Modeling Immune Checkpoint Inhibitor Associated Myocarditis In Vitro

Introduction: Immune checkpoint inhibitor-associated myocarditis (ICI myocarditis) is a severe side effect of treating malignancies with immune checkpoint inhibitors. Patients suffering from ICI myocarditis often display an extraordinarily high mortality rate. Establishing a clinically relevant model to address the lack of identifiable risk factors, screening tests, or effective treatments is critically urgent. Hypothesis: Human ICI myocarditis can be accurately modeled in vitro. Methods and Results: We present the first cell culture-based model of ICI myocarditis. We use a novel method to co-culture human iPSC-derived cardiomyocytes (hiPSC-CM), human peripheral blood mononuclear cells, and immune checkpoint inhibitors to recapitulate critical aspects of clinical ICI myocarditis. Using this platform, we show rapid, significant cardiomyocyte necrosis after model initiation. We observe substantial disruption to hiPSC-CM cell morphology and sarcomere structure, and we use powerful multi-electrode array technology to define contractile functions and electrophysiological changes, demonstrating the critical similarities between this cell-based ICI myocarditis model and patient myocarditis. Our model also reveals an increased risk of arrhythmia, recapitulating, in vitro , the primary cause of death in patients suffering from ICI myocarditis. Finally, we demonstrate that this hiPSC-CM-based “model in a dish” can be rescued pharmacologically and identify specific leukocyte populations required for myocarditis development. In summary, we present the first in vitro model of ICI myocarditis and demonstrate its scalability, validity, patient relevance, and reproducibility. Utilizing the model can aid in accomplishing precision medicine objectives and holds significant potential for preventing and treating ICI myocarditis.