E3 ubiquitin ligase TRIM21-mediated K48-linked ubiquitination of ALDH2 rs671 mutant promotes adverse cardiac remodeling.

Heart failure (HF) persists as the primary cause of death among patients recovering from acute myocardial infarction (AMI). Protein ubiquitination has been implicated as a key modulator of HF pathogenesis, yet the role of ubiquitination in the Aldh2 rs671 mutant - the most common single-nucleotide variant in human populations - remains poorly understood. We discovered TRIM21 as a previously unrecognized E3 ubiquitin ligase for the ALDH2 rs671 mutant and elucidated its mechanistic involvement in HF progression. Using Aldh2 BM chimeric mice to model AMI, we observed that WT mice transplanted with Aldh2 rs671 donor BM developed severe myocardial fibrosis and markedly reduced cardiac systolic function 2 weeks after infarction compared with controls. This phenotype arose from defective macrophage efferocytosis caused by myeloid-specific Aldh2 rs671 mutation. Through high-resolution mass spectrometry proteomics, we identified TRIM21 as the E3 ligase targeting ALDH2. TRIM21 catalyzed K48-linked ubiquitination at ALDH2 lysine 73. Macrophage-specific Trim21 knockdown via AAV-shTrim21 reversed both the exacerbated cardiac fibrosis and systolic dysfunction by restoring macrophage efferocytosis. These findings delineate the upstream E3 ubiquitin ligase and the ubiquitination site of ALDH2, revealing a potential therapeutic target for HF.