Supraventricular tachyarrhythmias after hematopoietic stem cell transplantation: incidence, risk factors and outcomes

Risk factors for fatal cardiac complications after allogeneic hematopoietic cell transplantation: Japanese Society for Transplantation and Cellular Therapy transplant complications working group

Fatal cardiac complications can occur from the early to late phases after hematopoietic cell transplantation (HCT). Herein, the Japanese transplant registry database was used to retrospectively analyze health records of 33,791 allogeneic HCT recipients to elucidate the pathogenesis and risk factors involved. Overall, 527 patients died of cardiac complications at a median of 130 (range 0-3924) days after HCT. The cumulative incidence of fatal cardiac complications was 1.2% (95% confidence interval [CI]: 1.0-1.3) and 1.6% (95% CI: 1.5-1.8) at 1 and 5 years after HCT, respectively. Fatal cardiovascular events were significantly associated with an HCT-specific comorbidity index (HCT-CI) score of ≥1 specific to the three cardiovascular items, lower performance status, conditioning regimen cyclophosphamide dose of >120 mg/kg, and female sex. Cardiovascular death risk within 60 days after HCT was associated with the type of conditioning regimen, presence of bacterial or fungal infections at HCT, and number of blood transfusions. Contrastingly, late cardiovascular death beyond 1 year after HCT was associated with female sex and older age. Lower performance status and positive cardiovascular disease-related HCT-CI were risk factors for cardiac complications in all phases after HCT. Systematic follow-up may be necessary according to the patients' risk factors and conditions.

Association of atrial fibrillation and outcomes in patients undergoing bone marrow transplantation

AIMS

Haematopoietic stem cell transplantation (HSCT) is a potentially curative therapy for several malignant and non-malignant haematologic conditions. Patients undergoing HSCT are at an increased risk of developing atrial fibrillation (AF). We hypothesized that a diagnosis of AF would be associated with poor outcomes in patients undergoing HSCT.

METHODS AND RESULTS

The National Inpatient Sample (2016-19) was queried with ICD-10 codes to identify patients aged >50 years undergoing HSCT. Clinical outcomes were compared between patients with and without AF. A multivariable regression model adjusting for demographics and comorbidities was used to calculate the adjusted odds ratio (aOR) and regression coefficients with corresponding 95% confidence intervals and P-values. A total of 50 570 weighted hospitalizations for HSCT were identified, out of which 5820 (11.5%) had AF. Atrial fibrillation was found to be independently associated with higher inpatient mortality (aOR 2.75; 1.9-3.98; P < 0.001), cardiac arrest (aOR 2.86; 1.55-5.26; P = 0.001), acute kidney injury (aOR 1.89; 1.6-2.23; P < 0.001), acute heart failure exacerbation (aOR 5.01; 3.54-7.1; P < 0.001), cardiogenic shock (aOR 7.73; 3.17-18.8; P < 0.001), and acute respiratory failure (aOR 3.24; 2.56-4.1; P < 0.001) as well as higher mean length of stay (LOS) (+2.67; 1.79-3.55; P < 0.001) and cost of care (+67 529; 36 630-98 427; P < 0.001).

CONCLUSION

Among patients undergoing HSCT, AF was independently associated with poor in-hospital outcomes, higher LOS, and cost of care.

Cardiovascular diseases in patients after hematopoietic stem cell transplantation: Systematic review and Meta-analysis

BACKGROUND

Hematopoietic Stem Cell Transplantation (HSCT), is performed to treat many malignancies such as autologous or allogenic. Despite the success of this method in treating patients, - sometimes some HSCT recipients face problems such as cardiovascular complications. Therefore, this systematic review and meta-analysis aimed to evaluate the prevalence of cardiovascular complications in post-transplant patients.

METHOD

In order to review the published studies, we examined PubMed, MEDLINE, Cochrane Library, Scopus, and web of science databases from the beginning to the end of January 2022, and we used tools by the Newcastle-Ottawa Scale to evaluate the quality of the studies.

RESULT

In this study, 37 articles were included in the meta-analysis and 30,957 patients were examined. Also, the mean age of patients was 35.37 years. Based on the results of the meta-analysis, the prevalence of cardiovascular disease (CVD), was 16.84%. In addition, other complications related to CVD which include Arrhythmias, Congestive Heart Failure (CHF), Hypertension, stroke, and mortality were examined in patients who had hematopoietic stem cell transplantation and the resulting amounts were 3.91%, 3.66, 17.71, 0.22%, and 1.53%, respectively.

CONCLUSION

This study showed that the prevalence of cardiovascular disease after hematopoietic stem cell transplantation is high and needs special attention.

Atrial Fibrillation and Cancer Patients: Mechanisms and Management

PURPOSE OF REVIEW

Cancer-related mortality has significantly declined over the past several decades as a result of improved screening, diagnostics, and therapeutics. Although cancer patients and survivors are living longer, there is increased risk of both short-term and long-term cardiovascular complications, including arrhythmia. In this review, we highlight the current evidence detailing the connections between atrial fibrillation and cancer, provide insight into the mechanisms driving this relationship, and share practical considerations for the management of atrial fibrillation in cancer patients and cancer survivors.

RECENT FINDINGS

Atrial fibrillation is an increasingly recognized condition among cancer patients, with epidemiological data showing increased incidence and worse outcomes in patients with cancer. Studies also describe a bidirectional relationship between cancer and atrial fibrillation, attributable in part to shared risk factors but also potentially due to shared biology. Cancer treatment-associated arrhythmia is an active area of investigation, with ongoing research to identify the mechanisms and pathophysiology behind this phenomenon. Furthermore, management of atrial fibrillation in patients with cancer presents unique challenges, particularly in management of anti-coagulation. Cancer patients have increased risk of developing atrial fibrillation due to the shared risk factors and biology of the two conditions. Moreover, various cancer therapeutics are known to be arrhythmogenic; however, mechanisms remain unclear. Further research is needed to better understand the pathophysiology of atrial fibrillation in cancer patient in order to establish prevention and treatment strategies specific to this population.

Cardiac complications associated with hematopoietic stem-cell transplantation

Advances in chemotherapy and supportive therapy have resulted in improved clinical outcomes in patients with hematological malignancies undergoing hematopoietic stem-cell transplantation (HSCT). However, the association between HSCT and early- and late-onset cardiotoxicity remains controversial as these cardiac complications, including acute heart failure and arrhythmia, such as atrial fibrillation, can occasionally be lethal. Although the overall pathophysiology has not been elucidated, initial/salvage chemotherapy before HSCT, such as anthracycline-combined regimens, conditioning regimens, thoracic radiotherapy, and pre-existing personal risk factors, could be associated with an increased risk of cardiac events. Routine monitoring of cardiac function using global longitudinal strain or left ventricular ejection fraction in echocardiogram and serum biomarkers could be an option to detect early changes in cardiac status before irreversible cardiac complications develop. While beta-blockers and angiotensin-converting enzyme inhibitors are commonly used for cardioprotection, their clinical benefit has not been fully established in HSCT-associated cardiotoxicity. In the future, genetic analysis to reveal individual vulnerability to cardiotoxicity and prospective trials assessing the clinical benefit of early interventions, including novel agents such as angiotensin receptor-neprilysin inhibitor, are warranted. Collaboration between oncologists and cardiologists is crucial to establishing a strategy to prevent cardiac complications.

Atrial Fibrillation in Patients Undergoing Allogeneic Hematopoietic Cell Transplantation

To examine the incidence and risk factors for de novo atrial fibrillation (AF) after allogeneic hematopoietic cell transplantation (HCT) and to describe the impact of AF on HCT-related outcomes.

Left Atrial Mechanics Associates With Paroxysmal Atrial Fibrillation in Light-Chain Amyloidosis Following Stem Cell Transplantation

Background

Atrial fibrillation (AF) during high-dose melphalan and autologous stem-cell transplantation (HDM/SCT) for light-chain (AL) amyloidosis confers significant morbidity. Traditional risk factors provide limited prediction for development of paroxysmal AF during this vulnerable period.

Objectives

We sought to assess the association of clinical and echocardiographic parameters, including left atrial (LA) mechanics and development of AF in patients undergoing HDM/SCT therapy.

Methods

Baseline echocardiograms, electrocardiograms, and electronic medical records were retrospectively assessed among patients with AL amyloidosis before HDM/SCT (n = 91). LA function analysis was performed using speckle-tracking echocardiography.

Results

In this study, 42 patients (46%) had cardiac involvement; in the peri-transplant period, 12 (13%) developed AF (7 with cardiac involvement). No significant differences in age, sex, cardiac biomarkers, or cardiac risk factors were seen between patients with and without development of AF; one-third of patients with AF peri-transplant had previous AF. Although LA reservoir strain was reduced in patients with development of AF, time to peak strain rate indexed to R-R interval (TPSRI) (p = 0.001) was prolonged in patients with development of AF compared with sinus rhythm patients in the total cohort but also in subgroups with and without cardiac involvement.

Conclusions

TPSRI, a parameter of mechanical dispersion in the early reservoir phase of LA function, is associated with development of AF among patients undergoing HDM/SCT for AL amyloidosis. These findings require validation in larger prospective cohorts.

Cardiac adverse events during stem cell transplantation for hematological malignancies: A single centre experience

Hematopoietic stem cell transplantation (HSCT) is a highly successful treatment option for many hematological malignancies. Several adverse effects can be seen in HSCT due to the infusion and damage caused by the conditioning regimens. Cardiovascular adverse effects are relatively common during HSCT, and they have the potential to cause devastating complications. The aim of present study was to evaluate the transplantation-related cardiac adverse effects and determine the risk factors in patients undergoing HSCT at our institution. A retrospective analysis has been performed in 662 patients who was treated at Hacettepe University Stem Cell Transplantation Unit. Amongst the 622 patients, 318 (51.1 %) underwent autologous and 304 (48.9 %) underwent allogeneic HSCT. The frequency of the cardiac adverse effects was found to be 10.8 % in all the study population. The most common adverse effect was tachyarrhythmia, constituting 7.9 % of all population. These adverse effects were mostly occurred in lymphoma patients (14 %). Nineteen (3.0 %) of all patients developed atrial fibrillation mostly on the 4th day (range of 1-9 days) after transplantation. Life-threatening events are extremely rare. These adverse effects appear to be related to the type of transplantation rather than the underlying disease. Therefore, close follow-up of patients is important during the peri-transplantation period.

Cardiotoxicity in Hematopoietic Stem Cell Transplant: Keeping the Beat

INTRODUCTION

The number of hematopoietic stem cell transplants (HSCTs) performed in the United States and worldwide is increasing. Cardiac events have been well described in HSCT, and the incidence and type of cardiac events have not changed over recent decades.

PATIENTS AND METHODS

This study adds to the body of evidence in describing the incidence and type of cardiac events experienced by an allogeneic and autologous HSCT population at a single institution from 2012 to 2017.

RESULTS

Sixty-five (9.8%) patients experienced cardiac events, including atrial arrhythmia (N = 39), acute heart failure (N = 9), acute coronary syndrome (N = 7), and new onset hypertension (N = 9), with a few instances of bradycardia, ventricular arrhythmia, pericardial effusion, and pericarditis. Our multivariable regression analysis identified age (older), creatinine (higher), and history of coronary artery disease to significantly correlate with risk of cardiac event (P = .005, P = .039, and P = .038, respectively). A subgroup analysis of those patients experiencing a cardiac event found pre-transplant atrial dilation by trans-thoracic echocardiogram to correlate with increased risk of atrial arrhythmia (33.8% vs. 9.7%; P = .03). Patients developing a CE had an increased risk of death within 1 year (11% vs. 32%; P < .001).

CONCLUSION

We review our results in context of other important HSCT cardiac studies to illuminate the most relevant factors of medical history, laboratory data, and cardiac measurements that will identify patients at higher risk, allowing for intervention to improve HSCT outcomes.

Arrhythmias in hematopoietic stem cell transplantation: A systematic review and meta-analysis

BACKGROUND

There are controversial data regarding the relationship between hematopoietic stem cell transplantation and arrhythmias. This meta-analysis was performed to evaluate the incidence of arrhythmias in patients following hematopoietic stem cell transplantation (HSCT).

METHODS

A literature search was conducted utilizing MEDLINE, EMBASE, and Cochrane Databases from inception through April 2019. Pooled incidence with 95% confidence interval (CI) were calculated using random-effects meta-analysis. The protocol for this meta-analysis is registered with PROSPERO (International Prospective Register of Systematic Reviews; no. CRD42019131833).

RESULTS

Thirteen studies consisting of 10,587 patients undergoing HSCT were enrolled in this systematic review. Overall, the pooled estimated incidence of all types of arrhythmias following HSCT was 7.2% (95% CI: 4.9%-10.5%). With respect to the most common type of arrhythmia, the pooled estimated incidence of atrial fibrillation/atrial flutter (AF/AFL) within 30 days following HSCT was 4.2% (95% CI: 1.7%-9.6%). Egger's regression test demonstrated no significant publication bias in this meta-analysis of post-HSCT arrhythmia incidence.

CONCLUSION

The overall estimated incidence of arrhythmias following HSCT was 7.2%. Future large scale studies are needed to further elucidate the significance and clinical impact of arrhythmias in post-HSCT patients.

Evaluation of the impact of treatment with hematopoietic stem cells transplantation (HSCT) on biochemical markers of heart function and novel electrocardiographic markers of repolarization in patients with hematological malignancies

High-dose chemotherapy (HDC) followed by stem cell transplantation (HSCT) is a well-established method in patients with hematological malignancies, and for last few years, many efforts have been made to estimate short- and long-term efficacy of this method, as well as early and late complications. The present study concentrates on cardiotoxic effects, mainly early changes using biochemical markers such as N-terminal natriuretic peptide type B (NT-proBNP) and cardiac troponins (cTn). Simultaneously, the analysis of 12-lead ECG was done before and after the procedure in which the novel repolarization markers: T_p-e and T_p-e/QT ratio were measured, together with standard markers: QT, QTc. It was found that NT-pro BNP was significantly increased after HSCT in comparison to results before it, and no significant changes were present in Troponin levels. Simultaneously, T_p-e interval and T_p-e/QT ratio were significantly higher after HSCT. The use of cyclophosphamide, advanced age, and higher level of blood cholesterol concentration were risk factors for the increase in NT-proBNP and treatment with cyclophosphamide as well as fludarabine and higher creatinine levels were risk factors for the increase in T_p-e/QT ratio. In conclusion, in the early term evaluation after HSCT in patients with no previously diagnosed heart disease, the mild changes in markers of heart overload and repolarization were noted. The observations suggest that in all patients undergoing HSCT, even the ones without pre-existing cardiovascular disease, the evaluation, and monitoring of heart function should be considered.

The analysis of the parameters of 24-hr ECG Holter monitoring in patients with blood neoplasms undergoing high-dose chemotherapy and stem cell transplantation

BACKGROUND

Hematopoietic stem cell transplantation (HSCT) is a widely used procedure in the treatment of malignant diseases, including blood neoplasms and has increased survival in hematological diseases. The aim of the study was to analyze parameters of 24-hr ECG monitoring in patients with selected blood neoplasms in whom the procedure of hematopoietic stem cell transplantation was performed.

METHODS

The study group consisted of 64 adults diagnosed with hematologic cancer qualified for HSCT with the previous high dose chemotherapy (HDC). In all patients 24-hr Holter monitoring was carried out twice. First examination took place prior to the HSCT procedure, and the second after finishing the procedure of HSCT.

RESULTS

The minimal and mean heart rate (HR min and HR max) from 24-hr ECG recording was statistically significantly higher after the transplantation in comparison with the first test. The number of premature ventricular complexes (PVCs) was higher in the test after HSCT. In the second examination there was significantly higher percentage of premature ventricular complexes, incidents of tachycardia, and Mobitz type 1 second degree atrioventricular block. In regression analysis, in a group of patients with blood neoplasms after HSCT and HDC, administration of cyclophosphamide, fludarabine and total body irradiation were independent risk factors for electrocardiographic abnormalities in 24-hr Holter monitoring, that is, the increase in HR min, HR mean and PVCs.

CONCLUSION

In patients with blood neoplasms undergoing HSCT more electrocardiographic abnormalities may be found after this procedure in comparison with the 24-hr Holter monitoring before transplantation.

TACHYARRHYTHMIAS IN PATIENTS WITH CANCER

Arrhythmia is often detected in cancer patient, from single ventricular premature contractions to sustained ventricular tachycardia, life threatening ventricular fibrillation and sudden cardiac death. Oncology per se, aggressive anticancer treatment, both chemotherapy and radiation and basic cardiac conditions are main causative factors for tachyarrhythmia. In this review we summarize evidence of arrhythmia and emphasize the importance of cardiac monitoring for the early diagnosis, intervention and surveillance of those patients more susceptible to develop proarrhythmia. Oncologists should be fully aware of arrhythmia and the close collaboration between cardiologists and oncologists would result in a better cardiovascular assessment, risk stratification, cardiac monitoring and treatment.

Cardiovascular complications of multiple myeloma in the elderly

INTRODUCTION

Multiple myeloma is a malignant neoplasm characterized by plasma cell proliferation in blood and bone marrow. Approximately two-thirds of the patients with multiple myeloma are >65 years at the time of diagnosis. Patients in this age group often have co-existing cardiovascular diseases. Areas covered: The presence of multiple myeloma adds to the malady by direct deposition of amyloid protein in the heart or via toxicity of chemotherapeutic agents. Cardiac contractile dysfunction, arrhythmias and thromboembolic disorders are the main issues in the management of elderly patients with multiple myeloma. Expert commentary: Assessment of cardiac risk and functional status requires careful evaluation by history, physical examination and imaging studies such as echocardiography and magnetic resonance imaging. The management of cardiovascular disorders in the presence of multiple myeloma is difficult and poses a challenge for the internist, the oncologist, and the cardiologist alike. This review is an overview of the problem of cardiovascular risk in and management of elderly patients with multiple myeloma.

Safety and Feasibility of Autologous Mesenchymal Stem Cell Transplantation in Chronic Stroke in Indian patients. A four-year follow up

Introduction: Stem cell (SC) therapy has been envisioned as a therapeutic vehicle to promote recovery in resistant neurological diseases. Knowing the logistics and paradigms in recovery processes after Stroke, clinicians have pioneered the transplantation therapy. This study presents four-year follow up of our previous trial transplanting bone-marrow-derived animal-free culture expanded intravenous mesenchymal stem cells (MSCs) in chronic stroke which was published in 2010. Methods: We performed an open-label, pilot trial on 12 patients with chronic stroke. Patients were allocated to two groups, those who received intravenous autologous ex vivo cultured mesenchymal stem cells (MSC group) or those who did not (control group), all followed for four years from the day of cell transplantation. Results: The reports have been optimistic regarding safety as we did not find any cell related side effects / mortality till 208th week. We observed that modified Barthel Index showed statistical significant improvement at 156 and 208 weeks of transplantation (95 % CI : -10.27 to 0.07; p =0.041) follow up in the MSC group as compared to controls. The 2nd and 3rd quartile for mBI in MSC group was 89 & 90 respectively suggesting good performance of patients in the stem cell group. The impairment scales i.e., Fugl Meyer, Ashworth tone scale, strength of hand muscles (MRC) did not show any significant improvement at 208th week which is similar to our previous published report. Conclusion: This follow up study primarily indicates safety, tolerance and applicability of autologous mesenchymal stem cells in Stroke. MSCs may act as "chaperones" or work through paracrine mechanisms leading to functional recovery post stroke.

Anthracycline Chemotherapy and Cardiotoxicity

Anthracycline chemotherapy maintains a prominent role in treating many forms of cancer. Cardiotoxic side effects limit their dosing and improved cancer outcomes expose the cancer survivor to increased cardiovascular morbidity and mortality. The basic mechanisms of cardiotoxicity may involve direct pathways for reactive oxygen species generation and topoisomerase 2 as well as other indirect pathways. Cardioprotective treatments are few and those that have been examined include renin angiotensin system blockade, beta blockers, or the iron chelator dexrazoxane. New treatments exploiting the ErbB or other novel pro-survival pathways, such as conditioning, are on the cardioprotection horizon. Even in the forthcoming era of targeted cancer therapies, the substantial proportion of today's anthracycline-treated cancer patients may become tomorrow's cardiac patient.

Effect of Remote Ischaemic Conditioning in Oncology Patients Undergoing Chemotherapy: Rationale and Design of the ERIC-ONC Study--A Single-Center, Blinded, Randomized Controlled Trial

Cancer survival continues to improve, and thus cardiovascular consequences of chemotherapy are increasingly important determinants of long‐term morbidity and mortality. Conventional strategies to protect the heart from chemotherapy have important hemodynamic or myelosuppressive side effects. Remote ischemic conditioning (RIC) using intermittent limb ischemia‐reperfusion reduces myocardial injury in the setting of percutaneous coronary intervention. Anthracycline cardiotoxicity and ischemia‐reperfusion injury share common biochemical pathways in cardiomyocytes. The potential for RIC as a novel treatment to reduce subclinical myocyte injury in chemotherapy has never been explored and will be investigated in the Effect of Remote Ischaemic Conditioning in Oncology (ERIC‐ONC) trial (clinicaltrials.gov NCT 02471885). The ERIC‐ONC trial is a single‐center, blinded, randomized, sham‐controlled study. We aim to recruit 128 adult oncology patients undergoing anthracycline‐based chemotherapy treatment, randomized in a 1:1 ratio into 2 groups: (1) sham procedure or (2) RIC, comprising 4, 5‐minute cycles of upper arm blood pressure cuff inflations and deflations, immediately before each cycle of chemotherapy. The primary outcome measure, defining cardiac injury, will be high‐sensitivity troponin‐T over 6 cycles of chemotherapy and 12 months follow‐up. Secondary outcome measures will include clinical, electrical, structural, and biochemical endpoints comprising major adverse cardiovascular clinical events, incidence of cardiac arrhythmia over 14 days at cycle 5/6, echocardiographic ventricular function, N‐terminal pro‐brain natriuretic peptide levels at 3 months follow‐up, and changes in mitochondrial DNA, micro‐RNA, and proteomics after chemotherapy. The ERIC‐ONC trial will determine the efficacy of RIC as a novel, noninvasive, nonpharmacological, low‐cost cardioprotectant in cancer patients undergoing anthracycline‐based chemotherapy.

Arrhythmias in the setting of hematopoietic cell transplants

Prior studies report 9–27% of persons receiving a hematopoietic cell transplant develop arrhythmias, but the effect on outcomes is largely unknown. We reviewed data from 1177 consecutive patients {greater than or equal to}40 years old receiving a hematopoietic cell transplant at one center during 1999–2009. Transplant indication was predominately leukemia, lymphoma and multiple myeloma. Overall, 104 patients were found to have clinically significant arrhythmia: 43 prior to and 61 following transplant. Post-transplant arrhythmias were most frequently atrial fibrillation(N=30), atrial flutter(N=7) and supraventricular tachycardia(N=11). Subjects with an arrhythmia post-transplant were more likely to have longer median hospital stays (32 days vs 23, P=<.001,) a greater probability of an ICU admission (52% vs 7%; P<.001), more inhospital deaths (28% vs 3%, P<0.001), and more deaths within one year of transplant (41% vs 15%; P<0.001) than patients without arrhythmia at any time. In a multivariate model including age at transplant, diagnosis, history of pre-transplant arrhythmia, and transplant-related variables, post-transplant arrhythmia was associated with a greater risk of death within a year of transplant (OR 3.5, 95% CI: 2.1, 5.9; P < 0.001). Our data suggest arrhythmias after transplants are associated with significant morbidity and mortality. A prospective study of arrhythmia in the transplant setting is warranted.

Autologous Stem-Cell Transplantation Without Hematopoietic Support for the Treatment of Hematologic Malignancies in Jehovah's Witnesses

PURPOSE

Autologous stem-cell transplantation (ASCT) has shown to provide curative benefit in patients with relapsed lymphoma and multiple myeloma (MM), often requiring hematopoietic support until marrow engraftment. Because of Jehovah's Witnesses' (JW) refusal of blood products, treatment challenges arise. This study represents 125 JWs with lymphoma (n = 55), MM (n = 68), or amyloidosis (n = 2), treated with high-dose chemotherapy (HDC) and ASCT without transfusions.

PATIENTS AND METHODS

Priming with intravenous iron and erythropoietin occurred to increase hemoglobin (Hb) pretransplantation. Cytokine mobilization of stem-cells was used. Delay to HDC was done to allow Hb and platelets to approach 11 g/dL and 100 × 10(3)/μL, respectively. Patients with MM received a standard dose of melphalan 200 mg/m(2), with dose reduction for severe kidney dysfunction. Patients with lymphoma received carmustine 300 mg/m(2), cyclophosphamide 1,500 mg/m(2) on days 2 through 5 (total 6 g/m(2)), and etoposide 700 mg/m(2) per day on days 2 through 4 (total 2,100 mg/m(2)). Post-transplantation, a combination of granulocyte colony-stimulating factor, erythropoietin, aminocaproic acid, and phytonadione was administered.

RESULTS

There were two major and 15 minor bleeding complications, none occurring at platelets less than 5.0 × 10(3)/μL, with six (4.8%) treatment-related mortalities. The median decrease in Hb was 5.0 g/dL, with median Hb nadir of 7.0 g/dL. The median number of days with platelet count less than 10 × 10(3)/μL was 3, with median platelet nadir of 5.0 × 10(3)/μL. Cardiac complications occurred in 40 patients (32%).

CONCLUSION

ASCT can safely be performed without transfusion support. A platelet transfusion trigger of ≤ 5 × 10(3)/μL may be appropriate in select patients. Pharmacotherapy and cardiac monitoring are effective in the management of cardiac complications.

Hematopoietic SCT with cryopreserved grafts: adverse reactions after transplantation and cryoprotectant removal before infusion

Transplantation of hematopoietic stem cells (HSCs) has been successfully developed as a part of treatment protocols for a large number of clinical indications, and cryopreservation of both autologous and allogeneic sources of HSC grafts is increasingly being used to facilitate logistical challenges in coordinating the collection, processing, preparation, quality control testing and release of the final HSC product with delivery to the patient. Direct infusion of cryopreserved cell products into patients has been associated with the development of adverse reactions, ranging from relatively mild symptoms to much more serious, life-threatening complications, including allergic/gastrointestinal/cardiovascular/neurological complications, renal/hepatic dysfunctions, and so on. In many cases, the cryoprotective agent (CPA) used-which is typically dimethyl sulfoxide (DMSO)-is believed to be the main causal agent of these adverse reactions and thus many studies recommend depletion of DMSO before cell infusion. In this paper, we will briefly review the history of HSC cryopreservation, the side effects reported after transplantation, along with advances in strategies for reducing the adverse reactions, including methods and devices for removal of DMSO. Strategies to minimize adverse effects include medication before and after transplantation, optimizing the infusion procedure, reducing the DMSO concentration or using alternative CPAs for cryopreservation and removing DMSO before infusion. For DMSO removal, besides the traditional and widely applied method of centrifugation, new approaches have been explored in the past decade, such as filtration by spinning membrane, stepwise dilution-centrifugation using rotating syringe, diffusion-based DMSO extraction in microfluidic channels, dialysis and dilution-filtration through hollow-fiber dialyzers and some instruments (CytoMate, Sepax S-100, Cobe 2991, microfluidic channels, dilution-filtration system, etc.) as well. However, challenges still remain: development of the optimal (fast, safe, simple, automated, controllable, effective and low cost) methods and devices for CPA removal with minimum cell loss and damage remains an unfilled need.

Incidence of supraventricular arrhythmias during autologous peripheral blood stem cell transplantation

Arrhythmias, especially supraventricular arrhythmias, often complicate the clinical course during autologous hematopoietic cell transplantation (AHCT). We wanted to determine the incidence and risk factors for cardiac arrhythmias during AHCT. The study included 983 patients (median age, 58 years [range, 19 to 77]; 61% male) who underwent AHCT between August 2006 and December 2010 at a single institution and for whom all relevant medical records were available for review. AHCT was done for plasma cell disorders in 58% patients and for lymphoma or leukemia in the remaining. Overall, 92 patients (9.4%) developed a supraventricular tachyarrhythmia at a median of 9 days posttransplantation (range, 0 to 18) and with a median duration of less than 1 day (range, <1 to 17 days). Atrial fibrillation was the most common and seen in 71 patients (7%), followed by atrial flutter and supraventricular tachycardia in 12 (1%) and 8 (1%) patients, respectively. In multivariate analysis, age older than 63 years, presence of premature supraventricular complexes or atrioventricular conduction delay on pretransplantation electrocardiogram, and history of any prior arrhythmia increased the risk of arrhythmia. Development of arrhythmia resulted in longer outpatient follow-up after AHCT, with the median follow-up for those developing an arrhythmia of 22 days compared with 19 days for the rest; P < .001. In conclusion, 9% of patients undergoing ASCT developed supraventricular arrhythmias posttransplantation, and this risk was elevated among older patients, those with a prior history of arrhythmias, and those with pretransplantation electrocardiographic abnormalities.

Factors affecting the development of atrial fibrillation and atrial flutter (AF/AFL) following autologous hematopoietic SCT (auto-HSCT)

The use of autologous hematopoietic SCT (auto-HSCT) has expanded to include older patients. Increasing age is a well-appreciated risk factor for the development of atrial fibrillation and/or atrial flutter (AF/AFL) in the general population. As more elderly patients undergo auto-HSCT, the risk of developing AF/AFL post transplant may also increase. However, few data evaluating other risk factors for the development of AF/AFL following auto-HSCT exist. Therefore, we performed a retrospective study to determine the incidence of AF/AFL following auto-HSCT and to determine the risk factors associated with the development of AF/AFL. Patients who developed AF/AFL were compared with a group of patients who received auto-HSCT within the same time period (April 1999 to May 2005) and were within 5 years of age. Of the 516 patients who underwent auto-HSCT at the University of Nebraska Medical Center 44 (8.5%) developed AF/AFL at a median time of 4 days (range, days 1-9) following auto-HSCT. In multivariate analysis, risk factors for developing AF/AFL were older age, odds ratio and 95% CI of 1.14 (1.07-1.21), elevated serum creatinine level, 2.69 (1.00-7.22), history of previous arrhythmia, 9.33 (3.01-28.99), and history of previous mediastinal irradiation, 11.12 (1.33-92.96).

Atrial fibrillation following autologous stem cell transplantation in patients with multiple myeloma: incidence and risk factors

Objectives:

Atrial fibrillation (AF) often develops in patients with multiple myeloma following autologous stem cell transplantation (ASCT), but the exact incidence of, and the risk factors for AF have not been described. In this study, we sought to determine the incidence of AF in patients with multiple myeloma undergoing ASCT.

Methods:

Patients who received ASCT for multiple myeloma between January 2000 and December 2009 were identified using the ICD-9 codes for multiple myeloma and ASCT, and formed the basis of this report.

Results:

The study included 278 patients (mean age, 63 ± 9.5 years). A total of 75 (27%) patients developed AF at a mean duration of 14.8 days following ASCT. On multiple regression analysis, baseline renal dysfunction (odds ratio 15.2 [confidence interval 5.08–45.6]), left ventricular systolic dysfunction (9.55 [2.78–32.79]), dilated left atrium on echocardiogram (4.97 [1.8–13.78]), and hypertension (3.6 [1.36–9.52]) were significantly associated with the development of AF after ASCT. The presence of light-chain secretion (0.21 [0.07–0.6]) was associated with a lower incidence of AF. Age, gender, and race were not significantly associated with the development of AF after ASCT.

Conclusions:

AF is very frequent in patients with multiple myeloma when they receive ASCT. The presence of abnormal renal function, left ventricular systolic dysfunction, dilated left atrium, or hypertension at baseline identifies patients at high risk of developing AF following ASCT.

Incident stroke and mortality associated with new-onset atrial fibrillation in patients hospitalized with severe sepsis

CONTEXT

New-onset atrial fibrillation (AF) has been reported in 6% to 20% of patients with severe sepsis. Chronic AF is a known risk factor for stroke and death, but the clinical significance of new-onset AF in the setting of severe sepsis is uncertain.

OBJECTIVE

To determine the in-hospital stroke and in-hospital mortality risks associated with new-onset AF in patients with severe sepsis.

DESIGN AND SETTING

Retrospective population-based cohort of California State Inpatient Database administrative claims data from nonfederal acute care hospitals for January 1 through December 31, 2007.

PATIENTS

Data were available for 3,144,787 hospitalized adults. Severe sepsis (n = 49,082 [1.56%]) was defined by validated International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code 995.92. New-onset AF was defined as AF that occurred during the hospital stay, after excluding AF cases present at admission.

MAIN OUTCOME MEASURES

A priori outcome measures were in-hospital ischemic stroke (ICD-9-CM codes 433, 434, or 436) and mortality.

RESULTS

Patients with severe sepsis were a mean age of 69 (SD, 16) years and 48% were women. New-onset AF occurred in 5.9% of patients with severe sepsis vs 0.65% of patients without severe sepsis (multivariable-adjusted odds ratio [OR], 6.82; 95% CI, 6.54-7.11; P < .001). Severe sepsis was present in 14% of all new-onset AF in hospitalized adults. Compared with severe sepsis patients without new-onset AF, patients with new-onset AF during severe sepsis had greater risks of in-hospital stroke (75/2896 [2.6%] vs 306/46,186 [0.6%] strokes; adjusted OR, 2.70; 95% CI, 2.05-3.57; P < .001) and in-hospital mortality (1629 [56%] vs 18,027 [39%] deaths; adjusted relative risk, 1.07; 95% CI, 1.04-1.11; P < .001). Findings were robust across 2 definitions of severe sepsis, multiple methods of addressing confounding, and multiple sensitivity analyses.

CONCLUSION

Among patients with severe sepsis, patients with new-onset AF were at increased risk of in-hospital stroke and death compared with patients with no AF and patients with preexisting AF.

A long-term follow-up study of intravenous autologous mesenchymal stem cell transplantation in patients with ischemic stroke

We previously evaluated the short-term follow-up preliminary data of mesenchymal stem cells (MSCs) transplantation in patients with ischemic stroke. The present study was conducted to evaluate the long-term safety and efficacy of i.v. MSCs transplantation in a larger population. To accomplish this, we performed an open-label, observer-blinded clinical trial of 85 patients with severe middle cerebral artery territory infarct. Patients were randomly allocated to one of two groups, those who received i.v. autologous ex vivo cultured MSCs (MSC group) or those who did not (control group), and followed for up to 5 years. Mortality of any cause, long-term side effects, and new-onset comorbidities were monitored. Of the 52 patients who were finally included in this study, 16 were the MSC group and 36 were the control group. Four (25%) patients in the MSC group and 21 (58.3%) in the control group died during the follow-up period, and the cumulative surviving portion at 260 weeks was 0.72 in the MSC group and 0.34 in the control group (log-rank; p = .058). Significant side effects were not observed following MSC treatment. The occurrence of comorbidities including seizures and recurrent vascular episodes did not differ between groups. When compared with the control group, the follow-up modified Rankin Scale (mRS) score was decreased, whereas the number of patients with a mRS of 0-3 increased in the MSC group (p = .046). Clinical improvement in the MSC group was associated with serum levels of stromal cell-derived factor-1 and the degree of involvement of the subventricular region of the lateral ventricle. Intravenous autologous MSCs transplantation was safe for stroke patients during long-term follow-up. This therapy may improve recovery after stroke depending on the specific characteristics of the patients.

How we approach patient evaluation for hematopoietic stem cell transplantation

The evaluation of patients for hematopoietic stem cell transplantation is a complex process. The decision to recommend transplantation is not simply dependent on patient diagnosis; instead it is a specialized analytic decision process intricately dependent on a number of variables including patient age, performance status, medical comorbidities, family support structure, socioeconomic viability and motivation to participate in self-care, to name a few. The process of pre-transplant patient evaluation has substantial variability across different transplant centers, owing to lack of formal published guidelines. This review summarizes the process of pre-transplant patient evaluation and workup, and aims to describe components of a well-organized and evidenced-based patient selection process for SCT.

Late potentials and QT dispersion after high-dose chemotherapy in patients with non-Hodgkin lymphoma

The most common cardiotoxic effects of high-dose cyclophosphamide (CY) are electrocardiographic changes and transient arrhythmias. Therefore, we prospectively assessed serial electrocardiogram (ECG) and signal-averaged electrocardiogram (SAECG) recordings in 30 adult patients with non-Hodgkin lymphoma (NHL) receiving high-dose CY as part of high-dose chemotherapy (HDT) regimen. All patients were treated with anthracyclines earlier. Heart-rate-corrected QT interval and QT dispersion (QTc and QTc dispersion) were measured from ECG. QRS duration and late potentials (LPs) were analysed from SAECG. Both ECG and SAECG were recorded 1 day (d) prior to HDT (d-7) at baseline, and 1 day (d-2), 7 days (d+7), 12 days (+12) and 3 months (m+3) after HDT. Stem cells were infused on day 0 (d0). Cardiac systolic and diastolic function were assessed on (d-7), (d+12) and (m+3) by radionuclide ventriculography. At baseline, four patients presented with LPs. Cardiac systolic function decreased significantly (53 +/- 2; 49 +/- 2%, P = 0.009 versus baseline), whilst no patient developed acute heart failure. QRS duration prolonged and RMS(40) reduced significantly versus baseline (104 +/- 3; 107 +/- 3 ms, P = 0.003; 41 +/- 4; 38 +/- 3 microV, P = 0.03), and six patients (21%) presented with LPs after CY treatment. Both QTc interval and QTc dispersion increased versus baseline (402 +/- 5; 423 +/- 5 ms, P<0.001; 32 +/- 2; 44 +/- 3 ms, P = 0.012), and six patients (20%) developed abnormal QT dispersion. In conclusion, high-dose CY causes subclinical and transient electrical instability reflected by occurrence of LPs as well as increased QTc interval and QT dispersion. Thus, longer follow-up is required to confirm the meaning of these adverse effects on cardiac function and quality of life.

Critical care considerations of hematopoietic stem cell transplantation

OBJECTIVE

To review the available clinical data on the critical care complications of hematopoietic stem cell transplantation (HSCT).

DATA SOURCE

The MEDLINE database and references from the identified articles related to the critical care in HSCT.

CONCLUSION

HSCT is an important treatment for a variety of malignant and nonmalignant conditions. The procedure is, however, limited by significant complications that may involve every organ of the body. Up to 40% of HSCT recipients are admitted to the intensive care unit as a result of severe complications related to the transplantation. The outcome of those critically ill patients has been traditionally poor. However, recent advances in the transplantation procedure, diagnostic studies, antimicrobial prophylaxis and therapy, and intensive care unit care have improved the outcome of these patients. The increasing number of HSCTs performed annually, the unique complications that develop in these patients, and the improvement in the intensive care unit outcome make knowledge about the critical care aspect of HSCT an essential part of the current practice of critical care medicine.