In Osteosarcoma and Anthracycline-Induced Heart Failure Mechanical Left Ventricular Assist Implantation Is Highly Recommended Due to High Relapse Rate of the Tumor

M. Schöber; M. Alkassar; A. Rüffer; R. Cesnjevar; F. Münch; M. Chada; M. Metzler; S. Dittrich

doi:10.1055/s-0039-1679085

The Thoracic and Cardiovascular Surgeon, Table of Contents

Thorac Cardiovasc Surg 2019; 67(S 02): S101-S128
DOI: 10.1055/s-0039-1679085

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Sunday, February 17, 2019

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Georg Thieme Verlag KG Stuttgart · New York

In Osteosarcoma and Anthracycline-Induced Heart Failure Mechanical Left Ventricular Assist Implantation Is Highly Recommended Due to High Relapse Rate of the Tumor

Authors

M. Schöber

¹Department of Pediatric Cardiology, University Erlangen, Erlangen, Germany
M. Alkassar

¹Department of Pediatric Cardiology, University Erlangen, Erlangen, Germany
A. Rüffer

²Department of Pediatric Cardiac Surgery, University Erlangen, Erlangen, Germany
R. Cesnjevar

²Department of Pediatric Cardiac Surgery, University Erlangen, Erlangen, Germany
F. Münch

²Department of Pediatric Cardiac Surgery, University Erlangen, Erlangen, Germany
M. Chada

³Department of Pediatric Oncology and Hematology, University Erlangen, Erlangen, Germany
M. Metzler

³Department of Pediatric Oncology and Hematology, University Erlangen, Erlangen, Germany
S. Dittrich

¹Department of Pediatric Cardiology, University Erlangen, Erlangen, Germany

Abstract

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Introduction: Anthracycline-induced cardiomyopathy can lead to rapid progressive heart failure shortly after chemotherapy. In this situation, heart transplantation would be a favored therapy. However, according to general medical consensus, less than 5 years after oncological treatment organ transplantation is contraindicated. We report on a child treated with left ventricular assist device (LVAD) as a bridge to transplant strategy.

Case Reports: A 14-year-old girl was diagnosed with osteosarcoma. She received standard chemotherapy including anthracycline treatment and operative resection. Six weeks after the end of chemotherapy, she developed clinical signs of congestive heart failure. Echocardiography revealed a dilated left atrium and ventricle with mitral regurgitation grade II. The left ventricular contractility was significantly reduced with ejection fraction of 34%. The patient was set on anticongestive medication. Within 6 weeks, left ventricular contractility rapidly deteriorated and the patient developed pulmonary venous congestion, right heart failure, severe tricuspid regurgitation, bilateral pleural effusions, and ascites. Treatment with milrinone and dobutamine was initiated. After viral myocarditis was ruled out by biopsy, an intracorporal LVAD was implanted (HVAD Pump, Heartware, Framingham, United States). After 10 months, the patient showed a steadily increasing exercise capacity which lets her take part in normal daily life activity. The NT-proBNP levels significantly decreased and echocardiography showed a reduction in LV diastolic diameter.

At 18 months of follow-up after LVAD implantation, the tumor relapsed in the lungs and the child received operation and chemotherapy. Currently, 33 months after LVAD implantation, no cardiac complications related to the LVAD were seen.

Conclusion: Shortly after cancer treatment, therapeutic options exclude heart transplantation mainly because of the risk of cancer relapse which is enhanced by the inevitable immunosuppressive therapy. Due to the 50% risk of tumor relapse in osteosarcoma, a mechanical LVAD is a recommendable and safe option in case of anthracycline-induced heart failure. Intracorporal devices enable patients to improve their life quality and offer a bridge-to-transplant option even in a 5-year perspective.