Autoantibodies in patients with arrhythmogenic cardiomyopathy activate GSK-3β resulting in a loss of cardiomyocyte cohesion

Arrhythmogenic cardiomyopathy (ACM) is an inherited cardiac desmosome disease, as more than 50% of affected patients carry pathogenic variants in desmosome protein-coding genes., In this study, we focused on the role and mechanisms of pathogenic and non-pathogenic autoantibodies against intercalated disc (ICD) proteins such as desmoglein2 (DSG2) in ACM patients, healthy relatives and murine ACM models. IgG fractions from ACM patients and healthy relatives, but not murine ACM model-derived or healthy control IgGs, revealed positive ICD staining. Antibodies reducing the loss of cardiomyocyte cohesion were found in three out of five ACM patients. Pathogenic autoantibodies, bound to DSG2 in hiPSC-CMs, cleaved DSG2 and reduced DSG2 interaction at the molecular level. We investigated GSK-3β contribution to the loss of cardiomyocyte cohesion and observed that GSK-3β reduced baseline cardiomyocyte cohesion in cultured cardiomyocytes and cardiac slices. Pathogenic ACM-IgGs activated GSK-3β upstream of p38MAPK, leading to phosphorylation and junctional loss of β-catenin. GSK-3β inhibition rescued the loss of cell cohesion induced by ACM-IgGs in ACM hiPSC-CMs. Pathogenic autoantibodies targeting DSG2 are present in ACM patients and impair cardiomyocyte cohesion in a GSK-3β-dependent manner. In contrast, autoantibodies are absent in murine ACM models and are non-pathogenic in some patients, healthy relatives.