Cardiac systolic function before and after hematopoietic stem cell transplantation

Abstract

Summary:In order to examine the effect of hematopoietic stem cell transplantation (HSCT) on cardiac systolic function, we measured left ventricular ejection fraction (LVEF) by radioventriculography (RVG) before and after the transplantation procedure. One hundred and fortyeight patients were examined, 96 undergoing allogeneic grafting and 52 autologous. Fifty patients had CML, 48 AML, 21 ALL, 18 multiple myeloma and 11 breast cancer. The second RVG examination was performed 22 to 227 days (median 60 days) after HSCT. The mean LVEF value in the whole patient group was 60.2% (range 39-81%) before and 61.1% (35-86%) after transplantation. Patients with CML had significantly higher LVEF before transplantation than patients with acute leukemia (P = 0.007) and multiple myeloma (P = 0.005). No significant changes in mean LVEF between the pre-and post-transplant measurements were seen in any of the diagnostic subgroups or in allogeneic or autologous recipients. None of the 148 patients in the study has shown any signs of clinical heart failure at 2, 5 to 10 years follow-up. Patients who had received anthracyclines in the previous treatment had significantly lower LVEF before transplantation but showed no increased risk of decline in cardiac function. In conclusion, the HSCT procedure does not seem to affect myocardial function 1-7 months after transplantation. Bone Marrow Transplantation (2000) 26, 187-192. Keywords: hematopoietic stem cell transplantation; cardiotoxicity; radioventriculography; anthracyclines Allogeneic or autologous HSCT offers a possibility of cure or long-term remission in hematological malignancies. However, gastrointestinal, pulmonary, infectious and immunological complications are major problems and limiting factors for HSCT. Acute cardiac toxicity has previously been described with mortality ranging from 1.2% to 9% and morbidity from 5% to 43%.1-3 Cardiac complications are generally considered to be less important than other side-effects, but may be serious in some patients. The most common cardiotoxic effects are electrocardiographic changes and transient arrhythmias, but pericarditis, heart failure, pulmonary edema and cardiac death are also seen.

Cardiac toxicity of high-dose chemotherapy

“…In at least seven studies, LVEF measured at rest was unable to predict future cardiac toxicity. 17,28,79,80,100,104,105 One of these studies also showed that measurement of cardiac reserve during exercise could not predict cardiac morbidity or mortality. 104 On the other hand, three studies reported a significant association between pre-transplant LVEF and cardiotoxicity 18,54,77 and two more described a trend in the same direction.…”

“…8,10,17,18,26,[76][77][78][79] On the other hand, Steinherz et al 22 observed that HD cyclophosphamide-associated cardiac damage was most frequent in pediatric patients receiving cyclophosphamide X170 mg/kg or in those receiving X120 mg/kg who had received X100 mg/m 2 anthracyclines prior to transplant. Other authors found a trend towards significance also.…”

“…76,101 However, measurement of LVEF before HD chemotherapy is of limited practical value: increased rates of minor cardiac events, rather than increased mortality due to severe cardiac toxicity, were recorded among patients with diminished (ie 50-54%) baseline LVEF, and 2/3 major cardiac events occurred in patients with normal LVEF. 100 Overall, resting LVEF measurement in every HD chemotherapy candidate is not recommended; 76,100 published evidence 7,25,76,79,100,106 suggests that for patients undergoing front-line HD chemotherapy cardiologic evaluation including a detailed history, physical examination, chest X-ray and resting ECG is likely to be a sufficient screening tool to recognize candidates at high risk for cardiac complications. On the other hand, full pre-transplant evaluation with resting 2D echo of patients with history, symptoms or signs of cardiac disease or a history of anthracycline exposure and/or left chest wall radiotherapy remains prudent.…”

“…103 Finally, in 11 patients whose pre-transplant LVEF was o50%, no signs of heart failure were recorded at prolonged follow-up after HSC transplantation. 79 Therefore, patients with subclinical impairment of cardiac function should not be excluded a priori from HSC transplantation if otherwise indicated, but thorough cardiologic evaluation and monitoring are warranted.…”

Cyclophosphamide-induced Cardiomyopathy in a Patient with Seminoma and a History of Mediastinal Irradiation

“…On the other hand, our patient was not treated with anthracyclines and showed a preserved ejection fraction before high-dose chemotherapy. Moreover, subsequent studies have shown that both of these conventional markers are insufficient to independently predict the onset of cardiomyopathy (14,15). In a recent report (5), prolongation of corrected QT interval before high-dose CY was strongly associated with the onset of cardiomyopathy.…”