Outcomes in patients with anthracycline‐induced cardiomyopathy undergoing left ventricular assist devices implantation

Abstract

Aims Improved cancer survivorship has led to a higher number of anthracycline-induced cardiomyopathy patients with end-stage heart failure. We hypothesize that outcomes following continuous-flow LVAD (CF-LVAD) implantation in those with anthracycline-induced cardiomyopathy are comparable with other aetiologies of cardiomyopathy. Methods and results Using the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) from 2008 to 2017, we identified patients with anthracycline-induced cardiomyopathy who received a CF-LVAD and compared them with those with idiopathic dilated (IDM) and ischaemic cardiomyopathies (ICM). Mortality was studied using the Cox proportional hazards model. Other adverse events were evaluated using competing risk models. Overall, 248 anthracycline-induced cardiomyopathy patients underwent CF-LVAD implantation, with a median survival of 48 months, an improvement compared with those before 2012 [adjusted hazards ratio (aHR): 0.53; confidence interval (CI): 0.33-0.86]. At 12 months, 85.1% of anthracycline-induced cardiomyopathy, 86.0% of IDM, and 80.2% of ICM patients were alive (anthracycline-induced cardiomyopathy vs. IDM: aHR: 1.12; CI: 0.88-1.43 and anthracycline-induced cardiomyopathy vs. ICM: aHR: 0.98; CI: 0.76-1.28). Anthracycline-induced cardiomyopathy patients had a higher major bleeding risk compared with IDM patients (aHR: 1.23; CI: 1.01-1.50), and a lower risk of stroke and prolonged respiratory support compared to ICM patients (aHR: 0.31 and 0.67 respectively; both P < 0.05). There was no difference in the risk of major infection, acute kidney injury, and venous thromboembolism. Conclusions After receiving a CF-LVAD, survival in patients with anthracycline-induced cardiomyopathy is similar to those with ICM or IDM. Further research into differential secondary endpoints-related disparities is warranted.

Left Ventricular Assist Device Implantation in Cancer-Therapy-Related Heart Failure

“…The survival rate in our study was comparable with the one described by Oliveira et al but significantly lower than the one published in the actual analysis for patients with anthracycline-induced cardiomyopathy from the INTERMACS registry by Guha et al [ 7 , 8 ]. However, Guha et al excluded patients who concomitantly received right ventricular support, which is a known indicator for poor prognosis.…”

“…The rethoracotomy rate was high (29%), which may be related to fibrosis and extensive dissection of typical adhesions, which are known risk factors for postoperative bleeding. Patients with anthracycline-induced cardiomyopathy also had a higher postoperative bleeding rate in analysis from the INTERMACS database [ 8 , 10 ]. However, the frequency of chest radiation in this cohort is unknown.…”

“…Several case reports and some case small series describe successful treatment of chemotherapy-induced cardiomyopathy with a left-ventricular-assist device (LVAD) in adults and in children [ 4 , 5 , 6 ]. Retrospective analysis from the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) database has compared the characteristics and outcomes of patients with anthracyline-induced cardiomyopathy with those of patients with ischemic cardiomyopathy and non-ischemic cardiomyopathy [ 7 , 8 ]. Only little is known about the medical histories, including cancer diagnosis, the interval between cancer treatment and onset of heart failure or the application of adjuvant radiotherapy.…”

Novel Therapeutics for Anthracycline Induced Cardiotoxicity

“…Evaluation for these invasive therapies can be complicated due to the patient's oncologic history including ongoing chemotherapies, prognosis or, if in remission, risk of recurrence. The use of VADs is still relatively rare and AIC was the etiology of cardiomyopathy in only 0.5% of registry patients on mechanical circulatory support (MCS) (83)(84)(85). Compared to idiopathic dilated cardiomyopathy and ischemic cardiomyopathy, AIC patients undergoing left-sided VAD (LVAD) implantation were more likely to be female and more likely to have LVAD as destination therapy (86).…”

Multimodality Advanced Cardiovascular and Molecular Imaging for Early Detection and Monitoring of Cancer Therapy-Associated Cardiotoxicity and the Role of Artificial Intelligence and Big Data

“…However, with the rise of newer oncologic therapies, there have been a spectrum of adverse cardiovascular toxicities including cardiomyopathy (CM), myocardial infarction, myocarditis, arrhythmia, hypertension (HTN) and thrombosis that have been associated with these agents. More traditional cardiotoxic agents like anthracyclines (i.e., doxorubicin), one of the most widely used class of chemotherapeutics due to improved overall cancer and survival outcomes has been shown to alter myocardial energetics, promote mitochondrial dysfunction, increase reactive oxygen species levels leading to activation of matrix metalloproteases, inhibit topoisomerase IIb and cause DNA strand breaks, thereby promoting cardiomyopathy (7)(8)(9).…”