Results
A 15-years-old girl was diagnosed with non-metastatic Epstein Barr virus infection related nasopharyngeal cancer, and a partial deficit of dihydropyrimidine dehydrogenase (DPD) was diagnosed.3Chemotherapy started including reduced doses of 5FU (1000 mg/m²) and cisplatin (1000 mg/m²) intravenously. On day 2, she presented nausea, heart rate 170/mn, blood pressure : 78/35 mmHg without chest pain or dyspnea. Electrocardiogram showed isolated sinus tachycardia. There was an increase in: NT-proBNP at 4707pg/ml (<125), troponin Ic at 1.78 µg/L (< 0.04), serum creatinin 114 µmol/l (versus60µmol/L at admission), normal thyroid function. In the Acute Coronary Unit (ACU) echocardiogram demonstrated left ventricular ejection fraction (LVEF) of 20%, low cardiac output, no chamber dilatation, no regional wall motion abnormalities, heart valve abnormalities or pericardial fluid. Cardiogenic shock became untreatable, requiring mechanical circulatory support by extracorporeal membrane oxygenation arteriovenous (ECMO-VA). Coronary angiogram was normal. Right ventricular myocardial biopsy showed myocyte necrosis with no lymphocyte, eosinophilic or giant cell infiltration (Figure). Outcomes were favorable after improvement of LVEF allowing weaning of ECMO-VA on D7 and of dobutamine on D11. At Day 30, the patient had been discharged, the echocardiogram showed LVEF of 60% on ACE-inhibitors. At 6 months follow-up, cardiac magnetic resonance (cMR) showed normal LVEF and right ventricular function, limited epicardial late gadolinium enhancement in the inferior and infero-lateral walls, and normal T1 and T2 mapping. Chemotherapy had been contra-indicated, and the patient remained disease-free after nasopharyngeal irradiation at 12 months follow-up.
A 86 years old male patient, non DPDP deficient, was given a first re-challenge cycle of chemotherapy including 5FU (400mg/m2 bolus followed by a 2400 mg/m2 infusion) and oxaliplatin (85g/m2) for relapsing colon cancer. Past medical history included: right sided small cell renal carcinoma treated by nephrectomy 11 years earlier; colon cancer treated by surgery and chemotherapy (5FU and oxaliplatin) 9 years earlier. Cardiovascular assessment prior chemotherapy included: sinus rhythm, complete left bundle branch block (LBBB); septal wall motion abnormalities, moderate left ventricular dysfunction (LVEF 45%) on echocardiogram; no ischaemia on stress myocardial nuclear imaging. The patient presented with acute dyspnea 2 days after chemotherapy: BP 125/75mmHg, HR 100/min, body core temperature 36.6°C and SaO2 97%; abnormal lung crackles; no ECG changes. Brain natriuretic peptide (BNP) was 769ng/L, troponin Ic 0.19µg/L, and serum creatinin 200µmol/L. Echocardiography showed a severe drop in LVEF as low as 10% and low cardiac output. In the ACU, the patient received high doses of loop diuretics (furosemide 1g/24hs IV) and vasoactive drugs (dobutamine 20 µg/Kg/min and noradrenalin 4mg/h). Renal failure with creatinin of 394µmol/L and urea 35mmol/L plateaued but subsequently improved however precluding coronary angiogram. Inotropes were weaned on Day 6 and LVEF subsequently recovered on ACE-inhibitors and spironolactone, discharged on Day 18. The patient received raltitrexed for colic cancer that controlled the disease. At 6 months follow-up, the patient was NYHA class I with LVEF of 41% on cMR mainly due to LBBB-related septal asynchrony, with focal inferior and inferolateral epicardial late gadolinium enhancement, identical pattern as the girl’s follow-up cMR (Figure).