Myocardial FDG uptake variation and its relationship with survival during immunotherapy

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Background: The rise of Immune Checkpoint Inhibitors (ICI) as a cancer treatment has been followed by the increase of cardiotoxicity events reports. Retrospective studies with anthracycline revealed a relationship between increased myocardial 18F-FDG uptake (MGU) and a slight drop in Left Ventricular Ejection Fraction (LVEF) values, suggesting that this may be a useful tool for early detection of cardiotoxicity. Our study is intended to evaluate the prognostic impact of the variation in MGU in advanced lung cancer undergoing treatment with ICI. Methods: This is a unicentric, retrospective study, that evaluated lung cancer patients treated with ICI from 2016 to 2020 and submitted to at least two positron emission tomography (PET-CT). The primary objective was to evaluate the MGU variation during ICI treatment (ΔSUV) and its impact on survival outcomes. Numerical variables are described using a median and interquartile range. Categorical variables are described using absolute and relative frequencies. Mann-Whitney test was applied to compare the median between groups. progression-free survival and overall survival were calculated using the Kaplan-Meier method and the Log Rank test was used to compare survival curves. Alpha level = 0.05. Results: 43 patients fulfilled all inclusion criteria. 51% received Immunotherapy plus chemotherapy and 49% received only immunotherapy. Global median ΔSUV was +0.14; among patients in the disease control group, the median ΔSUV was +0.3, while the median ΔSUV of the disease progression group was -0.47. Considering patients with positive myocardial ΔSUV versus negative ΔSUV, there was a median increase of progression-free survival (PFS) of 112 days in favour of the positive myocardial ΔSUV group (p = 0.087). The overall survival (OS) of patients that used beta-blockers(BB) was higher than those who did not, with an increase of 575 days on median OS (p = 0.159). The increase in the PFS median by 112 days on those patients who presented a positive ΔSUV may suggest that better treatment outcomes are related to the rise of myocardial SUV, although the sample size was not sufficient to reach statistical significance. Another important association, albeit not statistically significant, was the growth of PFS mean by 575 days with the usage of BB, such growth was not evidenced on the patients which used ACE inhibitors or ARBs; indicating that BB could have a supporting role on ICI treatment. Those findings correlate to recent evidence that shows an increase in MGU after BB usage and that BB may work as immune-modulating agents improving ICI therapies. Conclusions: The increase in MGU was associated with better outcomes, suggesting that it could be studied as a predictor of treatment response, in addition to the benefit also shown with the use of BB, which strengthens their possible synergistic effect in treatment. However, more robust studies are needed to better understand the MGU role on ICI treatment.

Early reduction of pulmonary arterial hypertension in patients using a long-term mechanical ventricular assistance device: a cross-sectional study

BACKGROUND

Severe pulmonary arterial hypertension (PAH) is a contraindication for heart transplantation (HT). It has been correlated with increased early and late mortality, mainly associated with right ventricular failure. Ventricular assistance devices (VADs) can promote reduction of intracardiac pressures and consequent reduction of PAH over the medium and long terms, thus enabling future candidature for HT. The diminution of early pulmonary pressure within this scenario remains unclear.

OBJECTIVE

To evaluate the reduction of PAH and correlate data from right catheterization with the earliness of this reduction.

DESIGN AND SETTING

Cross-sectional study in a general hospital in São Paulo, Brazil.

METHODS

This was a retrospective analysis on the medical records of patients undergoing VAD implantation in a single hospital. Patients for whom VAD had been indicated as a bridge to candidature for HT due to their condition of constant PAH were selected.

RESULTS

Four patients with VADs had constantly severe PAH. Their mean pulmonary artery systolic pressure (PASP) before VAD implantation was 66 mmHg. Over the 30-day period after the procedure, all the patients evolved with a drop in PASP to below 60 mmHg. Their new average was 36 mmHg, which was a drop of close to 50% from baseline values. The one-year survival of this sample was 100%.

CONCLUSION

VAD implantation can reduce PAH levels. Early reduction occurred in all patients. Thus, use of VAD is an important bridge tool for enabling candidature for HT among patients with constantly severe PAH.

COVID-19 complicating perioperative management of LVAD implantation: A case report and systematic review

The coronavirus 2019 disease (COVID-19) affected 125 million people worldwide and caused 2.7 million deaths. Some comorbidities are associated with worse prognosis and left ventricular assist device (LVAD) recipients are probably part of this high-risk population. We report a 31-year-old male patient who developed COVID-19 during LVAD implantation. His postoperative period was complicated by severe pneumonia and mechanical ventilation (MV) leading to right ventricular failure (RVF) and inotrope necessity. He experienced multiple complications, but eventually recovered. We present a systematic review of LVAD recipients and COVID-19. Among 14 patients, the mean age was 62.7 years, 78.5% were male. A total of 5 patients (35.7%) required MV and 3 patients (21.4%) died. A total of 2 patients (14.2%) had thromboembolic events. This case and systematic review suggest LVAD recipients are at particular risk of unfavorable outcomes and they may be more susceptible to RVF in the setting of COVID-19, particularly during perioperative period.

Worsening of heart failure by coronavirus disease 2019 is associated with high mortality

AIMS

Patients with advanced heart failure (HF) with reduced left ventricular ejection fraction (HFrEF) and concurrent coronavirus disease 2019 (COVID-19) might have a higher risk of severe events.

METHODS AND RESULTS

We retrospectively studied 16 patients with advanced HFrEF who developed COVID-19 between 1 March and 29 May 2020. Follow-up lasted until 30 September. Ten patients previously hospitalized with decompensated HFrEF were infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during hospitalization. Six patients undergoing ambulatory care at initiation of COVID-19 symptoms were hospitalized because of advanced HFrEF. All patients who experienced worsening of HFrEF due to COVID-19 required higher doses or introduction of additional inotropic drugs or intra-aortic balloon pump in the intensive care unit. The mean intravenous dobutamine dose before SARS-CoV-2 infection in previously hospitalized patients (n = 10) and the median (inter-quartile range) peak intravenous dobutamine dose during SARS-CoV-2 infection in all patients (n = 16) were 2 (0-7) μg/kg/min and 20 (14-20) (P < 0.001), respectively. During follow-up, 56% underwent heart transplantation (n = 2) or died (n = 7). Four patients died during hospitalization from mixed shock consequent to severe acute respiratory syndrome with inflammatory storm syndrome associated with septic and cardiogenic shock during COVID-19. After COVID-19 recovery, two patients died from mixed septic and cardiogenic shock and one from sustained ventricular tachycardia and cardiogenic shock. Five patients were discharged from hospital to ambulatory care. Four were awaiting heart transplantation.

CONCLUSION

Worsening of advanced HF by COVID-19 is associated with high mortality. This report highlights the importance of preventing COVID-19 in patients with advanced HF.

Prevention and Treatment of Chemotherapy-Induced Cardiotoxicity

Recent decades have seen an increase in survival rates for cancer patients, partially explained by earlier diagnoses and new chemotherapeutic agents. However, chemotherapy may be associated with adverse cardiovascular events, including hypertension and pulmonary hypertension, supraventricular and ventricular arrhythmias, cardiomyopathy, and other forms of cardiovascular disease. For patients, the benefits of chemotherapy may be partially obfuscated by deleterious effects on the cardiovascular system, resulting in a significant increase in morbidity and mortality. In this article, we review strategies for prevention and treatment of chemotherapy-related cardiotoxicity.

Hypertonic saline solution for renal failure prevention in patients with decompensated heart failure

BACKGROUND

Hyponatremia and congestive phenomena indicate a bad prognosis in decompensated heart failure. The occurrence of renal failure is associated to an increased death risk.

OBJECTIVE

To evaluate the safety and efficacy of the hypertonic saline solution in patients with decompensated heart failure for renal failure prevention.

METHODS

Patients with decompensated heart failure, congestion and hyponatremia participated in the study. In addition to the standard treatment, the patients received hypertonic saline solution and were submitted to clinical as well as laboratory assessment.

RESULTS

Nine patients were enrolled in the study. Mean age was 55 + 14.2 years, being 5 male (55.5%) and 4 (44.5%) female patients. All of them presented functional class III-IV of the New York Heart Association (NYHA), and 5 (55.5%) received dobutamine. All of them presented initial creatinine > 1.4 mg/dl. The mean tonicity of the solution was 4.39% + 0.018% (2.5% to 7.5%) and the duration of treatment was 4.9 days + 4.1 days (1-15 days). There were no severe adverse effects; none of the patients presented clinical worsening or neurologic disorders; hypokalemia occurred in 4 cases (44.5%). The comparison of the variables before and after treatment showed a decrease in urea (105 mg/dl + 74.8 mg/dl vs. 88 mg/dl + 79.4 mg/dl; p = 0.03) and increase in the urinary volume (1,183 ml/day vs. 1,778 ml/day; p = 0.03); there was no tendency to creatinine decrease (2.0 mg/dl + 0.8 mg/dl vs. 1.7 mg/dl + 1.0 mg/dl; p = 0.08). Despite the elevation in sodium levels (131 mEq/l + 2.8 mEq/l vs. 134 mEq/l + 4.9 mEq/l) and weight decrease (69.5 kg + 18.6 kg vs. 68.2 kg + 17.1 kg), there was no statistically significant difference.

CONCLUSION

The use of hypertonic saline solution in patients with decompensated heart failure can be a safe therapeutic method and potentially related to clinical improvement and renal failure prevention.

Effects of bisoprolol on cardiac function and exercise in patients with heart failure

OBJECTIVE

To assess the effects of bisoprolol on exercise capacity and ventricular function in patients with heart failure.

METHODS

Clinical and hemodynamic variables, ventricular function and remodeling, and ergospirometry of patients with heart failure of different etiologies were evaluated before and after the administration of bisoprolol.

RESULTS

Twenty-two patients were analyzed; one patient did not tolerate medication and 14 patients reached the study goal. The group consisted of 9 men and 5 women, the mean age was 52 (36-64) years, and patients were followed during 551 days (238-1109). We observed an improvement in NYHA functional class, reduction in resting heart rate (78.8+/-8.7 vs 63+/-6.4 bpm, p <0.001), increase in left ventricular ejection fraction (31.3+/-8.5% vs 39+/-14.7%. p=0.043), and a tendency towards improved quality of life scores (31+/-20.6 vs 17.8+/-14.8. p=0.058). The maximum heart rate dropped during exercise (138.1+/-20.2 vs 116.7+/-27.1. p=0.01), as did peak oxygen consumption (20.9+/-6.8 vs 15.1+/-3.5. p<0.001); no change was observed on the EV/VCO2 slope. The effects were observed for all etiologies, including Chagas disease.

CONCLUSION

Bisoprolol was safe and well tolerated in patients with heart failure. Bisoprolol therapy improved the symptoms, hemodynamic variables, as well as the cardiac function for all etiologies; however, it did not result in improved exercise capacity.