUEST-based pipeline. To define relative abundance measurements, each protein was scaled such that the summed signal-to-noise for that protein across all channels was 100. Intensity-based absolute quantification values were used39 to estimate absolute protein abundance using mass spectra processed using MaxQuant (Version Otherwise, mass spectra were processed using a SEQUEST-based pipeline.38 Protein quantification values were exported for further analysis in R (histograms, heatmaps, scatterplots) and bar graphs (GraphPad Prism).

Soluble/Insoluble Protein Fractionation of hiPSC-CMs

hiPSC-CMs protein lysates were fractionated into soluble and insoluble fractions using previously described methods.40 Cells were washed with PBS and then lysed in ice-cold CellLytic M buffer (Sigma) containing protease inhibitors (Roche) for 30 minutes. The cells were centrifuged at 12 000g for 15 minutes and supernatants were collected, generating the soluble fraction. The pellets were dissolved in DNAse I (Roche), homogenized, and gently sonicated for 4 minutes, generating the insoluble fraction. Insoluble fractions were then used for Western blotting or mass spectrometry.

Autophagic Flux Analyses

hiPSC-CMs were washed 1X with PBS and cultured in either RPMI B27 plus insulin (fed) or DMEM minus glucose (starved) for 4 hours. Cells were treated with and without 400nM of bafilomycin A1 for 4 hours. Western blotting was used to determine the expression of LC3b-I, LC3b-II, (microtubule associated protein 1 light chain 3 beta) and TUBB (β-tubulin), and densitometric quantitation was performed using the ChemiDoc BioRad imaging system. The absolute difference in the LC3-IIb/TUBB ratio between bafilomycin-treated and untreated cells was used to compute autophagic flux.

Statistical Analyses

Statistical analyses were performed using nonparametric tests (Wilcoxon rank-sum tests), or Student t tests (2-sided, assuming similar variances) when the dataset was large and normally distributed. P<0.05 was considered statistically significant. For transcriptome and proteome-wide analyses, Benjamini-Hochberg corrections were applied for multiple comparisons with an α=0.05 after restricting the analyses by fold-change, as specified in the main text. To assess the effects of genotype on levels of particular sets of proteins (including endoplasmic reticulum [ER] proteins, autophagy proteins, FLNC interactors, and lysosome protein levels), linear mixed models were fitted with protein concentrations as the outcome variable and the interaction of genotype and marker protein as the fixed effect. To allow for correlated measurements between experiments, the replicate number was used as a random variable, and χ2 values and P values are reported. For differential expression analyses, fold-change cutoffs were determined by varying the fold-change criteria and selecting a threshold at the inflection point of the resultant graph, such that the fold-change cutoff was neither too permissive nor too restrictive. DAVID functional annotation clustering was used to conduct enrichment analyses and the topmost significant functional categories were selected for display.41

For all figures that include representative images, the individual sample that best represented the group mean was selected.


CRISPR/Cas9 Genome Engineering of FLNC Mutant hiPSC Lines

FLNC variants were introduced via CRISPR/Cas9 into the hiPSC line PGP1, which contains an endogenous GFP tag on the N-terminus of the sarcomere protein titin (eGFP-TTN). We targeted exon 30, a region that encodes the 15th immunoglobulin domain (Figure 2A), and produced isogenic hiPSCs with wild-type (WT) or mutated FLNC sequences. To model human DCM variants, we introduced a heterozygous truncating variant (FLNC+/−, Table). For comparison, we also produced cells that carry this variant on both alleles (FLNC−/−, Table).

Table. FLNC RNA and Protein Levels From Replicates (n) of Independent Differentiations of WT and Mutant hiPSC-CMs, as Determined by RNAseq and Mass Spectrometry

cell lineCoding sequence Δpredicted protein sequence ΔFLNC RNA (RPKM), (n)FLNC protein (%WT), (n)
WTWTWT283 (3)100 (3)
FLNC−/−c.5021_5022insTp.Gly1674X20* (3)6±0.5 (4)
FLNC+/−c.5021_5022insTp.Gly1674X93* (2)47±5 (3)
FLNC+/Δ7aac.5002_5022del21p.Val1668_Gly1674del324 (2)90±21 (2)
FLNCG1674S/G1674Sc.5020G>Ap.Gly1674Ser249 (1)111±10 (3)

RNA and protein quantities are displayed as mean, and mean±95% CI, respectively. FLNC indicates filamin C; hiPSC-CM, human induced pluripotent stem cell–derived cardiomyocytes; RNAseq, RNA sequencing; RPKM, reads per kilobase of transcript per million; and WT, wild-type.

* Nonsense-mediated decay of the mutant FLNC transcript.

Figure 2.

Figure 2. CRISPR/Cas9 genome engineering of filamin C (FLNC) mutant human induced pluripotent stem cell (hiPSC) lines and effects on FLNC expression in hiPSC-derived cardiomyocytes (hiPSC-CMs).A, Structure of FLNC, depicting an N-terminal (N-term) actin-binding domain (red) and 24 immunoglobulin (Ig)-like domains (blue). The CRISPR/Cas9 guide RNA targeted a cut site (scissors) in exon 30 (encoding the 15th Ig domain). B, Western blots of FLNC mutant hiPSC-CM protein extracts probed with N-term (top) and C-terminal (C-term; bottom) FLNC antibodies and loading controls TUBB (β-tubulin) and cardiac TNNT2 (troponin T). Numbers below blots indicate quantification of the relative intensity of FLNC to TUBB, normalized to wild-type (WT).

Spurious CRISPR mutagenesis also resulted in a heterozygous in-frame deletion of amino acids 1668-1674 (FLNC+/Δ7aa, Table). As FLNC in-frame insertion/deletions occur in patients with restrictive, hypertrophic, and dilated cardiomyopathies,3,10 we included FLNC+/Δ7aa in our studies, recognizing that although not identified in patients, this variant had utility in understanding the fundamental biological mechanisms of mutant alleles that do not cause FLNC haploinsufficiency. We also produced and studied FLNCG1674S/G1674S cells. At the time, this study was initiated FLNC G1674S was a variant of unknown significance but has since been reclassified as likely benign given its high frequency (1.35×10-4) in the gnomAD (Genome Aggregation Database) database.42 As such, FLNCG1674S/G1674S hiPSC-CMs, which are isogenic to parental PGP1-derived CMs, serve as a control cell line.

Genotypes were confirmed with next-generation sequencing (Figure I in the Data Supplement). All lines differentiated into beating hiPSC-CMs, and principal component analyses of RNA sequencing profiles (Data Set I and Figure IIA in the Data Supplement) showed comparable degrees of maturity amongst all lines after 30 days of differentiation, with robust expression of prototypic cardiomyocyte genes, including PLN, SERCA2A, and TTN (Table I in the Data Supplement).

Using tandem-mass-tag quantitative mass spectrometry-based proteomics, we studied replicates of WT and FLNC mutant hiPSC-CMs, where each replicate represents total cellular protein extracted from an independent differentiation. In an 8-plex experiment, we quantified the relative expression levels of 7123 proteins from WT (n=4) and FLNC−/− (n=4) hiPSC-CMs (Data Set II in the Data Supplement), and in an 11-plex experiment, we quantified 6863 proteins from WT (n=3), FLNC+/− (n=3), FLNC+/Δ7aa (n=2), and FLNCG1674S/G1674S (n=3) hiPSC-CMs (Data Set III in the Data Supplement). Hierarchical clustering analyses of protein expression data from the 8-plex and 11-plex tandem-mass-tag experiments showed appropriate clustering by genotype (Figure IIB and IIC in the Data Supplement).

Mass spectrometry of WT hiPSC-CMs identified over 100 FLNC peptides, which was significantly greater than the average number (≈8) of mapped peptides per protein, hinting that FLNC was abundantly expressed in hiPSC-CMs (Data Set IV in the Data Supplement). Intensity-based absolute quantification43 estimated that FLNC was more abundant than 97.8% of proteins identified in hiPSC-CMs (Data Set IV in the Data Supplement).

Analysis of FLNC expression in WT and mutant hiPSC-CMs (Table) showed that FLNC−/− and FLNC+/− hiPSC-CMs had markedly reduced levels of FLNC transcript (7% and 33% of WT levels), likely reflecting mRNA nonsense-mediated decay. Mass spectrometry confirmed that FLNC protein levels were similarly reduced to 6% and 47% of WT, respectively (Table). By contrast, FLNC+/Δ7aa and FLNCG1674S/G1674S hiPSC-CMs had FLNC transcript and protein levels comparable to WT cells (Table). Western blotting using N-terminal and C-terminal FLNC antibodies confirmed these findings (Figure 2B).

FLNC Is Necessary for Actin and Thin Filament Gene Expression and Sarcomere Assembly

Proteome-wide comparisons of WT and FLNC−/− hiPSC-CMs (7123 total proteins) revealed 136 proteins that were differentially expressed (DE; Data Set II in the Data Supplement). Analyses of these DE proteins showed significant enrichment of actin-binding and sarcomere proteins (Table II in the Data Supplement). Parallel analyses of RNA sequencing data indicated that these decreased protein levels were largely attributable to reduced transcription, as there was a strong correlation between DE protein and transcript expression in FLNC−/− hiPSC-CMs (r=0.91, Figure 3A). Included among these DE genes were the FLNC-binding partner synaptopodin (SYNPO), thin filament-associated sarcomere components (tropomyosin (TPM2), troponin I (TNNI3), and troponin T (TNNT1)), as well as Z-disc components (synaptopodin 2-like [SYNPO2L], ankyrin repeat domain 1 [ANKRD1], PDZ and LIM domain 3 [PDLIM3], leomodin 2 [LMOD2], cysteine and glycine-rich protein 3 [CSRP3]; Figure 3A). By contrast, proteins of the thick filament and M-band (TTN, MYBPC3, [myosin binding protein C] nebulette, MYOM1, MYOM2) were only minimally (>75% of WT level) or not significantly affected, although the ratios of MYH6/MYH7 and MYL7/MYL2 (myosin light chain) transcripts were >5-fold increased, reflecting transcriptional isoform switches that are frequently observed in states of cardiomyocyte stress44 (Data Set I and II in the Data Supplement).

Figure 3.

Figure 3. Impaired sarcomere and actin-related gene expression and deficient sarcomere assembly in FLNC−/− human induced pluripotent stem cell–derived cardiomyocytes (hiPSC-CMs).A, Correlation (r=0.91) of sarcomere and actin-binding protein and RNA expression (quantified by mass spectrometry; wild-type (WT): n=4, FLNC−/−: n=4 and RNA sequencing [RNAseq]; WT: n=3, FLNC−/: n=3). B, Costaining of F-actin (red) and eGFP-TTN (endogenous GFP titin; green, Z-discs) and DAPI (blue) in WT and FLNC−/− hiPSC-CMs. Scale bar=25 μm. C, Sarcomere content of individual hiPSC-CMs on unpatterned (UP) surfaces and on micropatterned surfaces, quantified 2 (P2) and 8 (P8) d after replating (WT: n=20 [UP], 28 [P2], 30 [P8]; FLNC−/−: n=21 [UP], 25 [P2], 25 [P8], Wilcoxon rank-sum tests). D, Anisotropic quantification of actin cytoskeletal organization from unpatterned images (WT: n=23, FLNC−/− n=25, Wilcoxon rank-sum test). E, Persistence of sarcomere orientation in individual unpatterned hiPSC-CMs (WT: n=29, FLNC−/−: n=21). F, Persistence of sarcomere orientation in individual patterned hiPSC-CMs 2 days postreplating (P2; WT: n=28, FLNC−/−: n=25). G, Persistence of sarcomere orientation in individual patterned hiPSC-CMs 8 days postreplating (P8; WT: n=30, FLNC−/−: n=21). For E–G, analyses were conducted on cells in the field of view from ≈10 representative images, and shaded area indicates SEM). ACTA indicates actin; ANKRD, ankyrin repeat domain containing; CNN, calponin; LMOD, leiomodin; MICAL, microtubule associated monooxygenase, calponin and LIM domain containing; MYH, myosin heavy chain; MYL, myosin light chain; NRAP, nebulin related anchoring protein; SYNPO (synaptopodin); TAGLN, transgelin; TNN, troponin; and TPM, tropomyosin.

Immunofluorescent analyses of actin and sarcomere structure in hiPSC-CMs (Figure 3B) showed that FLNC−/− hiPSC-CMs had significantly reduced sarcomere content (Figure 3C; mass spectrometry and flow cytometry showed comparable expression of eGFP-TTN in WT and FLNC−/− hiPSC-CMs (Figure IIIA and IIIB in the Data Supplement), thereby excluding an artifactual effect of the tagged TTN protein). FLNC−/− hiPSC-CMs also had disordered actin cytoskeletons (Figure 3B and 3D). Examination of individual replated cells also showed aberrant actin crosslinking in FLNC−/− hiPSC-CMs demonstrated by the marked size variation and breakage of actin bundles (Figure IIIC in the Data Supplement).

In our prior work, we demonstrated that sarcomere assembly and organization can often be promoted by culturing hiPSC-CMs on surfaces with micropatterned fibronectin matrices, which support the alignment of costameres with the ECM (extracellular matrix).37 However, even when plated on micropatterned surfaces, FLNC−/− hiPSC-CMs had reduced sarcomere content (Figure 3E through 3G, Figure IIID in the Data Supplement). Although these surfaces improved sarcomere persistence, a metric of myofibril continuity, in both WT and FLNC−/− hiPSC-CMs, myofibrils in FLNC−/− hiPSC-CMs still remained less persistent compared with WT at both 2 and 8 days postreplating (Figure 3E through 3G). These studies indicate that even in the presence of an organized ECM, FLNC−/− hiPSC-CMs are unable to properly assemble and organize sarcomeres.

Despite severe deficits in sarcomere assembly, residual sarcomeres in FLNC−/− hiPSC-CMs were still contractile (Movies I and II in the Data Supplement). However, these sarcomeres were significantly less contractile relative to WT, as assessed by high-throughput analysis of thousands of sarcomeres36 (Figure 4, Data Set V in the Data Supplement). Many FLNC−/− sarcomeres exhibited a conspicuous bending motion during cardiomyocyte relaxation (Movie III in the Data Supplement), a phase of the cardiac cycle when tropomyosin undergoes azimuthal movements to reposition it close to actin where electrostatic interactions maintain tropomyosin in a blocked state.45 We suspect that inadequate actin crosslinking in FLNC−/− hiPSC-CMs disrupted these movements and resulted in relaxation-dependent bending.

Figure 4.

Figure 4. Sarcomere structure and function in FLNC mutant human induced pluripotent stem cell–derived cardiomyocytes (hiPSC-CMs).A, FLNC−/− hiPSC-CMs have fewer, often fragmented sarcomeres, whereas the other FLNC mutant lines assemble intact sarcomeres (eGFP-TTN [titin], green, Z-discs). Scale bar=25 μm. B, Sarcomere contractile function (average % shortening) in wild-type (WT) and FLNC mutant hiPSC-CMs, determined by SarcTrack high-throughput video analyses. Data are displayed as mean±SEM where each dot represents averaged sarcomere contraction percent calculated from one video. Data were gathered from multiple differentiations (n), videos (v), and total tracked sarcomeres (s) as follows: WT (n=6, v=181, s=47 498); FLNCG1674S/G1674S (n=2, v=44, s=12 934); FLNC+/− (n=3, v=59, s=13 006); FLNC+/Δ7aa (n=2, v=20, s=3571); FLNC−/− (n=3, v=83, s=12 138). ns indicates nonsignificant.

Taken together, these studies of FLNC−/− hiPSC-CMs demonstrate multiple essential roles of FLNC in sarcomere biology including expression of a network of actin and thin filament genes, actin crosslinking at Z-discs, and maintenance of sarcomere structure during relaxation.

Distinct Abnormalities in hiPSC-CMs With Damaging Heterozygous FLNC Variants

Having identified impaired sarcomere structure, contractility, and relaxation in FLNC−/− hiPSC-CMs, we expected similar defects in the heterozygous mutant lines. However, neither FLNC+/−, FLNC+/Δ7aa nor FLNCG1674S/G1674S had significant changes in sarcomere structure or contractile performance in vitro (Figure 4, Movies IV through VI in the Data Supplement). Furthermore, unlike FLNC−/− hiPSC-CMs, the expression levels of most thin filament (TNNC1, TNNT2, TPM2) and thick filament (TTN, MYH6, MYH7, MYBPC3) proteins in these three lines were comparable to WT (Data Sets II and III in the Data Supplement).

To assess for other potentially pathogenic effects of these variants, we compared the entire proteomes (6863 proteins) of FLNC+/−, FLNC+/Δ7aa, FLNCG1674S/G1674S and WT hiPSC-CMs. These proteome-wide analyses showed that FLNCG1674S/G1674S was indistinguishable from WT (Figure 5A), confirming G1674S as a benign variant and allowing its use as an additional independent control line. By contrast, FLNC+/− and FLNC+/Δ7aa hiPSC-CMs had 212 and 568 DE proteins relative to WT (Data Set III in the Data Supplement); >50% of these DE proteins were shared by both FLNC+/− and FLNC+/Δ7aa hiPSC-CMs, suggesting overlapping pathogenic effects (Figure 5A). The identity and expression patterns of DE proteins in FLNC+/− and FLNC+/Δ7aa hiPSC-CMs were largely distinct from those of FLNC−/− hiPSC-CMs (Figure IVA in the Data Supplement), further implying that FLNC heterozygous alleles evoked different consequences than those caused by complete absence of FLNC.

Figure 5.

Figure 5. Damaging heterozygous FLNC variants in human induced pluripotent stem cell–derived cardiomyocytes (hiPSC-CMs) increase lysosome expression and cause intracellular accumulation of membrane and secreted proteins.A, From 6863 total proteins quantified by tandem-mass-tag mass spectrometry, differentially expressed (DE) proteins were identified in FLNC+/− (212 DE proteins), FLNCG1674S/G1674S (0 DE proteins), and FLNC+/Δ7aa hiPSC-CMs (568 DE proteins) relative to wild-type (WT; DE: log2[fold-change]|>0.67 and Benjamini-Hochberg adjusted P<0.05). Three hundred fifty of these proteins were shared between FLNC+/− and FLNC+/Δ7aa hiPSC-CMs (overlap criteria: |log2(fold-change)|>0.5). Replicate columns in heatmap represent independent differentiations of each cell line (WT: n=3, FLNC+/−: n=3, FLNCG1674S/G1674S: n=3, FLNC+/Δ7aa: n=2). B and C, Row-scaled heatmaps of enriched protein groups (B: lysosome proteins, C: trafficked proteins). D, Endoplasmic reticulum markers are upregulated with increasing derangement in genotype from WT to FLNC+Δ7aa (linear mixed model, χ2=22.7, P=0.0001). E, Representative confocal images of LysoTracker labeling (red) show increased lysosome content and clustering near nuclei (blue) in FLNC+/− and FLNC+/Δ7aa hiPSC-CMs (scale bar=100 μm). F, Quantification of Lysotracker-stained particles, normalized to nuclear number (n=10 representative images per cell line, Wilcoxon rank-sum tests). G, Quantification of Lysotracker-stained particle size (WT: n=1869, FLNC−/−: n=2055, FLNC+/Δ7aa: n=1910, where n=number of lysosomes quantitated from 10 representative images per cell line, Wilcoxon rank-sum tests). BiP/GRP78 indicates endoplasmic reticulum chaperone; CHOP, C/EBP-homologous protein 10; ERp72, protein disulfide isomerase family A member; ns, nonsignificant; PDI, prolyl hydroxylase subunit beta; and PERK, PRK-like ER kinase.

Among the 350 DE proteins shared between the FLNC+/− and FLNC+/Δ7aa hiPSC-CMs, there was significant enrichment for lysosomal proteins (Table III in the Data Supplement, Figure 5B). Levels of lysosomal membrane proteins, as well as proteins that mediate lysosomal acidification, and lysosomal enzymes including proteases, glycosidases, sulfatases, phospholipases, and ceramidases were increased (Figure 5B). Neither FLNC−/− nor FLNCG1674S/G1674S hiPSC-CMs showed large changes in lysosomal protein expression (Figure IVB in the Data Supplement).

Additional enrichment was observed for proteins containing signal peptides, disulfide bonds, glycoproteins, and extracellular proteins in both FLNC+/− and FLNC+/Δ7aa hiPSC-CMs (Table III in the Data Supplement, Figure 5C). As these terms reflect features of proteins that are destined for membrane incorporation or secretion,46 we hypothesized that the increased abundance of these proteins within the cell could reflect ER stress and dysfunctional protein trafficking. Consistent with this hypothesis, FLNC+/− and FLNC+/Δ7aa hiPSC-CMs had increased protein levels of ER stress markers including PERK (PRK-like ER kinase), CHOP (C/EBP homologous protein 10), PDI (prolyl 4-hydroxylase subunit beta), BiP/GRP78 (endoplasmic reticulum chaperone), and ERp72 (protein disulfide isomerase family A member 4), which infers activation of the PERK and ATF6 arms of the unfolded protein response (Figure 5D).47 Involvement of the IRE-1 (inositol-requiring enzyme) arm of the unfolded protein response appeared minimal, as splicing of the XBP1 mRNA48 was not observed in either the WT or FLNC heterozygous cell lines (Figure IVC in the Data Supplement).

The levels of most lysosomal proteins, trafficked proteins, and ER stress markers were even higher in FLNC+/Δ7aa than in FLNC+/− hiPSC-CMs (Figure 5B through 5D), inferring that the Δ7aa allele caused a similar, but more severe, cellular phenotype than that of the haploinsufficient allele.

Increased Lysosome Content in FLNC+/− and FLNC+/Δ7aa hiPSC-CMs

We considered whether increased lysosomal protein levels in FLNC+/− and FLNC+/Δ7aa hiPSC-CMs reflected changes in organelle number or size. Using LysoTracker, a red fluorescent membrane-permeable dye that accumulates in acidic organelles, we directly visualized lysosomes in WT, FLNC+/−, and FLNC+/Δ7aa hiPSC-CMs (Figure 5E). Live-cell imaging showed active movement of Lysotracker-stained structures along linear paths in all cell lines (Movies VII through IX in the Data Supplement), indicating that these were appropriately acidic and dynamically motile along microtubules.49 Quantification of LysoTracker staining demonstrated that LysoTracker structures were significantly larger in FLNC+/− hiPSC-CMs and FLNC+/Δ7aa (Figure 5F), as well as more numerous in FLNC+/Δ7aa relative to WT hiPSC-CMs (Figure 5G). Although the RNA and protein levels of TFEB (transcription factor EB), a master regulator of lysosomal biogenesis,50 were not significantly changed in FLNC+/− or FLNC+/Δ7aa hiPSC-CMs (Figure VA in the Data Supplement), the proportion of nuclear to cytoplasmic TFEB was increased in FLNC+/Δ7aa hiPSC-CMs relative to WT (Figure VB and VC in the Data Supplement), indicating TFEB activation.51,52 Additionally, genes containing a Coordinated Lysosomal Expression and Regulation motif through which TFEB activates transcription50 had modest but significantly increased transcription in FLNC+/− and FLNC+/Δ7aa hiPSC-CMs (Figure VD, Data Set I in the Data Supplement), suggesting that increased TFEB activity may have partially contributed to the increased expression of lysosomal genes, particularly in FLNC+/Δ7aa hiPSC-CMs, although additional mechanisms are likely involved.

Increased Autophagic Flux and Altered Z-Disc Protein Handling in FLNC+/− and FLNC+/Δ7aa hiPSC-CMs

The increase in lysosome expression and abundance in FLNC+/− and FLNC+/Δ7aa hiPSC-CMs suggested that autophagic pathways could be activated in these mutants. Consistent with this hypothesis, the levels of several autophagic proteins, including those involved in early phagophore formation (BECN1 [beclin-1], ATG13 [autophagy-related gene]), autophagosome formation (ATG2B, MAP1LC3A [microtubule associated protein 1 light chain 3 alpha], ATG7, ATG12, ATG5, ATG16L1), and regulators of autophagy including PRKACA and PRKACB53–55 were found in lower abundance in FLNC+/− and FLNC+/Δ7aa compared with WT and FLNCG1674S/G1674S hiPSC-CMs (Figure 6A, Data Set III in the Data Supplement). We hypothesized that the depletion of these proteins reflected their consumption due to increased autophagic flux.

Figure 6.

Figure 6. Heterozygous damaging FLNC variants cause depletion of autophagic proteins, increased autophagic flux, and accumulation of Z-disc proteins in human induced pluripotent stem cell–derived cardiomyocytes (hiPSC-CMs).A, Levels of proteins involved in autophagy (including phagophore formation, autophagosome elongation, autophagosome maturation, regulation of autophagy) showing increasing derangement by genotype from FLNCG1674S/G1674S to FLNC+/Δ7aa hiPSC-CMs (linear mixed model, chi-squared=271.6, P=3.2×10-42). B, Representative Western blot showing LC3-I and LC3-II protein levels with TUBB (β-tubulin) as loading control. The relative difference in LC3-II/TUBB levels with and without Baf A1 (bafilomycin A1) was used to calculate autophagic flux under both fed and starved (glucose-depleted) conditions. C, Densitometric quantitation of LC3-II/TUBB normalized to total signal intensity per blot (n= 3 biological replicates×2 technical replicates per genotype). Under both fed and starved conditions, the autophagic flux increases by genotype from wild-type (WT) to FLNC+/Δ7aa (linear mixed model, χ2=19.1, P=1.2×10-5). The mean autophagic flux for each genotype is shown on plot. D, Quantitation of levels of FLNC and FLNC-interacting partners in insoluble protein fractions extracted from hiPSC-CMs by mass spectrometry (WT: n=4, FLNC+/−: n=4, FLNC+/Δ7aa: n=3). FLNC+/Δ7aa hiPSC-CMs show increased levels of FLNC and interacting partners in the insoluble fraction relative to WT (mean increase 88% [95% CI, 75%–100%], linear mixed model, P=8.6×10-51); FLNC+/− hiPSC-CMs are not significantly affected. E, Western blot validation of enrichment of FLNC and DES (desmin) in the insoluble fraction of FLNC+/Δ7aa relative to WT hiPSC-CMs (WT: n=4, FLNC+/−: n=4, FLNC+/Δ7aa: n=5). TUBB indicates beta tubulin; and VINC, vinculin.

To measure autophagic flux, we assessed LC3b phosphatidylethanolamine conjugation in hiPSC-CMs cultured in both full and starvation (glucose-depleted) media (Figure 6B and 6C). Autophagic flux increased by genotype from WT to FLNC+/− to FLNC+/Δ7aa hiPSC-CMs. This increase in flux by genotype was observed under both fed and starved conditions (Figure 6C). As autophagic flux was not significantly further upregulated by starvation in WT hiPSC-CMs, it is likely that 4 hours of glucose depletion was an insufficient stressor to result in a further increase in flux; nevertheless, the effect of genotype on flux is significant regardless of condition.

We hypothesized that the increase in lysosome content and autophagic flux in FLNC+/− and FLNC+/Δ7aa hiPSC-CMs was triggered by protein aggregation of FLNC or other FLNC-binding partners. To test this hypothesis, total cellular protein from WT and FLNC mutant hiPSC-CMs was fractionated into soluble and insoluble fractions, and the insoluble fractions were subjected to analysis by mass spectrometry (Data Set VI in the Data Supplement). Analysis of FLNC-binding partners and associated Z-disc proteins showed that these proteins were enriched in the insoluble fractions of FLNC+/Δ7aa hiPSC-CMs relative to WT (Figure 6D). The proteins with the greatest enrichment in FLNC+/Δ7aa hiPSC-CMs included FLNC, striated muscle actin (ACTA1), PDLIM3 (PDZ and LIM Domain 3), DES (desmin), FILIP1 (FLNA interacting protein 1), and migfilin/FBLIM1 (FLN-binding LIM protein 1). The enrichment of these proteins in the insoluble fraction indicated that the FLNCΔ7aa protein formed aggregates of FLNC and other FLNC-binding partners, similar to those that form with FLNC HCM missense variants.9 Western blotting further confirmed the enrichment of FLNC and DES in the insoluble fractions of FLNC+/Δ7aa hiPSC-CMs (Figure 6E). In contrast, FLNC+/− hiPSC-CMs did not show significant enrichment of FLNC or its binding partners in the insoluble fraction relative to WT (Figure 6D and 6E; although FLNC+/− also carry only 50% of the amount of total FLNC protein).

Despite lacking enrichment of FLNC and FLNC-binding partners in the insoluble protein fraction, further analyses of total cellular lysate from FLNC+/− hiPSC-CMs showed significant accumulation of FLNC-binding partners and Z-disc proteins relative to WT (Figure VI, Data Set III in the Data Supplement); this accumulation was even greater in FLNC+/Δ7aa hiPSC-CMs compared to FLNC+/− hiPSC-CMs. Sarcomere proteins that were not part of the Z-disc including those of the thin (eg, TNNC1, TPM2) and thick filament (eg, MYH6, MYH7, MYBPC3) did not show these effects (Figure VI in the Data Supplement). These data suggest that Z-disc protein turnover is modestly affected in FLNC+/− hiPSC-CMs, and more severely so in FLNC+/Δ7aa hiPSC-CMs which form aggregates of FLNC and FLNC-binding proteins.


We demonstrate that FLNC is critical for sarcomere assembly and define the effects of damaging FLNC variants on cardiomyocyte biology (Figure 7). Complete loss of FLNC expression (FLNC−/−) disrupted the coordinated expression of actin and thin filament genes, which reduced sarcomere content and impaired sarcomere function. FLNC haploinsufficiency (FLNC+/−), a cause of DCM, did not disrupt sarcomere assembly and performance but rather impaired cardiomyocyte proteostasis, as reflected by the presence of ER stress, increased lysosome expression, and enhanced autophagic flux. Even more profound abnormalities in proteostasis occurred with an in-frame deletion mutant encoding a misfolded FLNC protein (FLNC+/Δ7aa), which formed aggregates akin to those that accrue with damaging FLNC HCM missense variants.9

Figure 7.

Figure 7. A model of the damaging effects of filamin C (FLNC) variants in human cardiomyocytes.A, Ablation of FLNC (FLNC−/−) causes deficient actin crosslinking at Z-discs and inhibits transcription and translation of actin-related and sarcomere thin filament genes including SYNPO, TPM2, TNNI3, TNNI3, SYNPO2L, ANKRD1, PDLIM3, LMOD2, and CSRP3. This impairs sarcomere assembly, contractility, and relaxation in FLNC−/− human induced pluripotent stem cell–derived cardiomyocytes. B, FLNC heterozygous variants disrupt sarcomere protein turnover at the Z-disc causing activation of autophagic clearance mechanisms and increases in lysosome content. Eventually, autophagic clearance mechanisms are overwhelmed and proteins begin to accumulate in the endoplasmic reticulum (ER)/Golgi, impairing the normal forward trafficking of sarcolemmal and secreted proteins. Variants that cause haploinsufficiency result in cardiac dilation and variants that cause misfolding and aggregation of FLNC and its binding partners result in hypertrophy. Made in ©Biorender:

The severe consequences of FLNC ablation on sarcomere structure in hiPSC-CMs are consistent with observations in other organisms and partially explained by the known role of FLNC in crosslinking actin at Z-discs.26,27 Surprisingly, FLNC−/− hiPSC-CMs also failed to transcribe (and translate) an entire network of sarcomere and actin-associated genes, including SYNPO, TPM2, TNNI3, TNNT1, SYNPO2L, ANKRD1, PDLIM3, LMOD2, and CSRP3. The disruption of RNA transcription of these genes indicates that FLNC has underappreciated roles in the coordinated regulation of the thin filament gene network. Ultimately, loss of FLNC-mediated actin crosslinking and deficient thin filament gene expression caused severe impairment of both contractility and relaxation in FLNC−/− hiPSC-CMs. These effects explain the embryonic lethality of homozygous null alleles in mice26,28 and the absence of homozygous null alleles in humans.42

In contrast to FLNC−/− hiPSC-CMs, the sarcomere content, organization, and function of FLNC+/− hiPSC-CMs was indistinguishable from WT. Although experimental in vitro conditions cannot fully recapitulate in vivo mechanics and hemodynamics, the substantial differences between FLNC−/− and FLNC+/− hiPSC-CMs implied that haploinsufficiency evoked a different pathogenetic mechanism. The FLNC+/Δ7aa mutant, which encoded a misfolded FLNC protein and shared >50% of DE proteins with FLNC+/− hiSPC-CMs, caused a similar but more profound cellular phenotype and was ultimately quite useful in elucidating abnormal proteostasis as a key disease mechanism for both heterozygous variants.

Proteomic analyses of insoluble protein fractions revealed that FLNC+/Δ7aa hiPSC-CMs formed prominent aggregates of FLNC and its binding partners, akin to those that occur with FLNC missense alleles that also cause FLNC misfolding.9 Given its considerable abundance (top 3% of cardiomyocyte proteins), we suspect that aggregation of FLN imposes a profound burden on protein clearance mechanisms, which may evoke hypertrophic remodeling similar to other proteopathies such as cardiac amyloidosis.56 It is possible that the variable sequestration of particular FLNC-binding partners caused by distinct FLNC variants may contribute to the diversity of clinical phenotypes caused by FLNC variants.10

Proteome-wide comparisons of the FLNC+/Δ7aa and FLNC+/− lines showed that FLNC+/− had a similar, although less severe phenotype than the FLNC+/Δ7aa hiPSC-CMs. Like FLNC+/Δ7aa hiPSC-CMs, FLNC+/− hiPSC-CMs also showed evidence of ER stress as well as increased lysosome content and autophagy, implying that the FLNC+/− variant also activated protein handling pathways. We suspect that the activation of protein handling pathways in the FLNC+/− and FLNC+/Δ7aa lines occurred by similar mechanisms induced by inefficient protein turnover at the Z-disc. The greater severity of phenotype in FLNC+/Δ7aa is likely secondary to the formation of aggregates of FLNC and a wide range of FLNC-binding partners in this mutant, which places an even greater burden on protein clearance pathways. However, FLNC+/− hiPSC-CMs produce half-normal levels of FLNC protein, and thus the accumulation of FLNC and its binding partners is likely more modest, resulting in an intermediate phenotype. Although our investigations suggest that both FLNC haploinsufficient and aggregate forming variants ultimately both cause proteotoxicity by similar mechanisms, one limitation of this study is that FLNC+/Δ7aa is not a clinical variant. Future studies will investigate whether other FLNC clinical missense and indel variants also produce proteotoxicity, as proposed by our model (Figure 7).

Our investigations add to a growing body of work that recognizes the importance of lysosomes in the turnover of Z-disc proteins. The central role of lysosomes in this process is highlighted by the profound cardiomyopathy that occurs with damaging variants in X-linked LAMP2 which deplete the encoded lysosomal-associated membrane protein-2 and cause multisystem disease in affected males.57 Electrostimulation of soleus muscles isolated from Lamp2-null mice results in Z-disc disintegration—another indication that lysosome-mediated degradation is essential at the Z-disc.58 The importance of lysosomes in Z-disc protein turnover may explain their accumulation with damaging heterozygous FLNC variants and also why lysosome content was not increased with homozygous null alleles, in which Z-disc and thin filament gene expression is inhibited. The downregulation of thin filament gene transcription in FLNC−/− hiPSC-CMs suggests that cardiomyocytes may have intrinsic mechanisms to sense Z-disc stoichiometry and negatively regulate their transcription and assembly in the absence of key components such as FLNC, perhaps so as to prevent pathological protein aggregation. Further study of the mechanisms by which cardiomyocytes determine the stoichiometry of Z-disc protein complexes and then dispose of excess or damaged proteins in lysosomes is likely to provide further insights into the fundamental processes of sarcomere assembly and repair.

Impaired proteostasis is an emerging mechanism of cardiomyopathy that also occurs with pathogenic variants in other Z-disc genes including MYOT and DES, both of which, like FLNC, cause DCM and MFM.59 Furthermore, loss of function variants in Z-disc chaperones also cause DCM and MFM. These include the DES chaperone, αβ-cystallin (CRYAB),59,60 and the BAG domain–containing cochaperone (BAG3), which concentrates at Z-discs and cooperates with the autophagy adaptor protein, p62, to dispose of ubiquitinated FLNC.58FLNC+/− hiPSC-CMs had depleted levels of two additional Z-disc chaperones—HSPB1 and HSPB7—both of which interact with FLNC and promote its proper localization and folding.18,25 Loss of HSPB7 leads to FLNC aggregation, cardiomyocyte dysfunction, and myopathy in zebrafish, mice, and cultured human cardiomyocytes.25,61,62 Replenishment of these critical Z-disc chaperone proteins, and further augmentation of protein handling pathways that are inadequate in FLNC+/− cardiomyocytes, may be broadly therapeutic for patients with Z-disc-related cardiac and skeletal myopathies. Additional interventions to increase autophagic flux through pharmacological modulation and lifestyle modifications, such as endurance exercise and caloric restriction, may also have clinical value.63,64 hiPSC-CMs carrying FLNC variants provide an ideal model system to test the efficacy of these interventions.

In conclusion, damaging FLNC variants produce proteopathic cardiomyopathies and reinforce the critical roles for the lysosome-dependent turnover of excess, misfolded, or damaged proteins in cardiomyocytes. The growing recognition of pathological protein accumulation that occurs in many genetic and unsolved causes of DCM, HCM, and MFM indicates that an improved understanding of associated mechanisms and development of appropriate interventions has the potential to benefit many patients with these proteopathic myopathies.

Nonstandard Abbreviations and Acronyms


dilated cardiomyopathy


differentially expressed




migfilin/filamin binding LIM protein 1


filamin A interacting protein 1


filamin C


hypertrophic cardiomyopathy


human induced pluripotent stem cell


human induced pluripotent stem cell–derived cardiomyocytes


heat shock proteins


β1-integrin tail


myofibrillar myopathy






PDZ and LIM domain 3






costamere-associated protein


synaptopodin 2




xin proteins


We thank the Harvard Medical School (HMS) Micron Core for assistance with cardiomyocyte imaging and the National Science Foundation (NSF) Engineering Research Center on Cellular Metamaterials (EEC-1647837) for expertise in patterning human induced pluripotent stem cell–derived cardiomyocytes (hiPSC-CMs). Graphics including graphical abstract were created with

Supplemental Materials

Expanded Materials and Methods

Data Supplement Figures I–VI

Data Supplement Movies I–IX

Data Sets I–VI

References 31–39

Disclosures C.E. Seidman and J.G. Seidman are founders and own shares in Myokardia Inc., a startup company that is developing therapeutics that target the sarcomere. C.N. Toepfer is a consultant for Myokardia Inc. The other authors report no conflicts.


*S.P. Gygi, C.E. Seidman, and J.G. Seidman contributed equally.

The Data Supplement is available with this article at

For Sources of Funding and Disclosures, see page 764.

Correspondence to: J.G Seidman, PhD, 77 Avenue Louis Pasteur, Boston, MA 02115. Email


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Novelty and Significance

What Is Known?

  • Dominant heterozygous variants in filamin C (FLNC) can cause diverse cardiomyopathies.

  • FLNC is a muscle-specific member of the class of actin crosslinking filamin proteins that is expressed primarily at sarcomere Z-discs.

  • FLNC homozygous variants that cause loss of FLNC protein expression result in early lethality.

  • FLNC heterozygous variants cause diverse forms of human cardiomyopathy with missense variants most often associated with hypertrophy and truncating variants most often associated with dilation.

What New Information Does This Article Contribute?

  • FLNC homozygous variants profoundly impair sarcomere assembly and thin filament gene expression in human induced pluripotent stem cell–derived cardiomyocytes.

  • Diverse FLNC heterozygous variants including those that cause haploinsufficiency and those that cause FLNC misfolding impair the turnover of Z-disc proteins, activate autophagy, and increase lysosome content in human induced pluripotent stem cell–derived cardiomyocytes.

Dominant heterozygous variants in FLNC cause diverse presentations of cardiomyopathy. Complete ablation of FLNC expression (FLNC−/−) in human induced pluripotent stem cell–derived cardiomyocytes causes profound impairment of sarcomere assembly and thin filament gene expression. Human induced pluripotent stem cell–derived cardiomyocytes bearing FLNC heterozygous variants assemble sarcomeres but increase lysosome content and activate protein handling pathways due to impaired turnover of Z-disc proteins (FLNC+/−, FLNC+/Δ7aa) and protein aggregation of FLNC and its binding partners (FLNC+/Δ7aa). Therapies to facilitate the appropriate degradation and disposal of accumulating Z-disc proteins may help antagonize cardiomyopathy progression caused by FLNC variants.