Expression-System Biases Compromise the Functional Assessment of KCNH2 Variants and Clinical Risk Assessment

Background: Functional characterization of KCNH2 variants is essential for assessing pathogenicity in long QT syndrome type 2. Because hERG channels assemble as tetramers, the relative expression of wild-type (WT) and variant subunits critically influences channel function and pathogenicity assessment. However, commonly used experimental systems may not reproduce the balanced allelic expression observed in heterozygous patients. Methods: Allele-specific KCNH2 expression was analyzed in two independent RNA-sequencing datasets from human left ventricular tissue. Using the dominant-negative T74R hERG variant as a model, we calibrated the relationship between WT-to-variant expression ratios and hERG current amplitude. Using automated patch-clamp electrophysiology, we compared 3 dual-expression strategies: internal ribosome entry site (IRES), P2A-linked tandem constructs, and dual cytomegalovirus promoter (dCMV) constructs. Co-electroporation of WT and variant plasmids in different ratios was the reference. Results: Allele-specific expression analysis supported balanced KCNH2 expression in human left ventricular tissue. At a 1:1 WT-to-T74R expression ratio, hERG current amplitude was reduced to 31.0% of WT, consistent with a dominant-negative mechanism in which incorporation of 2 or more T74R subunits renders the channel nonfunctional. All 3 dual-expression strategies produced substantial expression imbalances, with the first cassette consistently favored. IRES constructs showed the greatest asymmetry. P2A constructs partially improved expression balance but introduced an additional N-terminal proline in the second cassette altering T74R-associated trafficking and channel biophysics. The dCMV system also failed to achieve balanced expression, including after stable integration. Co-electroporation of separate WT and variant plasmids provided the most reliable means of controlling their relative expression. Conclusions: Commonly used dual-expression constructs do not reliably reproduce balanced WT and variant hERG expression, potentially distorting assessments of dominant-negative effects and variant pathogenicity. Co-electroporation of separate plasmids provides a robust approach for high-throughput functional phenotyping under heterozygous conditions, with implications for the interpretation of KCNH2 variants and potentially other genes encoding multimeric ion channels.