Introduction
Non-Hodgkin’s lymphoma includes a variety of tumors originating from
lymphoid tissues. With an estimated 500,000 new cases in 2018,
non-Hodgkin’s lymphoma accounts for approximately 3% of all cancer
cases worldwide[1]. There is growing evidence that patients with
cancer are at substantially increased risk of developing cardiovascular
adverse event [2]. The reasons behind this observation are thought
to be multifactorial, including the common risk factors between cancer
and cardiovascular disease and the cardiovascular toxic effects of
antineoplastic drugs[3, 4]. Even when impaired LVEF was diagnosed
immediately after anthracycline therapy, 36% of patients failed to
regain normal LV function despite therapeutic interventions[5].
Research into more sensitive markers of subclinical cardiac dysfunction
or myocardial injury remains imminent.
Left ventricular ejection fraction (LVEF) has long been considered a key
criterion for evaluating cardiotoxicity[6]. Left ventricular global
longitudinal strain (GLS) has been shown to detect cardiac dysfunction
earlier than LVEF and is an important predictor of chemotherapy-induced
cardiotoxicity in patients with preserved LVEFs[7, 8]. LVEF and GLS
are recognized as criteria for assessing cardiac function and monitoring
chemotherapy-induced cardiotoxicity in most patients with heart disease
and as per guidelines[9]. However, few data are available on right
ventricular (RV) function in cancer survivors, especially in long-term
cancer survivors. It is possible that measurements of RV function are
more predictive of mortality than measures of left ventricular function
in many cardiac diseases, e.g. late post-myocardial infarction, and
chronic heart failure[10-12]. After treatment with anthracyclines,
27% of childhood cancer survivors had impaired right ventricular
ejection fraction as assessed by cardiac magnetic resonance
imaging[13]. However, the availability of cardiac magnetic resonance
imaging (CMR) is limited in many areas, and echocardiography is the
method of choice for screening cardiac toxicity after cancer treatment.
Three-dimensional transthoracic echocardiography (3DTTE) has the
advantage of full-volume acquisition of the entire right ventricle and
can overcome the technical and clinical limitations of 2D transthoracic
echocardiography[14]. The accuracy of 3D TTE in measuring RV volume
and RVEF against CMR has been confirmed in recent studies, and it has
been documented that RV volume measured by 3D TTE correlates well with
the corresponding values obtained by CMR by using new RV analysis
software[15-17]. Our previous study showed that subclinical changes
in RV function and size by 3DE-derived RV volume occurred after the
anthracycline-based chemotherapy[18]. However, the value of right
ventricular function in predicting cardiovascular events in patients
treated with anthracyclines remains to be investigated. Identifying
patients at high risk for heart failure and cardiac death is
particularly important in patients at high risk for clinical events,
such as those with hematologic malignancies.
The purpose of this study was to assess the value of 3D echo right
ventricular function measured during chemotherapy in identifying
cardiovascular events in patients with hematologic malignancies treated
with anthracyclines.