Cardiotoxicity associated with high-dose cyclophosphamide therapy

The cardiac effects of chemotherapeutic regimens using high doses of cyclophosphamide (180 mg/kg over four days) were assessed in 32 patients with hematologic malignant neoplasms. Left ventricular systolic function, determined by the fractional shortening on echocardiogram, declined substantially five to 16 days after the initiation of cyclophosphamide therapy. Although pericardial effusion on echocardiogram occurred in 33% of the patients studied, ECG voltage decreased five to 14 days after beginning cyclophosphamide therapy even in those patients without pericardial effusion. Congestive heart failure was noted in nine patients (28%) within three weeks of cyclophosphamide administration. Six of these patients (19%) died of myocardial failure. Pericardial tamponade occurred in six patients (19%), including five who died of myocardial failure. Histopathologic and electron microscopic findings showed endothelial injury and a hemorrhagic myopericarditis. Cyclophosphamide in this high dose is associated with a toxic, often fatal, pericardiomyopathy. Depression of ECG voltage and systolic left ventricular function, though common, do not necessarily predict clinical cardiac deterioration.

Doxorubicin cardiotoxicity: assessment of late left ventricular dysfunction by radionuclide cineangiography

Radionuclide cineangiography was used to evaluate 32 patients who sustained long-term remission of soft tissue sarcoma after adjuvant therapy with a cumulative doxorubicin dose from 480 to 550 mg/m body surface area. Left ventricular ejection fraction at rest was below normal (less than 45%) in eight of 32 patients. The abnormal response of ejection fraction to exercise identified an additional 12 patients with diminished left ventricular functional reserve. Ejection fraction determined at rest or during exercise did not differ 1 to 9 months) and those studied 30 months (range, 21 to 43 months) after completing doxorubicin treatment. Sequential studies in 13 patients, done 6 to 15 months after initial post-doxorubicin evaluation also showed persistent depression of average ejection fraction at rest and with exercise, with the continued deterioration of left ventricular function in six patients. Left ventricular dysfunction, evident in over half of asymptomatic patients even long after "acceptable" cumulative doses of doxorubicin, may persist for years.

Specificity of systolic anterior motion of anterior mitral leaflet for hypertrophic cardiomyopathy. Prevalence in large population of patients with other cardiac diseases

The value of systolic anterior motion of the anterior mitral leaflet as a diagnostic marker for hypertrophic cardiomyopathy has been questioned because of its reported occurrence in other heart diseases. To determine the true specificity of systolic anterior motion for hypertrophic cardiomyopathy, 721 echocardiograms from patients with a wide variety of cardiac diseases were reviewed for its presence or absence under basal conditions. Systolic anterior motion of the anterior mitral leaflet was present in only 22 (3.0%) of the 721 patients, giving a specificity of 97 per cent. It was most common in patients with d-transposition of the great vessels (11 of 51, or 21%). With patients having transposition of the great vessels excluded from the analysis, the prevalence of systolic anterior motion of the anterior mitral leaflet was only 1.6 per cent (specificity 98%). Of note, eight of the 11 patients with systolic anterior motion of the anterior mitral leaflet and diseases other than transposition of the great vessels had disproportionate thickening of the ventricular septum, making it exceedingly rare in a patient population with normal septal-free wall thickness ratios (prevalence 0.4%; specificity 99%). Hence, while systolic anterior motion is not pathognomonic of hypertrophic cardiomyopathy, it was an uncommon finding in a large population of patients with a variety of cardiac diseases; when present in such patients systolic anterior motion of the anterior mitral leaflet is usually associated with disproportionate septal thickening.

Hypertrophic cardiomyopathy with unusual locations of left ventricular hypertrophy undetectable by M-mode echocardiography. Identification by wide-angle two-dimensional echocardiography

Twenty-one patients without evidence of hypertrophy by M-mode echocardiography were studied by wide-angle two-dimensional echocardiography to determine if they had a form of hypertrophic cardiomyopathy that could not be detected by conventional M-mode echocardiography. Each patient was suspected clinically of having hypertrophic cardiomyopathy because of a distinctly abnormal ECG and either a family history of hypertrophic cardiomyopathy or cardiac symptoms. Patients were 5-49 years old (mean 16 years) and 16 of the 21 had no functional limitation. The most common electrocardiographic abnormalities were deep Q waves, T-wave inversion and right ventricular hypertrophy. Using wide-angle two-dimensional echocardiography to reconstruct the geometry of the left ventricular wall, 16 of the 21 patients (76%) were shown to have prominent but unusually located regions of left ventricular wall hypertrophy. In each instance, the hypertrophy involved regions of the left ventricular wall through which the M-mode ultrasound beam does not usually pass, i.e., posterior ventricular septum (seven patients), anterior or lateral left ventricular free wall (seven patients) and ventricular septum near the apex (two patients). There was no echocardiographic or hemodynamic evidence of left ventricular outflow tract obstruction in any patient. Hence, some patients with hypertrophic cardiomyopathy may have substantial hypertrophy present in unusual locations of the left ventricular wall. Although electrocardiographic abnormalities suggested the presence of myocardial disease, conventional M-mode echocardiography (performed from standard parasternal positions) did not reliably identify such sites of hypertrophy, which were limited to regions of the left ventricle not accessible to the M-mode beam. Only wide-angle two-dimensional echocardiography permits definitive identification of these unusually located regions of cardiac hypertrophy and confirmation of the diagnosis of hypertrophic cardiomyopathy.

Left ventricular function in mitral valve prolapse: assessment with radionuclide cineangiography

Abnormalities of left ventricular contraction in patients with mitral valve prolapse have suggested a myocardial factor in this disease. To determine systolic left ventricular function in mitral valve prolapse, technetium-99m gated equilibrium radionuclide cineangiography was performed in 47 patients with this diagnosis. In 39 patients without mitral regurgitation the average ejection fraction was normal at rest (average [+/- standard error of the mean] 57 +/- 3 percent, normal 57 +/- 1 percent, difference not significant) and exceeded the lower limits of normal in all but 1 patient, whose ejection fraction was 41 percent. However, ejection fraction during maximal exercise was lower for the group of patients with mitral prolapse without mitral regurgitation than for normal subjects (average 64 +/- 2 percent, normal 71 +/- 2 percent, p < 0.005). In eight patients with mitral prolapse and mitral regurgitation, the average ejection fraction was normal at rest but was diminished with exercise in comparison with both normal subjects and patients with mitral valve prolapse without mitral regurgitation. Chest pain, arrhythmia and the pattern or extent of mitral valve prolapse on echocardiography were not independently associated with impaired left ventricular functional reserve. We conclude that, although many patients with mitral valve prolapse have normal left ventricular function, there is a subgroup without mitral regurgitation in whom diminished left ventricular functional reserve is suggestive of a cardiomyopathic process.

Myocardial infarction?--a conflict between electrocardiographic changes and biochemical data

We present a case of hypovolemic shock accompanied by electrocardiographic changes classically associated with acute myocardial infarction. Prompt therapeutic intervention, which included correction of the hypovolemic shock, resulted in stabilization of the patient's clinical course, increased activities of the cardiac-specific enzymes in serum were not documented. Serial electrophoretic determinations of the isoenzymes of serum lactate dehydrogenase did not show the characteristic changes associated with myocardial infarction. Accurate determination of the serum isoenzymes provided valuable diagnostic information which, accompanied by the patient's clinical improvement, militated strongly against the occurrence of myocardial infarction.

Myocardial infarction?--a conflict between electrocardiographic changes and biochemical data

We present a case of hypovolemic shock accompanied by electrocardiographic changes classically associated with acute myocardial infarction. Prompt therapeutic intervention, which included correction of the hypovolemic shock, resulted in stabilization of the patient's clinical course, increased activities of the cardiac-specific enzymes in serum were not documented. Serial electrophoretic determinations of the isoenzymes of serum lactate dehydrogenase did not show the characteristic changes associated with myocardial infarction. Accurate determination of the serum isoenzymes provided valuable diagnostic information which, accompanied by the patient's clinical improvement, militated strongly against the occurrence of myocardial infarction.

Whole body hyperthermia: a phase-I trial of a potential adjuvant to chemotherapy

Fourteen patients with a variety of neoplasms not responsive to standard forms of therapy underwent whole body hyperthermia for a maximum 4 h at 41.8 degrees C. This was a phase-I cancer trial designed to develop whole body hyperthermia as an adjuvant to systemic chemotherapy. Intravenous analgesia was used to sedate patients, obviating the need for general endotracheal anesthesia. Hyperthermia was induced by means of a high-flow water perfusion suit. Cardiovascular performance was evaluated using a flow-directed pulmonary artery catheter. Patients developed a twofold mean increase in cardiac index without evidence of cardiac damage by ECG or creatine phosphokinase (CPK) isoenzymes. An acute fall in serum magnesium and phosphate and an acute rise in arterial pH, serum CPK values, and granulocyte count occurred in all patients. There were no clotting abnormalities. Toxicity included fatigue, diarrhea, nausea, and transient elevations in liver enzymes. Four patients were febrile for 36 h after initial defervescence. Peripheral neuropathy developed in four. These results show that with carefully monitored conditions whole body hyperthermia is feasible.

Nongenetically transmitted disproportionate ventricular septal thickening associated with left ventricular outflow obstruction

Clinical, haemodynamic, and morphological features are described in 2 patients with disproportionate ventricular septal thickening, left ventricular outflow obstruction with systolic anterior motion of the anterior mitral leaflet, and either acquired or congenital heart disease. The disproportionate septal thickening in these patients appeared to be secondary to their underlying cardiac disease rather than a manifestation of genetically transmitted hypertrophic cardiomyopathy. One patient with combined aortic and mitral stenosis had severe systolic anterior motion of the anterior mitral leaflet and a residual large systolic pressure gradient between left ventricle and systemic artery after aortic valve replacement. In this patient the systolic anterior motion was evident in the presence of mitral valve stenosis. The other patient with mild aortic stenosis and a previously repaired coarctation of the aorta also had mild systolic anterior motion and a small subaortic systolic pressure gradient. Hence, these 2 patients demonstrate that disproportionate septal thickening secondary to acquired or congenital heart disease may be associated with left ventricular outflow obstruction and systolic anterior motion of the anterior mitral leaflet.

Effects of self-induced starvation on cardiac size and function in anorexia nervosa

Cardiac size, function and rhythm were examined in 11 patients with anorexia nervosa. Mean left ventricular, left atrial and aortic dimensions on echocardiogram were below normal adult values at baseline. In addition to decreased cardiac dimensions--ventricular ectopy, relative hypotension, bradycardia and blunted heart rate--response to exercise were noted. Left ventricular systolic function, however, was unimpaired as indicated by normal echocardiographic fractional shortening, and by normal exercise augmentation of ejection fraction determined by radionuclide cineangiography. Eight of the patients responded to treatment with a mean weight gain of 32%. In these eight, cardiac dimensions increased toward normal: left ventricular dimension increased by 13%; left atrial dimension by 20%; aortic dimension by 15% and estimated left ventricular mass by 20%. We conclude that abnormalities of heart size and rhythm occur in patients with anorexia nervosa. However, cardiac dimensions, including left ventricular mass, may increase following nutritional rehabilitation, accompanied by an increase in heart rate and blood pressure.

Noninvasive assessment of cardiac dysfunction in the cancer patient

The concepts of left ventricular function are reviewed with an emphasis on the pitfalls in the clinical assessment of myocardial performance. The application of noninvasive cardiac diagnostic techniques is discussed, including physical examination, systolic time intervals with external pulse recordings, echocardiography, and radionuclide cineangiography.

Cardiac manifestations in polymyositis

Twenty-one patients with polymyositis were prospectively examined with echocardiography, phonocardiography and electrocardiography. Cardiac performance, estimated with echocardiography, was enhanced as shown by a significant (P less than 0.01) increase in ejection phase indexes of left ventricular function compared with values in a matched control group. Known causes of the high output state, such as anemia or thyrotoxicosis, were not clinically evident. There was no evidence of left ventricular enlargement, left ventricular wall hypertrophy, or left atrial enlargement in the echocardiogram or chest X-ray film. The echocardiogram showed systolic mitral valve prolapse in 11 of 17 patients (65 percent) with an adequately imaged mitral valve; midsystolic clicks were present in 7 of these. One patient, who did not have prolapse, had echocardiographic evidence of a small pericardial effusion. Electrocardiographic abnormalities were present in 11 of 21 patients (52 percent) and included evidence of atrioventricular conduction disturbances, atrial and ventricular arrhythmias and left atrial abnormality. The pathophysiology of mitral valve prolapse and increased systolic left ventricular function in polymyositis remains uncertain; however, the spectrum of cardiac abnormalities, detected noninvasively in 16 of 21 of our patients (76 percent) may represent a high frequency rate of cardiac involvement in this disease.

Left ventricular outflow tract obstruction due to systolic anterior motion of the anterior mitral leaflet in patients with concentric left ventricular hypertrophy

Patients with hypertrophic cardiomyopathy (i.e., asymmetric septal hypertrophy) may show obstruction to left ventricular outflow under basal conditions or with provocative maneuvers. The presence of dynamic left ventricular outflow tract obstruction in patients with concentric ventricular wall thickening (but without abnormalities of the aortic valve) has been less well appreciated. Clinical and morphologic features of five patients with nondilated left ventricles and with left ventricular outflow obstruction are presented. In each patient peak systolic pressure gradients between left ventricle and systematic artery were measured at cardiac catheterization and ranged from 60-140 mm Hg under basal conditions or with provocation. Each patient had echocardiographically documented systolic anterior motion of the anterior mitral leaflet, which was apparently responsible for the outflow obstruction, and concentric left ventricular wall thickening (septal-free wall thickness ratio of less than 1.3). Two of the five patients had evidence of genetically transmitted hypertrophic cardiomyopathy, as evidenced by disorganized muscle cells in the ventricular septum or asymmetric septal hypertrophy in first degree relatives. Hence, left ventricular outflow tract obstruction associated with systolic anterior motion of the anterior mitral leaflet may occur in some patients with concentric left ventricular hypertrophy who do not have typical hypertrophic cardiomyopathy.

Mid-systolic click and mitral valve prolapse following mitral commissurotomy

Five patients with rheumatic mitral stenosis were observed to have mid-systolic clicks with murmurs of mitral regurgitation at various intervals after mitral commissurotomy. In two patients echocardiography showed an unusually rapid posterior deflection of the mitral valve coinciding exactly with a systolic nonejection click. It is speculated that the shortened, fused chordae tendineae, compromised by mitral commissurotomy, rigidly hold the valve leaflets fixed at the onset of systole. During systole, ventricular conformational changes, in the face of marginal coaptation of thickened and fibrotic mitral leaflets, allow the mitral valve to be forced abruptly towards the left atrium with great velocity. This is manifested by a loud systolic click and, in some patients, a near vertical posterior systolic deflection of the mitral valve on the echocardiogram. The systolic click may occur without echocardiographic or angiographic evidence of mitral valve prolapse. Unusually loud mid-systolic clicks can be heard in patients with rheumatic heart disease after mitral commissurotomy and may be accompanied by a distinctive echocardiographic appearance of the mitral valve.