Results
A 15-years-old girl was diagnosed with non-metastatic Epstein Barr virus
infection related nasopharyngeal cancer, and a partial deficit of
dihydropyrimidine dehydrogenase (DPD) was diagnosed.3Chemotherapy started including reduced doses of 5FU (1000 mg/m²) and
cisplatin (1000 mg/m²) intravenously. On day 2, she presented nausea,
heart rate 170/mn, blood pressure : 78/35 mmHg without chest pain or
dyspnea. Electrocardiogram showed isolated sinus tachycardia. There was
an increase in: NT-proBNP at 4707pg/ml (<125), troponin Ic at
1.78 µg/L (< 0.04), serum creatinin 114 µmol/l (versus60µmol/L at admission), normal thyroid function. In the Acute Coronary
Unit (ACU) echocardiogram demonstrated left ventricular ejection
fraction (LVEF) of 20%, low cardiac output, no chamber dilatation, no
regional wall motion abnormalities, heart valve abnormalities or
pericardial fluid. Cardiogenic shock became untreatable, requiring
mechanical circulatory support by extracorporeal membrane oxygenation
arteriovenous (ECMO-VA). Coronary angiogram was normal. Right
ventricular myocardial biopsy showed myocyte necrosis with no
lymphocyte, eosinophilic or giant cell infiltration (Figure). Outcomes
were favorable after improvement of LVEF allowing weaning of ECMO-VA on
D7 and of dobutamine on D11. At Day 30, the patient had been discharged,
the echocardiogram showed LVEF of 60% on ACE-inhibitors. At 6 months
follow-up, cardiac magnetic resonance (cMR) showed normal LVEF and right
ventricular function, limited epicardial late gadolinium enhancement in
the inferior and infero-lateral walls, and normal T1 and T2 mapping.
Chemotherapy had been contra-indicated, and the patient remained
disease-free after nasopharyngeal irradiation at 12 months follow-up.
A 86 years old male patient, non DPDP deficient, was given a first
re-challenge cycle of chemotherapy including 5FU
(400mg/m2 bolus followed by a 2400
mg/m2 infusion) and oxaliplatin
(85g/m2) for relapsing colon cancer. Past medical
history included: right sided small cell renal carcinoma treated by
nephrectomy 11 years earlier; colon cancer treated by surgery and
chemotherapy (5FU and oxaliplatin) 9 years earlier. Cardiovascular
assessment prior chemotherapy included: sinus rhythm, complete left
bundle branch block (LBBB); septal wall motion abnormalities, moderate
left ventricular dysfunction (LVEF 45%) on echocardiogram; no ischaemia
on stress myocardial nuclear imaging. The patient presented with acute
dyspnea 2 days after chemotherapy: BP 125/75mmHg, HR 100/min, body core
temperature 36.6°C and SaO2 97%; abnormal lung crackles; no ECG
changes. Brain natriuretic peptide (BNP) was 769ng/L, troponin Ic
0.19µg/L, and serum creatinin 200µmol/L. Echocardiography showed a
severe drop in LVEF as low as 10% and low cardiac output. In the ACU,
the patient received high doses of loop diuretics (furosemide 1g/24hs
IV) and vasoactive drugs (dobutamine 20 µg/Kg/min and noradrenalin
4mg/h). Renal failure with creatinin of 394µmol/L and urea 35mmol/L
plateaued but subsequently improved however precluding coronary
angiogram. Inotropes were weaned on Day 6 and LVEF subsequently
recovered on ACE-inhibitors and spironolactone, discharged on Day 18.
The patient received raltitrexed for colic cancer that controlled the
disease. At 6 months follow-up, the patient was NYHA class I with LVEF
of 41% on cMR mainly due to LBBB-related septal asynchrony, with focal
inferior and inferolateral epicardial late gadolinium enhancement,
identical pattern as the girl’s follow-up cMR (Figure).