Mitochondrial DNA heteroplasmy in disease and targeted nuclease‐based therapeutic approaches

Mitochondrial DNA (mtDNA) encodes a subset of the genes which are responsible for oxidative phosphorylation. Pathogenic mutations in the human mtDNA are often heteroplasmic, where wild‐type mtDNA species co‐exist with the pathogenic mtDNA and a bioenergetic defect is only seen when the pathogenic mtDNA percentage surpasses a threshold for biochemical manifestations. mtDNA segregation during germline development can explain some of the extreme variation in heteroplasmy from one generation to the next. Patients with high heteroplasmy for deleterious mtDNA species will likely suffer from bona‐fide mitochondrial diseases, which currently have no cure. Shifting mtDNA heteroplasmy toward the wild‐type mtDNA species could provide a therapeutic option to patients. Mitochondrially targeted engineered nucleases, such as mitoTALENs and mitoZFNs, have been used in vitro in human cells harboring pathogenic patient‐derived mtDNA mutations and more recently in vivo in a mouse model of a pathogenic mtDNA point mutation. These gene therapy tools for shifting mtDNA heteroplasmy can also be used in conjunction with other therapies aimed at eliminating and/or preventing the transfer of pathogenic mtDNA from mother to child. Graphical Abstract Mitochondrial diseases are mainly caused by maternally inherited heteroplasmic mitochondrial DNA mutations. This review discusses mitochondrial DNA heteroplasmy and disease and the use of mitochondria‐targeted endonucleases as a therapeutic tool to shift heteroplasmy and restore mitochondrial function.