Comparison of echocardiography and radionuclide ventriculography in the follow-up of left ventricular systolic function in adult lymphoma patients during doxorubicin therapy

Cardiotoxicity in pediatric lymphoma survivors

INTRODUCTION

Over the past five decades, the diagnosis and management of children with various malignancies have improved tremendously. As a result, an increasing number of children are long-term cancer survivors. With improved survival, however, has come an increased risk of treatment-related cardiovascular complications that can appear decades later.

AREAS COVERED

This review discusses the pathophysiology, epidemiology and effects of treatment-related cardiovascular complications from anthracyclines and radiotherapy in pediatric lymphoma survivors. There is a paucity of evidence-based recommendations for screening for and treatment of cancer therapy-induced cardiovascular complications. We discuss current preventive measures and strategies for their treatment.

EXPERT OPINION

Significant cardiac adverse effects occur due to radiation and chemotherapy received by patients treated for lymphoma. Higher lifetime cumulative doses, female sex, longer follow-up, younger age, and preexisting cardiovascular disease are associated with a higher incidence of cardiotoxicity. With deeper understanding of the mechanisms of these adverse cardiac effects and identification of driver mutations causing these effects, personalized cancer therapy to limit cardiotoxic effects while ensuring an adequate anti-neoplastic effect would be ideal. In the meantime, expanding the use of cardioprotective agents with the best evidence such as dexrazoxane should be encouraged and further studied.

Cardiotoxicity Associated with Chemotherapy Used in Gastrointestinal Tumours

Cardiotoxicity is a well-recognised side effect of cancer-related therapies with a great impact on outcomes and quality of life in the cancer survivor population. The pathogenesis of chemotherapy-induced cardiotoxicity in patients with gastrointestinal cancers involves various molecular mechanisms, and the combined use of various chemotherapies augments the risk of each drug used alone. In terms of cardiotoxicity diagnosis, novel biomarkers, such as troponins, brain natriuretic peptide (BNP), myeloperoxidases and miRNAs have been recently assessed. Echocardiography is a noninvasive imaging method of choice for the primary assessment of chemotherapy-treated patients to generally evaluate the cardiovascular impact of these drugs. Novel echocardiography techniques, like three-dimensional and stress echocardiography, will improve diagnosis efficacy. Cardiac magnetic resonance (CMR) can evaluate cardiac morphology, function and wall structure. Corroborated data have shown the importance of CMR in the early evaluation of patients with gastrointestinal cancers, treated with anticancer drugs, but further studies are required to improve risk stratification in these patients. In this article, we review some important aspects concerning the cardiotoxicity of antineoplastic drugs used in gastrointestinal cancers. We also discuss the mechanism of cardiotoxicity, the role of biomarkers and the imaging methods used in its detection.

Cardiovascular Magnetic Resonance Imaging: Identifying the Effects of Cancer Therapy

The era of modern oncology incorporates an ever-evolving personalized approach to hematological malignancies and solid tumors. As a result, patient survival rates have, in part, substantially improved, depending on the specific type of underlying malignancy. However, systemic therapies may come along with potential cardiotoxic effects resulting in heart failure with increased morbidity and mortality. Ultimately, patients may survive their malignancy but die as a result of cancer treatment. Cardiovascular magnetic resonance imaging has long been in use for the assessment of function and tissue characteristics in patients with various nonischemic cardiac diseases. Besides an introductory overview on the general definition of cardiotoxicity including potential underlying mechanisms, this review provides insight into the application of various cardiovascular magnetic resonance imaging techniques in the setting of cancer therapy-related cardiac and vascular toxicity. Early identification of cardiotoxic effects may allow for on-time therapy adjustment and/or cardioprotective measures to avoid subsequent long-term heart failure with increased mortality.

Speckle-Tracking Echocardiography for Cardioncological Evaluation in Bevacizumab-Treated Colorectal Cancer Patients

Angiogenesis inhibitor Bevacizumab (BVZ) may lead to the development of adverse effects, including hypertension and cardiac ischemia. Whether assessment of changes in myocardial strain by two-dimensional speckle-tracking echocardiography (2D-STE) can be of value in detecting BVZ-mediated cardiotoxicity at an earlier stage is not known. We investigated whether 2D-STE can non-invasively detect early evidence of cardiotoxicity in metastatic colorectal cancer (mCRC) patients treated with BVZ. Between January and June 2019, 25 consecutive patients (71.8 ± 7.5 year/old, 17 males) with mCRC were prospectively enrolled. Patients underwent physical examination, blood tests, and conventional 2D-transthoracic echocardiography implemented with 2D-STE analysis, at baseline and at 3 and 6 months following treatment with BVZ (15 mg/kg every 15 days) + 5-fluorouracil/folinic acid plus oxaliplatin (FOLFOX i.v.). At 6-month follow-up, we assessed occurrence of global longitudinal strain (GLS) impairment (> 15% decrease in GLS compared with baseline) as primary end-point and a new-onset systemic hypertension (secondary end-point). On average, GLS showed a progressive significant impairment after BVZ, from - 17.4 ± 3.2% at baseline to - 16 ± 2.9% (p = 0.003) at 6-month follow-up; > 15% decrease in GLS (primary end-point) was detected in 9 patients (36%). All other strain parameters remained unchanged. New-onset systemic hypertension (secondary end-point) was diagnosed in five patients (20%). No significant changes were observed in serial high-sensitivity cardiac troponin I measurements. No patient developed significant changes in LV size or LV ejection fraction; no case of clinically symptomatic HF was observed during BVZ-treatment. Measurement of GLS by 2D-STE analysis can effectively detect BVZ-mediated cardiotoxicity at an early stage.

Effect of Dual-Source Radiofrequency Transmission on Left Ventricular Measurements and Measurement Reproducibility at 3.0 T Cardiac MR Imaging: Comparison with Conventional Single-Source Transmission Reference

RATIONALE AND OBJECTIVES

To prospectively assess effect of dual-source radiofrequency (RF) transmission on left ventricular (LV) measurements and measurements reproducibility at 3.0 T MR using balanced steady-state free precession (b-SSFP) cine imaging, compared to the conventional single-source RF transmission reference approach.

MATERIALS AND METHODS

Cardiac b-SSFP cine imaging was performed in 19 subjects at 3.0 T MR equipped with dual-source RF transmission. All images were analyzed to obtain LV end-diastolic volume, end-systolic volume, stroke volume, ejection fraction, mass, LV end-diastolic inferior wall thickness, and interventricular septal thickness. The difference of all LV measurements between the two imaging techniques was tested with the paired t test and the intertechnique agreement was tested through linear regression and Bland-Altman analyses. Additionally, repeated LV measurements were performed to determine intra and interobserver variability with the Bland-Altman method, the 95% limits of agreement, the coefficient of variation (CV) and the intraclass correlation coefficient.

RESULTS

Compared to conventional single-source, dual-source slightly overestimated end-diastolic volume, end-systolic volume, and stroke volume (mean differences, 3.9 mL ± 9.7, 1.1 mL ± 2.6, and 2.8 mL ± 9.1, respectively; p > 0.05), resulting in a small but significant positive bias in ejection fraction (1.5% ± 2.6; p = 0.021). Mass was significantly smaller with dual-source than with single-source (-4.0 g ± 6.5, p = 0.001). Dual-source slightly underestimated interventricular septal thickness (-0.29 mm ± 0.6, p = 0.067) and significantly underestimated LV end-diastolic inferior wall thickness (-0.55 mm ± 0.4, p < 0.0001). The two techniques in measurements correlated highly (r² = 0.81 to 0.96, p < 0.0001). Intra and interobserver variability in dual-source measurements was much lower than that in single-source, and variability values were <14.0%.

CONCLUSION

Improved image quality of b-SSFP cine imaging at 3.0 T MR with dual-source RF transmission may provide more reproducible LV measurements compared to conventional single-source approach. Dual-source RF transmission also provides a reasonable estimate of the LV measurements.

Incidence and risk factors associated with development of clinical cardiotoxicity in dogs receiving doxorubicin

Background

Doxorubicin (DOX) can cause cumulative cardiotoxicity in dogs, but the incidence of clinical cardiotoxicity in dogs receiving DOX has not been determined.

Hypothesis/Objectives

To determine if the duration of DOX infusion influences the incidence of cardiotoxicity, to characterize the incidence of clinical cardiotoxicity in dogs during or after DOX chemotherapy, and to identify any risk factors associated with cardiotoxicity.

Animals

Four‐hundred ninety‐four dogs that received at least 1 dose of DOX for the treatment of cancer.

Methods

Retrospective study of dogs that received DOX from 2006 to 2015.

Results

Of 494 dogs, 20 (4.0%) developed clinical cardiotoxicity. The duration of DOX infusion was not significantly associated with clinical cardiotoxicity, whereas a higher cumulative dose of DOX, higher body weight, decreases in fractional shortening after 5 doses of DOX, and development of ventricular premature contractions were significantly associated with clinical cardiotoxicity. High‐risk breeds for developing dilated cardiomyopathy had an incidence of 15.4%, whereas low‐risk breeds had an incidence of 3.0%.

Conclusions and Clinical Importance

Although the duration of DOX infusion did not influence the incidence of cardiotoxicity, premature contractions and decreases in fractional shortening should raise concern for the development of clinical cardiotoxicity. Overall, the incidence of clinical DOX‐induced cardiotoxicity is low, but Boxers and other breeds at high risk for dilated cardiomyopathy may be at an increased risk.

Echocardiographic Assessment for the Detection of Cardiotoxicity Due to Vascular Endothelial Growth Factor Inhibitor Therapy in Metastatic Renal Cell and Colorectal Cancers

BACKGROUND

Cardio-oncology is a recently established discipline that focuses on the management of patients with cancer who are at risk for developing cardiovascular complications as a result of their underlying oncologic treatment. In metastatic colorectal cancer (mCRC) and metastatic renal cell carcinoma (mRCC), vascular endothelial growth factor inhibitor (VEGF-i) therapy is commonly used to improve overall survival. Although these novel anticancer drugs may lead to the development of cardiotoxicity, whether early detection of cardiac dysfunction using serial echocardiography could potentially prevent the development of heart failure in this patient population requires further study. The aim of this study was to investigate the role of two-dimensional speckle-tracking echocardiography in the detection of cardiotoxicity due to VEGF-i therapy in patients with mCRC or mRCC.

METHODS

Patients with mRCC or mCRC were evaluated using serial echocardiography at baseline and 1, 3, and 6 months following VEGF-i treatment.

RESULTS

A total of 40 patients (34 men; mean age, 63 ± 9 years) receiving VEGF-i therapy were prospectively recruited at two academic centers: 26 (65%) were receiving sunitinib, eight (20%) pazopanib, and six (15%) bevacizumab. The following observations were made: (1) 8% of patients developed clinically asymptomatic cancer therapeutics-related cardiac dysfunction; (2) 30% of patients developed clinically significant decreases in global longitudinal strain, a marker for early subclinical cardiac dysfunction; (3) baseline abnormalities in global longitudinal strain may identify a subset of patients at higher risk for developing cancer therapeutics-related cardiac dysfunction; and (4) new or worsening hypertension was the most common adverse cardiovascular event, afflicting nearly one third of the study population.

CONCLUSIONS

Cardiac dysfunction defined by serial changes in myocardial strain assessed using two-dimensional speckle-tracking echocardiography occurs in patients undergoing treatment with VEGF-i for mCRC or mRCC, which may provide an opportunity for preventive interventions.

Diagnostic Strategies for Early Recognition of Cancer Therapeutics-Related Cardiac Dysfunction

Cardiovascular toxicity in the form of cardiac dysfunction continues to be an obstacle for patients with cancer. Survival and quality of life of cancer survivors are frequently affected by increased incidence of cardiovascular disease. The involvement of the cardiovascular system by primary or secondary malignancies, as well as its dysfunction secondary to the administration of antineoplastics, has led to the development of a new discipline called Cardio-Oncology, an exciting cardiology subspecialty with more questions than answers and as a result an enormous opportunity for research in the field. Multidisciplinary efforts have been focused on the prevention, diagnosis, and treatment of cancer therapeutics-related cardiovascular dysfunction (CTRCD). This review article will focus on the early diagnosis of left ventricular dysfunction associated with chemotherapy. Currently, the identification of cardiac toxicity associated with cancer treatment is the cornerstone for critical decisions regarding anticancer therapy and cardioprotective strategies. Its early detection, especially in subclinical phases, allows immediate intervention to prevent further impairment of the myocardium and other cardiovascular structures. The most significant published studies were selected for this revision, providing an updated document for the health professionals involved in the care of patients with cancer. We examined the current evidence and recommendations for biochemical and noninvasive diagnostic techniques, including their specific role for identification of CTRCD. Traditional and advanced imaging modalities, used alone or in combination with cardiovascular biomarkers, are essential for the recognition of cardiotoxicity during cancer therapy. Evolving basic and clinical research are focused on the development of more sensitive and specific diagnostic tools and for the recognition of cardiac toxicity.

Comparison of left ventricular ejection fraction values obtained using invasive contrast left ventriculography, two-dimensional echocardiography, and gated single-photon emission computed tomography

Objectives:

Left ventricular ejection fraction can be measured by a variety of invasive and non-invasive cardiac techniques. This study assesses the relation of three diagnostic modalities to each other in the measurement of left ventricular ejection fraction: invasive contrast left ventriculography, two-dimensional echocardiography, and quantitative gated single-photon emission computed tomography.

Methods:

Retrospective chart review was conducted on 58 patients hospitalized with chest pain, who underwent left ventricular ejection fraction evaluation using each of the aforementioned modalities within a 3-month period not interrupted by myocardial infarction or revascularization.

Results:

The mean left ventricular ejection fraction values were as follows: invasive contrast left ventriculography (0.44±0.15), two-dimensional echocardiography (0.46±0.13), and gated single-photon emission computed tomography (0.37±0.10). Correlations coefficients and associated p values were as follows: invasive contrast left ventriculography versus two-dimensional echocardiography (r=0.69, p<0.001), invasive contrast left ventriculography versus gated single-photon emission computed tomography (r=0.80, p<0.0001), and gated single-photon emission computed tomography versus two-dimensional echocardiography (r=0.69, p<0.001).

Conclusion:

Our results indicate that strong positive correlations exist among the three techniques studied.

Update on cardiotoxicity of anti-cancer treatments

BACKGROUND AND AIMS

Anti-cancer treatments markedly improved the prognosis of patients, but unfortunately might be hampered by cardiotoxicity. Both symptomatic and asymptomatic clinical forms of heart failure have been reported, which may be reversible or irreversible. The aim of this review is to provide an overview of the antineoplastic agents associated with cardiac toxicity and of the available diagnostic techniques.

METHODS AND METHODS

This narrative review is based on material from MEDLINE and PUBMED up to November 2015. We looked at the terms antineoplastic drugs and cardiac toxicity in combination with echocardiography, troponins, cardiac magnetic resonance, and positron emission tomography.

RESULTS

Anthracyclines, monoclonal antibodies, fluoropyrimidines, taxanes, alkylating agents, vinka alkaloids were reported to induce different clinical manifestations of cardioxicity. Chest radiotherapy is also associated with various forms of cardiac damage, which are indistinguishable from those found in patients with heart disease of other aetiologies and that may even appear several years after administration. Among diagnostic techniques, echocardiography is a noninvasive, cost-effective, and widely available imaging tool. Nuclear imaging and cardiac magnetic resonance may be used but are not so widely available and are more difficult to perform. Finally, some biomarkers, such as troponins, may be used to evaluate cardiac damage, but establishing the optimal timing of troponin assessment remains unclear and defining the cut-off point for positivity is still an important goal.

CONCLUSIONS

Cardiotoxicity of anti-cancer treatments is associated with development of heart failure. Novel diagnostic tools might be relevant to early recognize irreversible forms cardiac diseases.

Cardiotoxicity due to chemotherapy: role of cardiac imaging

The identification of patients at risk of cardiac toxicity (cardiotoxicity) from cancer therapy is challenging. There is an increasing focus on early detection of cardiotoxicity such that interventions can be instituted to prevent advanced heart failure. Clinical risk prediction tools are limited and clinical symptoms are not specific. Direct assessment of myocardial function before and during cancer treatment using cardiac imaging appears to be an objective method to identify patients at risk. Although, multiple imaging modalities and measures of cardiac function are available, the best modality or the optimal measure of function is unknown. Measurement of left ventricular ejection fraction is most commonly used; however, growing literature suggests that it is inadequate for the detection of early cardiac injury. Other measures include left ventricular diastolic function, myocardial deformation, and myocardial tissue characterization. This review will provide an overview of the clinically available measures for the assessment of cardiotoxicity.

Catching broken hearts: pre-clinical detection of doxorubicin and trastuzumab mediated cardiac dysfunction in the breast cancer setting

Although breast cancer is one of the leading causes of death in women worldwide, there is an overall improvement in the survival of this patient population. This is likely due to a combination of early detection through screening and awareness, improved targeted biological therapy, and an overall improvement in disease management. Despite the beneficial effects of the 2 anti-cancer drugs doxorubicin (DOX) and trastuzumab (TRZ) in women with breast cancer, development of cardiotoxicity is a major concern. The occurrence of left ventricular systolic dysfunction is unacceptably high in nearly 1 in 4 women treated with DOX+TRZ in the breast cancer setting. In this review, we explore the use of non-invasive cardiac imaging for the early detection of chemotherapy-mediated cardiotoxicity in women with breast cancer, in the hope of preventing end-stage heart disease in this cancer population.

Noninvasive diagnosis of chemotherapy related cardiotoxicity

Chemotherapeutic agents reduce mortality and can prevent morbidity in a wide range of malignancies. These agents are, however, associated with toxicities of their own, and the treating physician must remain ever vigilant against the risk outgrowing the benefit of therapy. Thus, pre-treatment evaluation and monitoring for toxicity during and following administration is a fundamental tenet of oncologic practice. Among the most insidious and deadly toxicities of anti-tumor agents is cardiac toxicity, which in some cases may be irreversible. Early detection of cardiotoxicity allows the treating oncologist to redirect therapy or dose modify, taking into account the cost of a reduction in therapy against the potential of further injury to the patient. In these instances, the role of the cardiologist is to assist and advise the oncologist by providing diagnostic and prognostic information regarding developing cardiotoxicity. This review discusses noninvasive diagnostic options to identify and characterize cardiotoxicity and their use in prognosis and guiding therapy. We also review established protocols for cardiac safety monitoring in the treatment of malignancy.

Equilibrium radionuclide angiocardiography: Its usefulness in current practice and potential future applications

The routine and potential future applications of equilibrium radionuclide angiocardiography/multigated acquisition (MUGA) in clinical decision making are explored in this review. The non-invasive nature of the test, less operator dependence, lower radiation dose and ease of performing, even in ill patients, are important considerations in clinical cardiology practice. Two important routine uses of this modality in day-to-day clinical practice include the following: serial assessment of left ventricular ejection fraction (LVEF) in patients receiving cardiotoxic chemotherapy, and determination of accurate LVEF in patients with intractable heart failure. Other potential utilities of MUGA that could be translated into clinical practice include determination of regional LVEF, obtaining information about both right and left ventricle in suitable patients as a part of first pass angiocardiography, identification of diastolic dysfunction in patients with heart failure with preserved LVEF, and demonstration of dyssynchrony prior to cardiac resynchronisation, specifically by MUGA single photon emission tomography.The last two indications are particularly important and evolving at this point.

Value of echocardiography and electrocardiography as screening tools prior to Doxorubicin administration

The dose-limiting toxicity of doxorubicin is cardiotoxicosis. The authors of this report hypothesized that by using their institution's adopted guidelines (that involve prescreening echocardiography and electrocardiography), they would detect pre-existing cardiac abnormalities that preclude doxorubicin administration in <10% of dogs. Of 101 dogs, only 6 were excluded from doxorubicin administration based on electrocardiogram abnormalities, with a majority of those arrhythmias classified as ventricular premature contractions. One patient was excluded based on echocardiogram alone due to hypertrophic cardiomyopathy. The incidence of cardiotoxicity in treated dogs was 8% (8/101). Additional pretreatment and ongoing studies are indicated to identify risk factors for cardiotoxicity.

Scintigraphic techniques for early detection of cancer treatment-induced cardiotoxicity

New antitumor agents have resulted in significant survival benefits for cancer patients. However, several agents may have serious cardiovascular side effects. Left ventricular ejection fraction measurement by (99m)Tc multigated radionuclide angiography is regarded as the gold standard to measure cardiotoxicity in adult patients. It identifies left ventricular dysfunction with high reproducibility and low interobserver variability. A decrease in left ventricular ejection fraction, however, is a relatively late manifestation of myocardial damage. Nuclear cardiologic techniques that visualize pathophysiologic processes at the tissue level could detect myocardial injury at an earlier stage. These techniques may give the opportunity for timely intervention to prevent further damage and could provide insights into the mechanisms and pathophysiology of cardiotoxicity caused by anticancer agents. This review provides an overview of past, current, and promising newly developed radiopharmaceuticals and describes the role and recent advances of scintigraphic techniques to measure cardiotoxicity. Both first-order functional imaging techniques (visualizing mechanical [pump] function), such as (99m)Tc multigated radionuclide angiography and (99m)Tc gated blood-pool SPECT, and third-order functional imaging techniques (visualizing pathophysiologic and neurophysiologic processes at the tissue level) are discussed. Third-order functional imaging techniques comprise (123)I-metaiodobenzylguanidine scintigraphy, which images the efferent sympathetic nervous innervations; sympathetic neuronal PET, with its wide range of tracers; (111)In-antimyosin, which is a specific marker for myocardial cell injury and necrosis; (99m)Tc-annexin V scintigraphy, which visualizes apoptosis and cell death; fatty-acid-use scintigraphy, which visualizes the storage of free fatty acids in the lipid pool of the cytosol (which can be impaired by cardiotoxic agents); and (111)In-trastuzumab imaging, to study trastuzumab targeting to the myocardium. To define the prognostic importance and clinical value of each of these functional imaging techniques, prospective clinical trials are warranted.

Role of three-dimensional echocardiography in breast cancer: comparison with two-dimensional echocardiography, multiple-gated acquisition scans, and cardiac magnetic resonance imaging

PURPOSE

In patients with breast cancer, the administration of doxorubicin and trastuzumab is associated with an increased risk of cardiotoxicity. Although multiple-gated acquisition (MUGA) scans and two-dimensional transthoracic echocardiography (TTE) are conventional methods for baseline and serial assessment of left ventricular ejection fraction (LVEF) in these patients, little is known about the use of real-time three-dimensional TTE (RT3D TTE) in this clinical setting. The aim of this study was to assess the accuracy of MUGA, 2D TTE, and RT3D TTE for determining LVEF in comparison to cardiac magnetic resonance imaging (CMR).

METHODS

Between 2007 and 2009 inclusive, 50 female patients with human epidermal growth factor receptor 2-positive breast cancer received adjuvant trastuzumab after doxorubicin. Serial MUGA, 2D TTE, RT3D TTE, and CMR were performed at baseline, 6, and 12 months after the initiation of trastuzumab.

RESULTS

A comparison of left ventricular end diastolic volume (LVEDV) demonstrated a modest correlation between 2D TTE and CMR (r = 0.64 at baseline; r = 0.69 at 12 months, respectively). A comparison of LVEDV between RT3D TTE and CMR demonstrated a stronger correlation (r = 0.87 at baseline; r = 0.95 at 12 months, respectively). Although 2D TTE demonstrated a weak correlation with CMR for LVEF assessment (r = 0.31 at baseline, r = 0.42 at 12 months, respectively), both RT3D TTE and MUGA showed a strong correlation when compared with CMR (r = 0.91 at baseline; r = 0.90 at 12 months, respectively).

CONCLUSION

As compared with conventional MUGA, RT3D TTE is a feasible, accurate, and reproducible alternate imaging modality for the serial monitoring of LVEF in patients with breast cancer.

Monitoring chemotherapy-induced cardiotoxicity: role of cardiac nuclear imaging

Cardiotoxicity may result from a range of chemotherapeutic agents. The prevalence of cardiotoxicity from certain cytotoxic agents is reported to be significantly high. In addition to serious side effects and increased long-lasting morbidity and mortality, dose limitation and suboptimal usage is an important adverse effect. Nuclear cardiac imaging has played a quintessential and important role in identifying patients at risk and in the prevention and reduction of cardiac injury resulting from cytotoxic agents. Despite exploring a number of other diagnostic imaging or biochemical tools for identification of cardiac injury, nuclear cardiac imaging in the form of radionuclide angiocardiography continues to be the most suitable and cost-effective tool for reducing the prevalence of cases of cardiac dysfunction resulting from chemotherapy. This article reviews the prevalence, mechanisms, and prevention strategies for cardiotoxicity associated with some of the commonly known cytotoxic agents and the role of nuclear cardiac imaging in its monitoring and prevention, along with recent advances in this area.

Tei index in adult patients submitted to adriamycin chemotherapy: failure to predict early systolic dysfunction

AIMS

This study prospectively assessed whether Tei index is predictive of early systolic dysfunction in adults undergoing adriamycin treatment.

METHODS AND RESULTS

Left ventricular ejection fraction (LVEF) was obtained by radionuclide ventriculography at baseline and after treatment. Tei index was evaluated by echocardiography at baseline, at an intermediary cycle and at the end of chemotherapy. Fifty-five predominantly female patients (91%) with breast cancer (80%) and without known cardiac disease were evaluated. After treatment (adriamycin dose of 304 +/- 47 mg/m(2)), systolic dysfunction (final LVEF < 50%) occurred in eight patients (14%). Baseline, intermediate or variation of Tei index were not accurate to predict early systolic dysfunction ("c" statistics < or = 0.60). Baseline Tei index > 0.39, for example, had a sensitivity of 75%, specificity of 55%, positive predictive value of 22% and negative predictive value of 93%.

CONCLUSION

Tei index does not appear to be a useful tool for detection of early adriamycin cardiotoxicity in adults.

Monitoring Cardiac Function in Patients Receiving Doxorubicin

Despite its well-known cardiotoxicity, doxorubicin continues to be an effective and widely used antineoplastic agent. Many efforts have focused on understanding the mechanism of doxorubicin-induced cardiotoxicity and on preventing it completely. Currently protective agents, eg, liposomal doxorubicin formulation, which results in less myocardial uptake, and the use of dexrazoxane, an intracellular iron chelator reducing the formation of radical complexes, have shown evidence of reducing incidences of cardiotoxicity at high dose of doxorubicin. However, they have not been able to completely eliminate cardiotoxicity. Therefore, it is crucial that careful monitoring to identify those patients who are at risk of developing unpredictable and sometimes-irreversible cardiac dysfunction is conducted while allowing other patients who respond to doxorubicin-containing therapy to receive their maximal therapeutic dose. Serial measurement of left ventricular ejection fraction by radionuclide angiocardiography remains a useful and widely adopted modality in monitoring patients that are receiving doxorubicin. Efforts are continuing on finding a more sensitive and reliable predictor of eventual clinical cardiac dysfunction.

Concomitant impairment of left ventricular systolic and diastolic function during doxorubicin therapy: a prospective radionuclide ventriculographic and echocardiographic study

Thirty adult lymphoma patients were studied prospectively with serial radionuclide ventriculography (RVG) and echocardiography (ECHO) to investigate whether changes in left ventricular (LV) diastolic function precede the impairment of LV systolic function during doxorubicin therapy. The patients received 8-10 cycles of CHOP to a cumulative doxorubicin dose of 400-500 mg/m2. RVG and ECHO were performed at baseline and after cumulative doxorubicin doses of 200, 400 and 500 mg/m2. Left ventricular ejection fraction (LVEF) decreased from 58 +/- 1.3 to 49.6 +/- 1.7% (p < 0.001) and from 58 +/- 1.7 to 52.5 +/- 1.3% (p = 0.036) as assessed with RVG and 2D ECHO, respectively. Of the diastolic ECHO doppler indices peak E wave velocity decreased from 63.3 +/- 3.2 to 51.3 +/- 2.6 cm/s (p = 0.008) and LV filling during the first 1/3 of diastole (1/3FF) from 42.2 +/- 1.7 to 36.5 +/- 2.0% (p < 0.001). The decrease in LVEF was statistically significant after the cumulative doxorubicin dose of 200 mg/m2 as assessed with RVG and after 400 mg/m2 as assessed with 2D ECHO. The decrease in 1/3FF reached the statistical significance after the cumulative doxorubicin dose of 400 mg/m2 and the decrease in peak E wave velocity after 500 mg/m2. This study shows that during doxorubicin therapy there are significant changes both in systolic and diastolic LV function. In addition, these changes manifest at relatively low cumulative doxorubicin doses and occur concomitantly. Thus, the assessment of diastolic function provides no advantage over monitoring systolic function during doxorubicin therapy.

Breath-hold FLASH and FISP cardiovascular MR imaging: left ventricular volume differences and reproducibility

PURPOSE

To compare fast imaging with steady-state precession (FISP) and fast low-angle shot (FLASH) magnetic resonance acquisitions to quantify left ventricular volumes, mass, and function and to determine if the two techniques are comparable.

MATERIALS AND METHODS

Left ventricular volume studies were performed in 10 patients with heart failure and in 10 healthy subjects by using FISP and FLASH imaging. Identical section positions were used for section-by-section contour comparisons. Manual analysis was performed by two experienced observers. The study was repeated on a different day and interobserver and interstudy reproducibility assessed.

RESULTS

With FISP, end-diastolic volume was larger (healthy subjects: +18 mL [13%], P <.001; patients: +6 mL [3%], not significant), end-systolic volume larger (healthy subjects: +9 mL [17%], P =.001; patients: +8 mL [6%], P =.001) and left ventricular mass smaller (healthy subjects: -25 g (19%), P <.001; patients: -21 g (11%), P <.001). There were no significant differences in ejection fraction. Both sequences had excellent interstudy and interobserver reproducibility, with statistically better reproducibility for interstudy healthy-subject ejection fraction on FISP images (P =.05). Section-by-section analysis determined that at FISP, endocardial contours were drawn larger and the epicardial contours smaller than on FLASH images. FISP enabled better delineation of epicardial fat from myocardium, of blood-myocardium interface in areas of trabeculation or papillary muscles, and of the atrioventricular ring.

CONCLUSION

FISP produces small but significantly higher left ventricular volume measurements, as compared with FLASH imaging. FLASH imaging and FISP have similar reproducibility.