Progressive and Reversible Conduction Disease With Checkpoint Inhibitors

Novel antineoplastic therapies are focused on harnessing our own immune system to fight cancer. To that end, cytotoxic T-lymphocyte-associated antigen 4 and programmed death ligand 1 are 2 coinhibitory signals that play central roles in decreasing T-cell response and represent a class of medications termed "checkpoint inhibitors." We present an unusual case of progressive conduction abnormalities induced by checkpoint inhibitors. Prompt medical intervention resulted in full recovery. Despite the anticancer efficacy, the newer antineoplastic agents pose a significant and often life-threatening risk of cardiotoxicity.

Outcomes of Cancer Patients Undergoing Percutaneous Pericardiocentesis for Pericardial Effusion

BACKGROUND

Pericardial effusion (PE) is common in cancer patients, but the optimal therapeutic approach is not well defined. Percutaneous pericardiocentesis is less invasive than surgery, but its long-term effectiveness and safety have not been well documented.

OBJECTIVES

The goal of this study was to evaluate outcomes of cancer patients undergoing percutaneous pericardiocentesis for PE and assess the procedure's safety in patients with thrombocytopenia.

METHODS

Cancer patients who underwent percutaneous pericardiocentesis for PE between November 2009 and October 2014 at the MD Anderson Cancer Center were included. Procedure-related complications, effusion recurrence rate, and overall survival were analyzed.

RESULTS

Of 1,645 cancer patients referred for PE, 212 (13%) underwent percutaneous pericardiocentesis. The procedure was successful in 99% of the cases, and there were no procedure-related deaths. Four patients had major procedure-related bleeding that did not vary by platelet count <50,000/μl or ≥50,000/μl (p = 0.1281). Patients with catheter drainage for 3 to 5 days had the lowest recurrence rate (10%). Median overall survival was 143 days; older age (i.e., >65 years), lung cancer, platelet count <20,000/μl, and malignant pericardial fluid were independently associated with poor prognosis. Lung cancer patients with proven malignant effusions had a significantly shorter median 1-year survival compared with those with nonmalignant effusions (16.2% vs. 49.0%, respectively; log-rank test p = 0.0101). A similar difference in 1-year survival was not observed in patients with breast cancer (40.2% vs. 40.0%; log-rank test p = 0.4170).

CONCLUSIONS

Percutaneous pericardiocentesis with extended catheter drainage was safe and effective as the primary treatment for PE in cancer patients, including in those with thrombocytopenia. Malignant PE significantly shortened the survival outcome of patients with lung cancer but not those with breast cancer.

Apical hypertrophic cardiomyopathy

We describe a patient with asymptomatic apical hypertrophic cardiomyopathy (AHCM) who later developed cardiac arrhythmias, and briefly discuss the diagnostic modalities, differential diagnosis and treatment option for this condition. AHCM is a rare form of hypertrophic cardiomyopathy which classically involves the apex of the left ventricle. AHCM can be an incidental finding, or patients may present with chest pain, palpitations, dyspnea, syncope, atrial fibrillation, myocardial infarction, embolic events, ventricular fibrillation and congestive heart failure. AHCM is frequently sporadic, but autosomal dominant inheritance has been reported in few families. The most frequent and classic electrocardiogram findings are giant negative T-waves in the precordial leads which are found in the majority of the patients followed by left ventricular (LV) hypertrophy. A transthoracic echocardiogram is the initial diagnostic tool in the evaluation of AHCM and shows hypertrophy of the LV apex. AHCM may mimic other conditions such as LV apical cardiac tumors, LV apical thrombus, isolated ventricular non-compaction, endomyocardial fibrosis and coronary artery disease. Other modalities, including left ventriculography, multislice spiral computed tomography, and cardiac magnetic resonance imagings are also valuable tools and are frequently used to differentiate AHCH from other conditions. Medications used to treat symptomatic patients with AHCM include verapamil, beta-blockers and antiarrhythmic agents such as amiodarone and procainamide. An implantable cardioverter defibrillator is recommended for high risk patients.

Prevention of radiocontrast-induced nephropathy with N-acetylcysteine in patients undergoing coronary angiography

OBJECTIVES

Acetylcysteine in patients undergoing computerized tomography with intravenous contrast reduces the incidence of acute renal dysfunction. We examined the effect of N-acetylcysteine in patients undergoing coronary angiography.

METHODS

Fifty-five consecutive patients receiving 3 doses of N-acetylcysteine prior to cardiac catheterization were compared to 55 historical controls. All patients in both groups had baseline serum creatinine > 1.2 mg/dl and received intravenous hydration before and after the procedure. Serum creatinine levels at baseline and 48 hours after the procedure were compared.

RESULTS

Univariate analysis of clinical variables revealed no significant differences between the groups except for a higher baseline creatinine in the treatment group (2.0 0.7 vs. 1.8 0.4 mg/dl; p = 0.04). There was no difference in the amount or type of contrast used. The mean change in creatinine after 48 hours was -0.4 0.3 versus +0.1 0.3 mg/dl for treatment and control groups (p < 0.001). In patients with baseline creatinine > 2 mg/dl, the benefit was larger (-0.4 0.4 vs. +0.5 0.3 mg/dl; p < 0.001). Multivariate analysis confirmed pre-treatment with N-acetylcysteine as an independent predictor of renal protection (p < 0.001).

CONCLUSIONS

Prophylactic use of acetylcysteine prevented reduction of renal function after coronary angiography. The benefit was greater in patients with baseline serum creatinine > 2 mg/dl.

Coronary artery "pseudothrombus" due to collateral flow artifact distal to left circumflex coronary stenosis

Since the complexity, morbidity, and costs of coronary interventions are increased when coronary thrombus is present, identification of the cause of an angiographic filling defect is potentially important. We present a case report and review our experience with a flow artifact that mimicked thrombus ("pseudothrombus") in the setting of a severe proximal stenosis in the left circumflex coronary artery.