1
|
Lin B, LeVee A, Cao L, Basho R, Tamarappoo B, Wei J, Shufelt C. Left ventricular global longitudinal strain is worse in BRCA mutation positive breast cancer patients prior to cancer treatment and premature menopause. Breast Cancer Res Treat 2024; 207:103-109. [PMID: 38717528 DOI: 10.1007/s10549-024-07344-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 04/10/2024] [Indexed: 07/09/2024]
Abstract
PURPOSE Breast cancer patients with mutations in human tumor suppressor genes BRCA1 and BRCA2 are at higher risk of cardiovascular disease (CVD) than the general population, as they are frequently exposed to cardiotoxic chemotherapy, anti-estrogen therapy, radiation, and/or oophorectomy for cancer-related treatment and prophylaxis. Animal and cell culture models suggest that BRCA mutations may play an independent role in heart failure. We sought to evaluate cardiac structure and function in female BRCA1 and BRCA2 mutation carriers with breast cancer compared to BRCA wildtype women with breast cancer. METHODS We performed a 1:2 age- and hypertension-matched retrospective cohort study comparing BRCA1 and BRCA2 mutation carriers (n = 38) versus BRCA wildtype controls (n = 76) with a new diagnosis of breast cancer. Echocardiographic data were obtained within 6 months of breast cancer diagnosis and prior to chemotherapy, anti-estrogen therapy, radiation, or oophorectomy. Left ventricular global longitudinal strain (LV-GLS), a highly sensitive marker of LV function, was measured using QLab 15 (Philips Healthcare). RESULTS In the total cohort of 114 patients with a new diagnosis of breast cancer, the median age was 45 ± 11 years and the prevalence of hypertension was 8%. There were no differences in traditional cardiovascular disease risk factors between cases and controls. BRCA carriers had lower LV-GLS (- 18.1% ± 4.7% vs. - 20.1% ± 3.8%, p = 0.02) and greater right atrial area (12.9 cm2 ± 2.7 cm2 vs. 11.8 cm2 ± 2.0 cm2, p = 0.04) compared to controls; however, both LV-GLS and right atrial area were within the normal range. Compared to controls, BRCA carriers had a trend toward worse LV posterior wall thickness (0.89 cm ± 0.15 cm vs. 0.83 cm ± 0.16 cm, p = 0.06) although not statistically significant. CONCLUSION In women with newly diagnosed breast cancer and prior to treatment, LV-GLS was worse in BRCA1 and BRCA2 mutation carriers compared to those with BRCA wildtype. These findings suggest that BRCA mutations may be associated with subtle changes in cardiac function. Whether differences in GLS translate to increased cardiovascular risk in women with BRCA mutations needs to be further characterized.
Collapse
Affiliation(s)
- Billy Lin
- Division of Cardiology, University of California Riverside, Riverside, CA, USA
- Department of Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Alexis LeVee
- Department of Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Louie Cao
- Department of Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Reva Basho
- Department of Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Ellison Institute of Technology, Los Angeles, CA, USA
| | - Balaji Tamarappoo
- Department of Cardiology, University of Arizona School of Medicine, Phoenix, AZ, USA
| | - Janet Wei
- Barbra Streisand Women's Heart Center, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, USA
| | - Chrisandra Shufelt
- Mayo Clinic Women's Health and Division of General Internal Medicine, Jacksonville, FL, USA.
| |
Collapse
|
2
|
Camilli M, Ferdinandy P, Salvatorelli E, Menna P, Minotti G. Anthracyclines, Diastolic Dysfunction and the road to Heart Failure in Cancer survivors: An untold story. Prog Cardiovasc Dis 2024:S0033-0620(24)00099-9. [PMID: 39025347 DOI: 10.1016/j.pcad.2024.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2024] [Accepted: 07/14/2024] [Indexed: 07/20/2024]
Abstract
Many cardiovascular diseases are characterized by diastolic dysfunction, which associates with worse clinical outcomes like overall mortality and hospitalization for heart failure (HF). Diastolic dysfunction has also been suspected to represent an early manifestation of cardiotoxicity induced by cancer drugs, with most of the information deriving from patients treated with anthracyclines; however, the prognostic implications of diastolic dysfunction in the anthracycline-treated patient have remained poorly explored or neglected. Here the molecular, pathophysiologic and diagnostic aspects of anthracycline-related diastolic dysfunction are reviewed in the light of HF incidence and phenotype in cancer survivors. We describe that the trajectories of diastolic dysfunction toward HF are influenced by a constellation of patient- or treatment- related factors, such as comorbidities and exposure to other cardiotoxic drugs or treatments, but also by prospective novel opportunities to treat diastolic dysfunction. The importance of a research-oriented multidimensional approach to patient surveillance or treatment is discussed within the framework of what appears to be a distinct pathophysiologic entity that develops early during anthracycline treatment and gradually worsens over the years.
Collapse
Affiliation(s)
- Massimiliano Camilli
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Péter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary; Pharmahungary Group, Szeged, Hungary; MTA-SE System Pharmacology Research Group, Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
| | | | - Pierantonio Menna
- Unit of Drug Sciences, University Campus Bio-Medico, Rome, Italy; Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Giorgio Minotti
- Unit of Drug Sciences, University Campus Bio-Medico, Rome, Italy; Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy.
| |
Collapse
|
3
|
Leger KJ, Absalon MJ, Demissei BG, Smith AM, Gerbing RB, Alonzo TA, Narayan HK, Hirsch BA, Pollard JA, Razzouk BI, Getz KD, Aplenc R, Kolb EA, Ky B, Cooper TM. Cardiotoxicity of CPX-351 in children and adolescents with relapsed AML: a Children's Oncology Group report. Front Cardiovasc Med 2024; 11:1347547. [PMID: 38947228 PMCID: PMC11211570 DOI: 10.3389/fcvm.2024.1347547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 05/07/2024] [Indexed: 07/02/2024] Open
Abstract
Introduction Anthracyclines are effective in treating acute myeloid leukemia (AML) but limited by cardiotoxicity. CPX-351, a liposomal daunorubicin and cytarabine, may provide therapeutic benefit with less cardiotoxicity. Acute changes in left ventricular systolic function and cardiac biomarkers were evaluated after a cycle of CPX-351 in children with relapsed AML treated on the phase 1/2 Children's Oncology Group study, AAML1421. Methods Subjects received 135 units/m2/dose of CPX-351 on days 1, 3, and 5 as cycle 1. Echocardiograms were performed and centrally quantitated at baseline and at the end of cycle 1 (day 29 +/- 1 week). High sensitivity troponin (hs-cTnT) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) were measured at baseline and serially through the end of cycle 1 (days 5, 8, 15, 22 and 29). Differences between baseline and post-CPX-351 echo/biomarker measures were analyzed using Wilcoxon signed rank tests. Linear regression was used to model post-CPX-351 left ventricular ejection fraction (LVEF) with cTnT/NT-proBNP at each time point, controlling for baseline LVEF. Cancer therapy related cardiac dysfunction (CTRCD) was defined as a decline in LVEF of ≥10%-<50%. Results Twenty-five of 38 heavily anthracycline pre-treated (median 348 mg/m2 daunorubicin equivalents) subjects enrolled on AAML1421 were included in the cardiac analyses. At baseline, centrally quantitated LVEF was <50% in 8 of 25 subjects (32%) with a median LVEF of 53.8% [48.0, 56.9]. Following CPX-351, LVEF declined significantly (ΔLVEF -3.3% [-7.8, 0]) and 6 of 25 subjects (24%) experienced CTRCD. Amongst all subjects, hs-cTnT was modestly increased at end of cycle 1 compared to baseline [baseline hs-cTnT 7.2 (3, 10.6); ΔcTnT 1.80 (0, 6.1), p = 0.03]. NT-proBNP remained stably elevated without significant change. No significant associations were seen between NT-proBNP or cTnT levels and post-CPX-351 LVEF. Discussion In this single arm study of anthracycline pre-treated children exposed to CPX-351, baseline abnormalities in cardiovascular function were prevalent. Following CPX-351, LVEF decreased, cTnT increased, and NT-proBNP did not change. Longer follow-up is needed to determine whether these changes result in clinically meaningful long-term decrements in cardiac function. An ongoing randomized trial of CPX-351 compared to standard anthracyclines in anthracycline naïve patients will provide further insight into the cardiac effects of CPX-351 (ClinicalTrials.gov; NCT04293562).
Collapse
Affiliation(s)
- Kasey J. Leger
- Division of Pediatric Hematology/Oncology, Seattle Children’s Hospital, University of Washington, Seattle, WA, United States
| | - Michael J. Absalon
- Department of Pediatrics, Oregon Health Sciences University, Portland, OR, United States
| | - Biniyam G. Demissei
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Amanda M. Smith
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | | | - Todd A. Alonzo
- Children’s Oncology Group, Monrovia, CA, United States
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA, United States
| | - Hari K. Narayan
- Department of Pediatrics, University of California San Diego, Rady Children’s Hospital San Diego, La Jolla, CA, United States
| | - Betsy A. Hirsch
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States
| | - Jessica A. Pollard
- Division of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Bassem I. Razzouk
- Department of Pediatrics, Peyton Manning Children’s Hospital at Ascension St. Vincent, Indianapolis, IN, United States
| | - Kelly D. Getz
- Departments of Biostatistics, Epidemiology & Informatics and Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Richard Aplenc
- Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - E. Anders Kolb
- Nemours Center for Cancer and Blood Disorders, A.I. DuPont Hospital for Children, Wilmington, DE, United States
| | - Bonnie Ky
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Todd M. Cooper
- Division of Pediatric Hematology/Oncology, Seattle Children’s Hospital, University of Washington, Seattle, WA, United States
| |
Collapse
|
4
|
Rankin S, Fountain C, Gemmell AJ, Quinn D, Henderson A, McClure J, Small S, Venugopal B, McKay P, Slomka PJ, Colville D, Petrie MC, Meléndez GC, Lang NN. Arterial effects of anthracycline: structural and inflammatory assessments in non-human primates and lymphoma patients using 18F-FDG positron emission tomography. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.05.30.596741. [PMID: 38895275 PMCID: PMC11185566 DOI: 10.1101/2024.05.30.596741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
Background Anthracyclines, such as doxorubicin, are important anti-cancer therapies but are associated with arterial injury. Histopathological insights have been limited to small animal models and the role of inflammation in the arterial toxic effects of anthracycline is unclear in humans. Our aims were: 1) To evaluate aortic media fibrosis and injury in non-human primates treated with anthracyclines; 2) To assess the effect of anthracycline on aortic inflammation in patients treated for lymphoma. Methods 1) African Green monkeys (AGM) received doxorubicin (30-60 mg/m2/biweekly IV, cumulative dose: 240 mg/m2). Blinded histopathologic analyses of collagen deposition and cell vacuolization in the ascending aorta were performed 15 weeks after the last doxorubicin dose and compared to 5 age- and gender-matched healthy, untreated AGMs. 2) Analysis of the thoracic aorta of patients with diffuse large B-cell lymphoma (DLBCL), at baseline and after doxorubicin exposure, was performed using 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) in this observational study. The primary outcome was change in maximal tissue-to-background ratio (TBRmax) of the thoracic aorta from baseline to their end-of-treatment clinical PET/CT. Results In AGMs, doxorubicin exposure was associated with greater aortic fibrosis (collagen deposition: doxorubicin cohort 6.23±0.88% vs. controls 4.67±0.54%; p=0.01) and increased intracellular vacuolization (doxorubicin 66.3 ± 10.1 vs controls 11.5 ± 4.2 vacuoles/field, p<0.0001) than untreated controls.In 101 patients with DLBCL, there was no change in aortic TBRmax after anthracycline exposure (pre-doxorubicin TBRmax 1.46±0.16 vs post-doxorubicin TBRmax 1.44±0.14, p=0.14). The absence of change in TBRmax was consistent across all univariate analyses. Conclusions In a large animal model, anthracycline exposure was associated with aortic fibrosis. In patients with lymphoma, anthracycline exposure was not associated with aortic inflammation.Further research is required to elucidate the mechanisms of anthracycline-related vascular harm.
Collapse
Affiliation(s)
- Stephen Rankin
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow UK
| | - Caitlin Fountain
- Departments of Internal Medicine, Section on Cardiology and Pathology, Section on Comparative Medicine. Wake Forest University School of Medicine, Winston-Salem, USA
| | - Alastair J Gemmell
- Department of Clinical Physics & Bioengineering, NHS Greater Glasgow & Clyde, Glasgow
- School of Medicine, Dentistry and Nursing, University of Glasgow
| | - Daire Quinn
- The Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Alasdair Henderson
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow UK
| | - John McClure
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow UK
| | - Sandy Small
- Department of Clinical Physics & Bioengineering, NHS Greater Glasgow & Clyde, Glasgow
- School of Medicine, Dentistry and Nursing, University of Glasgow
| | - Balaji Venugopal
- The Beatson West of Scotland Cancer Centre, Glasgow, UK
- School of Medicine, Dentistry and Nursing, University of Glasgow
| | - Pamela McKay
- The Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Piotr J Slomka
- Cedars-Sinai, Division of Artificial Intelligence in Medicine, Department of Medicine, Los Angeles, USA
| | - David Colville
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow UK
- School of Medicine, Dentistry and Nursing, University of Glasgow
| | - Mark C Petrie
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow UK
| | - Giselle C. Meléndez
- Departments of Internal Medicine, Section on Cardiology and Pathology, Section on Comparative Medicine. Wake Forest University School of Medicine, Winston-Salem, USA
| | - Ninian N Lang
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow UK
| |
Collapse
|
5
|
Beitzen-Heineke A, Rolling CC, Seidel C, Erley J, Molwitz I, Muellerleile K, Saering D, Senftinger J, Börschel N, Engel NW, Bokemeyer C, Adam G, Tahir E, Chen H. Long-term cardiotoxicity in germ cell cancer survivors after platinum-based chemotherapy: cardiac MR shows impaired systolic function and tissue alterations. Eur Radiol 2024; 34:4102-4112. [PMID: 37982836 PMCID: PMC11166766 DOI: 10.1007/s00330-023-10420-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 09/04/2023] [Accepted: 09/07/2023] [Indexed: 11/21/2023]
Abstract
OBJECTIVES Long-term toxicities of germ cell cancer (GCC) treatment are of particular importance in young men with a life expectancy of several decades after curative treatment. This study aimed to investigate the long-term effects of platinum-based chemotherapy on cardiac function and myocardial tissue in GCC survivors by cardiac magnetic resonance (CMR) imaging. METHODS Asymptomatic GCC survivors ≥ 3 years after platinum-based chemotherapy and age-matched healthy controls underwent CMR assessment, including left ventricular (LV) and right ventricular (RV) ejection fraction (EF), strain analysis, late gadolinium enhancement (LGE) imaging, and T1/T2 mapping. RESULTS Forty-four survivors (age 44 [interquartile range, IQR 37-52] years; follow-up time 10 [IQR 5-15] years after chemotherapy) and 21 controls were evaluated. LV- and RVEF were lower in GCC survivors compared to controls (LVEF 56 ± 5% vs. 59 ± 5%, p = 0.017; RVEF 50 ± 7% vs. 55 ± 7%, p = 0.008). Seven percent (3/44) of survivors showed reduced LVEF (< 50%), and 41% (18/44) showed borderline LVEF (50-54%). The strain analysis revealed significantly reduced deformation compared to controls (LV global longitudinal strain [GLS] -13 ± 2% vs. -15 ± 1%, p < 0.001; RV GLS -15 ± 4% vs. -19 ± 4%, p = 0.005). Tissue characterization revealed focal myocardial fibrosis in 9 survivors (20%) and lower myocardial native T1 times in survivors compared to controls (1202 ± 25 ms vs. 1226 ± 37 ms, p = 0.016). Attenuated LVEF was observed after two cycles of platinum-based chemotherapy (54 ± 5% vs. 62 ± 5%, p < 0.001). CONCLUSION Based on CMR evaluation, combination chemotherapy with cumulative cisplatin ≥ 200 mg/m2 is associated with attenuated biventricular systolic function and myocardial tissue alterations in asymptomatic long-term GCC survivors. CLINICAL RELEVANCE STATEMENT Platinum-based chemotherapy is associated with decreased systolic function, non-ischemic focal myocardial scar, and decreased T1 times in asymptomatic long-term germ cell cancer survivors. Clinicians should be particularly aware of the risk of cardiac toxicity after platinum-based chemotherapy. KEY POINTS • Platinum-based chemotherapy is associated with attenuation of biventricular systolic function, lower myocardial T1 relaxation times, and non-ischemic late gadolinium enhancement. • Decreased systolic function and non-ischemic late gadolinium enhancement are associated with a cumulative cisplatin dose of ≥ 200 mg/m2. • Cardiac MRI can help to identify chemotherapy-associated changes in cardiac function and tissue in asymptomatic long-term germ cell cancer survivors.
Collapse
Affiliation(s)
- Antonia Beitzen-Heineke
- Department for Oncology, Hematology and Bone Marrow Transplantation with the Section of Pneumology, University Medical Center Hamburg Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Christina Charlotte Rolling
- Department for Oncology, Hematology and Bone Marrow Transplantation with the Section of Pneumology, University Medical Center Hamburg Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Christoph Seidel
- Department for Oncology, Hematology and Bone Marrow Transplantation with the Section of Pneumology, University Medical Center Hamburg Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Jennifer Erley
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Isabel Molwitz
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Kai Muellerleile
- Department of General and Interventional Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Dennis Saering
- Information Technology and Image Processing, University of Applied Sciences Wedel, Wedel, Germany
| | - Juliana Senftinger
- Department of General and Interventional Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Niklas Börschel
- Department for Oncology, Hematology and Bone Marrow Transplantation with the Section of Pneumology, University Medical Center Hamburg Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Nils Wolfgang Engel
- Department for Oncology, Hematology and Bone Marrow Transplantation with the Section of Pneumology, University Medical Center Hamburg Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Carsten Bokemeyer
- Department for Oncology, Hematology and Bone Marrow Transplantation with the Section of Pneumology, University Medical Center Hamburg Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Gerhard Adam
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Enver Tahir
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Hang Chen
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital Hamburg Eppendorf, Hamburg, Germany
| |
Collapse
|
6
|
Deshmukh T, Selvakumar D, Thavapalachandran S, Archer O, Figtree GA, Feneley M, Grieve SM, Thomas L, Pathan F, Chong JJH. Correlation of Noninvasive Cardiac MRI Measures of Left Ventricular Myocardial Function and Invasive Pressure-Volume Parameters in a Porcine Ischemia-Reperfusion Model. Radiol Cardiothorac Imaging 2024; 6:e230252. [PMID: 38842454 PMCID: PMC11211950 DOI: 10.1148/ryct.230252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 03/24/2024] [Accepted: 05/03/2024] [Indexed: 06/07/2024]
Abstract
Purpose To assess the correlation between noninvasive cardiac MRI-derived parameters with pressure-volume (PV) loop data and evaluate changes in left ventricular function after myocardial infarction (MI). Materials and Methods Sixteen adult female swine were induced with MI, with six swine used as controls and 10 receiving platelet-derived growth factor-AB (PDGF-AB). Load-independent measures of cardiac function, including slopes of end-systolic pressure-volume relationship (ESPVR) and preload recruitable stroke work (PRSW), were obtained on day 28 after MI. Cardiac MRI was performed on day 2 and day 28 after infarct. Global longitudinal strain (GLS) and global circumferential strain (GCS) were measured. Ventriculo-arterial coupling (VAC) was derived from PV loop and cardiac MRI data. Pearson correlation analysis was performed. Results GCS (r = 0.60, P = .01), left ventricular ejection fraction (LVEF) (r = 0.60, P = .01), and cardiac MRI-derived VAC (r = 0.61, P = .01) had a significant linear relationship with ESPVR. GCS (r = 0.75, P < .001) had the strongest significant linear relationship with PRSW, followed by LVEF (r = 0.67, P = .005) and cardiac MRI-derived VAC (r = 0.60, P = .01). GLS was not significantly correlated with ESPVR or PRSW. There was a linear correlation (r = 0.82, P < .001) between VAC derived from cardiac MRI and from PV loop data. GCS (-3.5% ± 2.3 vs 0.5% ± 1.4, P = .007) and cardiac MRI-derived VAC (-0.6 ± 0.6 vs 0.3 ± 0.3, P = .001) significantly improved in the animals treated with PDGF-AB 28 days after MI compared with controls. Conclusion Cardiac MRI-derived parameters of MI correlated with invasive PV measures, with GCS showing the strongest correlation. Cardiac MRI-derived measures also demonstrated utility in assessing therapeutic benefit using PDGF-AB. Keywords: Cardiac MRI, Myocardial Infarction, Pressure Volume Loop, Strain Imaging, Ventriculo-arterial Coupling Supplemental material is available for this article. © RSNA, 2024.
Collapse
Affiliation(s)
- Tejas Deshmukh
- From the Centre for Heart Research, Westmead Institute for Medical
Research, 176 Hawkesbury Rd, Westmead, Sydney, NSW 2145, Australia (T.D., D.S.,
S.T., J.J.H.C.); Department of Cardiology, Westmead Hospital, Westmead,
Australia (T.D., D.S., S.T., O.A., L.T., J.J.H.C.); Sydney School of Health
Sciences, Faculty of Medicine and Health, University of Sydney, Sydney,
Australia (T.D., D.S., S.T., L.T., J.J.H.C.); Cardiovascular Discovery Group,
Kolling Institute, University of Sydney and Royal North Shore Hospital, St
Leonards, Sydney, Australia (G.A.F.); Department of Cardiology, St
Vincent’s Hospital, Darlinghurst, Australia (M.F.); Cardiac Mechanics
Laboratory, Victor Chang Cardiac Research Institute, Darlinghurst, Australia
(M.F.); Imaging and Phenotyping Laboratory, Faculty of Medicine and Health,
Charles Perkins Centre, University of Sydney, Sydney, Australia (S.M.G.);
Department of Radiology, Royal Prince Alfred Hospital, Camperdown, Australia
(S.M.G.); Nepean Clinical School of Medicine, Charles Perkin Centre Nepean,
University of Sydney, Kingswood, Australia (F.P.); and Department of Cardiology,
Nepean Hospital, Kingswood, Australia (F.P.)
| | - Dinesh Selvakumar
- From the Centre for Heart Research, Westmead Institute for Medical
Research, 176 Hawkesbury Rd, Westmead, Sydney, NSW 2145, Australia (T.D., D.S.,
S.T., J.J.H.C.); Department of Cardiology, Westmead Hospital, Westmead,
Australia (T.D., D.S., S.T., O.A., L.T., J.J.H.C.); Sydney School of Health
Sciences, Faculty of Medicine and Health, University of Sydney, Sydney,
Australia (T.D., D.S., S.T., L.T., J.J.H.C.); Cardiovascular Discovery Group,
Kolling Institute, University of Sydney and Royal North Shore Hospital, St
Leonards, Sydney, Australia (G.A.F.); Department of Cardiology, St
Vincent’s Hospital, Darlinghurst, Australia (M.F.); Cardiac Mechanics
Laboratory, Victor Chang Cardiac Research Institute, Darlinghurst, Australia
(M.F.); Imaging and Phenotyping Laboratory, Faculty of Medicine and Health,
Charles Perkins Centre, University of Sydney, Sydney, Australia (S.M.G.);
Department of Radiology, Royal Prince Alfred Hospital, Camperdown, Australia
(S.M.G.); Nepean Clinical School of Medicine, Charles Perkin Centre Nepean,
University of Sydney, Kingswood, Australia (F.P.); and Department of Cardiology,
Nepean Hospital, Kingswood, Australia (F.P.)
| | - Sujitha Thavapalachandran
- From the Centre for Heart Research, Westmead Institute for Medical
Research, 176 Hawkesbury Rd, Westmead, Sydney, NSW 2145, Australia (T.D., D.S.,
S.T., J.J.H.C.); Department of Cardiology, Westmead Hospital, Westmead,
Australia (T.D., D.S., S.T., O.A., L.T., J.J.H.C.); Sydney School of Health
Sciences, Faculty of Medicine and Health, University of Sydney, Sydney,
Australia (T.D., D.S., S.T., L.T., J.J.H.C.); Cardiovascular Discovery Group,
Kolling Institute, University of Sydney and Royal North Shore Hospital, St
Leonards, Sydney, Australia (G.A.F.); Department of Cardiology, St
Vincent’s Hospital, Darlinghurst, Australia (M.F.); Cardiac Mechanics
Laboratory, Victor Chang Cardiac Research Institute, Darlinghurst, Australia
(M.F.); Imaging and Phenotyping Laboratory, Faculty of Medicine and Health,
Charles Perkins Centre, University of Sydney, Sydney, Australia (S.M.G.);
Department of Radiology, Royal Prince Alfred Hospital, Camperdown, Australia
(S.M.G.); Nepean Clinical School of Medicine, Charles Perkin Centre Nepean,
University of Sydney, Kingswood, Australia (F.P.); and Department of Cardiology,
Nepean Hospital, Kingswood, Australia (F.P.)
| | - Oliver Archer
- From the Centre for Heart Research, Westmead Institute for Medical
Research, 176 Hawkesbury Rd, Westmead, Sydney, NSW 2145, Australia (T.D., D.S.,
S.T., J.J.H.C.); Department of Cardiology, Westmead Hospital, Westmead,
Australia (T.D., D.S., S.T., O.A., L.T., J.J.H.C.); Sydney School of Health
Sciences, Faculty of Medicine and Health, University of Sydney, Sydney,
Australia (T.D., D.S., S.T., L.T., J.J.H.C.); Cardiovascular Discovery Group,
Kolling Institute, University of Sydney and Royal North Shore Hospital, St
Leonards, Sydney, Australia (G.A.F.); Department of Cardiology, St
Vincent’s Hospital, Darlinghurst, Australia (M.F.); Cardiac Mechanics
Laboratory, Victor Chang Cardiac Research Institute, Darlinghurst, Australia
(M.F.); Imaging and Phenotyping Laboratory, Faculty of Medicine and Health,
Charles Perkins Centre, University of Sydney, Sydney, Australia (S.M.G.);
Department of Radiology, Royal Prince Alfred Hospital, Camperdown, Australia
(S.M.G.); Nepean Clinical School of Medicine, Charles Perkin Centre Nepean,
University of Sydney, Kingswood, Australia (F.P.); and Department of Cardiology,
Nepean Hospital, Kingswood, Australia (F.P.)
| | - Gemma A. Figtree
- From the Centre for Heart Research, Westmead Institute for Medical
Research, 176 Hawkesbury Rd, Westmead, Sydney, NSW 2145, Australia (T.D., D.S.,
S.T., J.J.H.C.); Department of Cardiology, Westmead Hospital, Westmead,
Australia (T.D., D.S., S.T., O.A., L.T., J.J.H.C.); Sydney School of Health
Sciences, Faculty of Medicine and Health, University of Sydney, Sydney,
Australia (T.D., D.S., S.T., L.T., J.J.H.C.); Cardiovascular Discovery Group,
Kolling Institute, University of Sydney and Royal North Shore Hospital, St
Leonards, Sydney, Australia (G.A.F.); Department of Cardiology, St
Vincent’s Hospital, Darlinghurst, Australia (M.F.); Cardiac Mechanics
Laboratory, Victor Chang Cardiac Research Institute, Darlinghurst, Australia
(M.F.); Imaging and Phenotyping Laboratory, Faculty of Medicine and Health,
Charles Perkins Centre, University of Sydney, Sydney, Australia (S.M.G.);
Department of Radiology, Royal Prince Alfred Hospital, Camperdown, Australia
(S.M.G.); Nepean Clinical School of Medicine, Charles Perkin Centre Nepean,
University of Sydney, Kingswood, Australia (F.P.); and Department of Cardiology,
Nepean Hospital, Kingswood, Australia (F.P.)
| | - Michael Feneley
- From the Centre for Heart Research, Westmead Institute for Medical
Research, 176 Hawkesbury Rd, Westmead, Sydney, NSW 2145, Australia (T.D., D.S.,
S.T., J.J.H.C.); Department of Cardiology, Westmead Hospital, Westmead,
Australia (T.D., D.S., S.T., O.A., L.T., J.J.H.C.); Sydney School of Health
Sciences, Faculty of Medicine and Health, University of Sydney, Sydney,
Australia (T.D., D.S., S.T., L.T., J.J.H.C.); Cardiovascular Discovery Group,
Kolling Institute, University of Sydney and Royal North Shore Hospital, St
Leonards, Sydney, Australia (G.A.F.); Department of Cardiology, St
Vincent’s Hospital, Darlinghurst, Australia (M.F.); Cardiac Mechanics
Laboratory, Victor Chang Cardiac Research Institute, Darlinghurst, Australia
(M.F.); Imaging and Phenotyping Laboratory, Faculty of Medicine and Health,
Charles Perkins Centre, University of Sydney, Sydney, Australia (S.M.G.);
Department of Radiology, Royal Prince Alfred Hospital, Camperdown, Australia
(S.M.G.); Nepean Clinical School of Medicine, Charles Perkin Centre Nepean,
University of Sydney, Kingswood, Australia (F.P.); and Department of Cardiology,
Nepean Hospital, Kingswood, Australia (F.P.)
| | - Stuart M. Grieve
- From the Centre for Heart Research, Westmead Institute for Medical
Research, 176 Hawkesbury Rd, Westmead, Sydney, NSW 2145, Australia (T.D., D.S.,
S.T., J.J.H.C.); Department of Cardiology, Westmead Hospital, Westmead,
Australia (T.D., D.S., S.T., O.A., L.T., J.J.H.C.); Sydney School of Health
Sciences, Faculty of Medicine and Health, University of Sydney, Sydney,
Australia (T.D., D.S., S.T., L.T., J.J.H.C.); Cardiovascular Discovery Group,
Kolling Institute, University of Sydney and Royal North Shore Hospital, St
Leonards, Sydney, Australia (G.A.F.); Department of Cardiology, St
Vincent’s Hospital, Darlinghurst, Australia (M.F.); Cardiac Mechanics
Laboratory, Victor Chang Cardiac Research Institute, Darlinghurst, Australia
(M.F.); Imaging and Phenotyping Laboratory, Faculty of Medicine and Health,
Charles Perkins Centre, University of Sydney, Sydney, Australia (S.M.G.);
Department of Radiology, Royal Prince Alfred Hospital, Camperdown, Australia
(S.M.G.); Nepean Clinical School of Medicine, Charles Perkin Centre Nepean,
University of Sydney, Kingswood, Australia (F.P.); and Department of Cardiology,
Nepean Hospital, Kingswood, Australia (F.P.)
| | - Liza Thomas
- From the Centre for Heart Research, Westmead Institute for Medical
Research, 176 Hawkesbury Rd, Westmead, Sydney, NSW 2145, Australia (T.D., D.S.,
S.T., J.J.H.C.); Department of Cardiology, Westmead Hospital, Westmead,
Australia (T.D., D.S., S.T., O.A., L.T., J.J.H.C.); Sydney School of Health
Sciences, Faculty of Medicine and Health, University of Sydney, Sydney,
Australia (T.D., D.S., S.T., L.T., J.J.H.C.); Cardiovascular Discovery Group,
Kolling Institute, University of Sydney and Royal North Shore Hospital, St
Leonards, Sydney, Australia (G.A.F.); Department of Cardiology, St
Vincent’s Hospital, Darlinghurst, Australia (M.F.); Cardiac Mechanics
Laboratory, Victor Chang Cardiac Research Institute, Darlinghurst, Australia
(M.F.); Imaging and Phenotyping Laboratory, Faculty of Medicine and Health,
Charles Perkins Centre, University of Sydney, Sydney, Australia (S.M.G.);
Department of Radiology, Royal Prince Alfred Hospital, Camperdown, Australia
(S.M.G.); Nepean Clinical School of Medicine, Charles Perkin Centre Nepean,
University of Sydney, Kingswood, Australia (F.P.); and Department of Cardiology,
Nepean Hospital, Kingswood, Australia (F.P.)
| | | | | |
Collapse
|
7
|
Gamarra A, Díez-Villanueva P, Salamanca J, Aguilar R, Mahía P, Alfonso F. Development and Clinical Application of Left Ventricular-Arterial Coupling Non-Invasive Assessment Methods. J Cardiovasc Dev Dis 2024; 11:141. [PMID: 38786963 PMCID: PMC11122267 DOI: 10.3390/jcdd11050141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 04/26/2024] [Accepted: 04/29/2024] [Indexed: 05/25/2024] Open
Abstract
The constant and dynamic interaction between ventricular function and arterial afterload, known as ventricular-arterial coupling, is key to understanding cardiovascular pathophysiology. Ventricular-arterial coupling has traditionally been assessed invasively as the ratio of effective arterial elastance over end-systolic elastance (Ea/Ees), calculated from information derived from pressure-volume loops. Over the past few decades, numerous invasive and non-invasive simplified methods to estimate the elastance ratio have been developed and applied in clinical investigation and practice. The echocardiographic assessment of left ventricular Ea/Ees, as proposed by Chen and colleagues, is the most widely used method, but novel echocardiographic approaches for ventricular-arterial evaluation such as left ventricle outflow acceleration, pulse-wave velocity, and the global longitudinal strain or global work index have arisen since the former was first published. Moreover, multimodal imaging or artificial intelligence also seems to be useful in this matter. This review depicts the progressive development of these methods along with their academic and clinical application. The left ventricular-arterial coupling assessment may help both identify patients at risk and tailor specific pharmacological or interventional treatments.
Collapse
Affiliation(s)
- Alvaro Gamarra
- Cardiology Department, Hospital Universitario de la Princesa, 28006 Madrid, Spain; (A.G.); (J.S.); (R.A.); (F.A.)
| | - Pablo Díez-Villanueva
- Cardiology Department, Hospital Universitario de la Princesa, 28006 Madrid, Spain; (A.G.); (J.S.); (R.A.); (F.A.)
| | - Jorge Salamanca
- Cardiology Department, Hospital Universitario de la Princesa, 28006 Madrid, Spain; (A.G.); (J.S.); (R.A.); (F.A.)
| | - Rio Aguilar
- Cardiology Department, Hospital Universitario de la Princesa, 28006 Madrid, Spain; (A.G.); (J.S.); (R.A.); (F.A.)
| | - Patricia Mahía
- Cardiology Department, Hospital Clínico San Carlos, 28040 Madrid, Spain;
| | - Fernando Alfonso
- Cardiology Department, Hospital Universitario de la Princesa, 28006 Madrid, Spain; (A.G.); (J.S.); (R.A.); (F.A.)
| |
Collapse
|
8
|
Lin J, Fan A, Yifu Z, Xie Q, Hong L, Zhou W. BTF3L4 Overexpression Mediates APAP-induced Liver Injury in Mouse and Cellular Models. J Clin Transl Hepatol 2024; 12:245-256. [PMID: 38426192 PMCID: PMC10899873 DOI: 10.14218/jcth.2023.00342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 11/01/2023] [Accepted: 11/17/2023] [Indexed: 03/02/2024] Open
Abstract
Background and Aims Acetaminophen (APAP)-induced liver injury (AILI) has an increasing incidence worldwide. However, the mechanisms contributing to such liver injury are largely unknown and no targeted therapy is currently available. The study aimed to investigate the effect of BTF3L4 overexpression on apoptosis and inflammation regulation in vitro and in vivo. Methods We performed a proteomic analysis of the AILI model and found basic transcription factor 3 like 4 (BTF3L4) was the only outlier transcription factor overexpressed in the AILI model in mice. BTF3L4 overexpression increased the degree of liver injury in the AILI model. Results BTF3L4 exerts its pathogenic effect by inducing an inflammatory response and damaging mitochondrial function. Increased BTF3L4 expression increases the degree of apoptosis, reactive oxygen species generation, and oxidative stress, which induces cell death and liver injury. The damage of mitochondrial function by BTF3L4 triggers a cascade of events, including reactive oxygen species accumulation and oxidative stress. According to the available AILI data, BTF3L4 expression is positively associated with inflammation and may be a potential biomarker of AILI. Conclusions Our results suggest that BTF3L4 is a pathogenic factor in AILI and may be a potential diagnostic maker for AILI.
Collapse
Affiliation(s)
- Junchao Lin
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Air Force Military Medical University, Xi’an, Shaanxi, China
| | - Aqiang Fan
- Department of Digestive Surgery, Xijing Hospital, Air Force Military Medical University, Xi’an, Shaanxi, China
| | - Zhujin Yifu
- Department of Digestive Surgery, Xijing Hospital, Air Force Military Medical University, Xi’an, Shaanxi, China
| | - Qibing Xie
- Department of Digestive Surgery, Xijing Hospital, Air Force Military Medical University, Xi’an, Shaanxi, China
| | - Liu Hong
- Department of Digestive Surgery, Xijing Hospital, Air Force Military Medical University, Xi’an, Shaanxi, China
| | - Wei Zhou
- Department of Digestive Surgery, Xijing Hospital, Air Force Military Medical University, Xi’an, Shaanxi, China
| |
Collapse
|
9
|
Lassen MCH, Arya F, Biering-Sørensen T, Reeh JLT, Melisko ME, Sarwary S, Baik AH, Aras MA, Qasim A. Left atrial strain is reduced following trastuzumab in breast cancer patients. Echocardiography 2024; 41:e15751. [PMID: 38284677 DOI: 10.1111/echo.15751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 12/11/2023] [Accepted: 01/02/2024] [Indexed: 01/30/2024] Open
Abstract
BACKGROUND The effect of trastuzumab therapy on left atrial (LA) function remains largely unknown. Our aim was to assess the changes in LA strain parameters longitudinally in patients treated with trastuzumab. METHODS We retrospectively studied 170 patients with stage I-IV HER2+ breast cancer. All patients had baseline echocardiograms and repeat echocardiograms at 3 months and after 1 year. We measured LA strain at all three time points. Changes in LA strain and strain rate (sr) parameters were evaluated using repeated-measures mixed-effects models. The cohort was stratified according to development of cancer therapeutics-related cardiac dysfunction (CTRCD) during follow-up. RESULTS The mean age was 52.7 ± 13.8 years, 25.3% had hypertension and 16.0% had metastatic disease. Multiple LA strain parameters (predicted delta value, [95%CI]) showed statistically significant declines in patients who developed CTRCD from baseline to the 3-month follow-up after multivariable adjustment; LA reservoir strain (LAεres ): -4.7%; [-8.1% to -1.3%], p = .007; LA conduit strain (LAεcon ): -2.8%; [-5.3% to -.4%], p = .021); and LAεres sr: -.2/s; [-.3/s to -.09/s], p < .001). In patients who did not develop CTRCD, LA strain parameters declined significantly but to a smaller degree than in the CTRCD group (LAεres : -1.7%; [-3.1% to -.3%], p = .020, LAεcon : -2.2%; [-3.3% to -1.1%], p < .001, and LA booster pump strain : -2.4%; [-3.5% to -1.4%], p < .001). LA strain rates did not decline significantly in the non-CTRCD group. CONCLUSION Trastuzumab treatment was associated with declines in LA strain parameters in patients with breast cancer. The largest declines were observed in patients who developed CTRCD during treatment.
Collapse
Affiliation(s)
- Mats C Højbjerg Lassen
- Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Farzin Arya
- Department of Medicine, Division of Cardiology, UCSF Medical Center, University of California San Francisco, San Francisco, California, USA
| | - Tor Biering-Sørensen
- Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jacob L T Reeh
- Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Michelle E Melisko
- Department of Medicine, Division of Hematology & Oncology, UCSF Medical Center, University of California San Francisco, San Francisco, California, USA
| | - Shabir Sarwary
- Department of Medicine, Division of Cardiology, UCSF Medical Center, University of California San Francisco, San Francisco, California, USA
| | - Alan H Baik
- Department of Medicine, Division of Cardiology, UCSF Medical Center, University of California San Francisco, San Francisco, California, USA
| | - Mandar A Aras
- Department of Medicine, Division of Cardiology, UCSF Medical Center, University of California San Francisco, San Francisco, California, USA
| | - Atif Qasim
- Department of Medicine, Division of Cardiology, UCSF Medical Center, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
10
|
Addison D, Neilan TG, Barac A, Scherrer-Crosbie M, Okwuosa TM, Plana JC, Reding KW, Taqueti VR, Yang EH, Zaha VG. Cardiovascular Imaging in Contemporary Cardio-Oncology: A Scientific Statement From the American Heart Association. Circulation 2023; 148:1271-1286. [PMID: 37732422 DOI: 10.1161/cir.0000000000001174] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
Advances in cancer therapeutics have led to dramatic improvements in survival, now inclusive of nearly 20 million patients and rising. However, cardiovascular toxicities associated with specific cancer therapeutics adversely affect the outcomes of patients with cancer. Advances in cardiovascular imaging have solidified the critical role for robust methods for detecting, monitoring, and prognosticating cardiac risk among patients with cancer. However, decentralized evaluations have led to a lack of consensus on the optimal uses of imaging in contemporary cancer treatment (eg, immunotherapy, targeted, or biological therapy) settings. Similarly, available isolated preclinical and clinical studies have provided incomplete insights into the effectiveness of multiple modalities for cardiovascular imaging in cancer care. The aims of this scientific statement are to define the current state of evidence for cardiovascular imaging in the cancer treatment and survivorship settings and to propose novel methodological approaches to inform the optimal application of cardiovascular imaging in future clinical trials and registries. We also propose an evidence-based integrated approach to the use of cardiovascular imaging in routine clinical settings. This scientific statement summarizes and clarifies available evidence while providing guidance on the optimal uses of multimodality cardiovascular imaging in the era of emerging anticancer therapies.
Collapse
|
11
|
Ardelean AM, Olariu IC, Isac R, Nalla A, Jurac R, Stolojanu C, Murariu M, Fericean RM, Braescu L, Mavrea A, Dumitru C, Doros G. Impact of Cancer Type and Treatment Protocol on Cardiac Function in Pediatric Oncology Patients: An Analysis Utilizing Speckle Tracking, Global Longitudinal Strain, and Myocardial Performance Index. Diagnostics (Basel) 2023; 13:2830. [PMID: 37685367 PMCID: PMC10486976 DOI: 10.3390/diagnostics13172830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 08/15/2023] [Accepted: 08/30/2023] [Indexed: 09/10/2023] Open
Abstract
Pediatric hemato-oncology patients undergoing anthracycline therapy are at risk of cardiotoxicity, with disease type and treatment intensity potentially affecting cardiac function. Novel echocardiographic measures like speckle tracking echocardiography (STE), global longitudinal strain (GLS), and the myocardial performance index (MPI) may predict early changes in cardiac function not detected by traditional methods. This study aimed to assess the impact of cancer type and treatment protocol on these parameters and their potential in predicting long-term cardiac complications. We conducted a single-center, retrospective cohort study of 99 pediatric oncology patients and 46 controls that were assessed at 3, 6, and 12 months. The median age was 10.7 ± 4.4 years for cases and 10.2 ± 3.6 years for controls. STE, GLS, and MPI were measured, and statistical analyses were performed to determine any significant correlations with cardiotoxicity. Significant variations were observed in traditional cardiac function measurements between the patient and control groups, with a lower average ejection fraction (EF) of 62.8 ± 5.7% in patients vs. 66.4 ± 6.1% in controls (p < 0.001), poorer GLS of -16.3 ± 5.1 in patients compared to -19.0 ± 5.4 in controls (p = 0.004), and higher MPI values of 0.37 ± 0.06 in patients compared to 0.55 ± 0.10 in controls, indicating worse overall cardiac function (p < 0.001). However, differences in cardiac function measurements by cancer histology or treatment protocol were not statistically significant. Regression analyses showed that the combination of GLS, SMOD, and MPI increased the odds of cardiac toxicity with an odds ratio of 7.30 (95% CI: 2.65-12.81, p < 0.001). The study underscores the predictive value of the combined GLS, SMOD, and MPI measurements in pediatric oncology patients undergoing anthracycline treatment for cardiotoxicity. Although variations across cancer types and treatment protocols were not significant, the study emphasizes the potential utility of these novel echocardiographic measures in early detection and long-term prediction of anthracycline-induced cardiotoxicity. Further studies in larger, multi-center cohorts are required for validation.
Collapse
Affiliation(s)
- Andrada Mara Ardelean
- Department of Pediatrics, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (A.M.A.); (I.C.O.); (R.I.); (R.J.); (G.D.)
- Doctoral School, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (C.S.); (M.M.); (R.M.F.); (L.B.)
- Louis Turcanu Emergency Hospital for Children, Iosif Nemoianu Street 2, 300011 Timișoara, Romania
| | - Ioana Cristina Olariu
- Department of Pediatrics, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (A.M.A.); (I.C.O.); (R.I.); (R.J.); (G.D.)
- Louis Turcanu Emergency Hospital for Children, Iosif Nemoianu Street 2, 300011 Timișoara, Romania
| | - Raluca Isac
- Department of Pediatrics, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (A.M.A.); (I.C.O.); (R.I.); (R.J.); (G.D.)
- Louis Turcanu Emergency Hospital for Children, Iosif Nemoianu Street 2, 300011 Timișoara, Romania
| | - Akhila Nalla
- Department of General Medicine, MNR Medical College, Sangareddy 502294, Telangana, India;
| | - Ruxandra Jurac
- Department of Pediatrics, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (A.M.A.); (I.C.O.); (R.I.); (R.J.); (G.D.)
- Louis Turcanu Emergency Hospital for Children, Iosif Nemoianu Street 2, 300011 Timișoara, Romania
| | - Cristiana Stolojanu
- Doctoral School, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (C.S.); (M.M.); (R.M.F.); (L.B.)
- Louis Turcanu Emergency Hospital for Children, Iosif Nemoianu Street 2, 300011 Timișoara, Romania
| | - Mircea Murariu
- Doctoral School, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (C.S.); (M.M.); (R.M.F.); (L.B.)
- Louis Turcanu Emergency Hospital for Children, Iosif Nemoianu Street 2, 300011 Timișoara, Romania
| | - Roxana Manuela Fericean
- Doctoral School, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (C.S.); (M.M.); (R.M.F.); (L.B.)
- Methodological and Infectious Diseases Research Center, Department of Infectious Diseases, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Laurentiu Braescu
- Doctoral School, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (C.S.); (M.M.); (R.M.F.); (L.B.)
- Department of Cardiovascular Surgery, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania
- Center for Translational Research and Systems Medicine (CERT-MEDS), “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Adelina Mavrea
- Department of Internal Medicine I, Cardiology Clinic, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Catalin Dumitru
- Department of Obstetrics and Gynecology, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania;
| | - Gabriela Doros
- Department of Pediatrics, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (A.M.A.); (I.C.O.); (R.I.); (R.J.); (G.D.)
- Louis Turcanu Emergency Hospital for Children, Iosif Nemoianu Street 2, 300011 Timișoara, Romania
| |
Collapse
|
12
|
Zuo ML, Chen QY, Pu L, Shi L, Wu D, Li H, Luo X, Yin LX, Siu CW, Hong DQ, Gan H. Impact of Hemodialysis on Left Ventricular-Arterial Coupling in End-Stage Renal Disease Patients. Blood Purif 2023; 52:702-711. [PMID: 37579725 DOI: 10.1159/000531188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 05/18/2023] [Indexed: 08/16/2023]
Abstract
INTRODUCTION As a key determinant of cardiovascular performance, vascular-arterial coupling (VAC) has been reported to be a predictor of clinical outcomes in various clinical scenarios. However, few studies have explored how acute fluid removal during hemodialysis (HD) impacts the interaction between cardiac function and the arterial system. METHODS We recruited 317 HD patients from an established renal dialysis unit for this cross-sectional study and a total of 285 were included in the final analyses. We measured left ventricle end-systolic elastance (Ees), the effective arterial elastance (Ea), and VAC before and after HD using noninvasive echocardiographic measurements. We also compared echocardiographic and hemodynamic parameters in ventriculo-arterial coupling and ventriculo-arterial uncoupling patients. RESULTS HD significantly altered partial ventricular and vascular function parameters such as blood pressure, left ventricular end-diastolic volume, stroke volume, left ventricular ejection fraction, and systemic vascular resistance index. Ea increased following HD from 3.5 ± 1.4 to 4.2 ± 1.8 mm Hg/mL (p < 0.0001), Ees increased following HD from 7.9 ± 5.5 to 9.2 ± 6.9 mm Hg/mL (p = 0.04), whereas VAC did not markedly alter as a result of HD. Ventriculo-arterial uncoupling was found to be related to abnormal cardiac structure and worse systolic function. CONCLUSIONS VAC obtained from echocardiography is likely to be load-independent and useful as a reliable index for stratifying the risk of cardiovascular diseases in HD patients. Further investigations on larger patient cohorts are needed to further validate our findings.
Collapse
Affiliation(s)
- Ming-Liang Zuo
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China,
| | - Qiu-Yi Chen
- Cardiovascular Ultrasound and Non-Invasive Cardiology Department, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Lei Pu
- Department of Nephrology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Lan Shi
- Cardiovascular Ultrasound and Non-Invasive Cardiology Department, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Dan Wu
- Cardiovascular Ultrasound and Non-Invasive Cardiology Department, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Hua Li
- Cardiovascular Ultrasound and Non-Invasive Cardiology Department, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Xian Luo
- Cardiovascular Ultrasound and Non-Invasive Cardiology Department, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Li-Xue Yin
- Cardiovascular Ultrasound and Non-Invasive Cardiology Department, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Chung-Wah Siu
- Cardiology Division, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong, China
| | - Da-Qing Hong
- Department of Nephrology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Hua Gan
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| |
Collapse
|
13
|
Leo I, Vidula M, Bisaccia G, Procopio MC, Licordari R, Perotto M, La Vecchia G, Miaris N, Bravo PE, Bucciarelli-Ducci C. The Role of Advanced Cardiovascular Imaging Modalities in Cardio-Oncology: From Early Detection to Unravelling Mechanisms of Cardiotoxicity. J Clin Med 2023; 12:4945. [PMID: 37568347 PMCID: PMC10419705 DOI: 10.3390/jcm12154945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 07/19/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
Advances in cancer therapies have led to a global improvement in patient survival rates. Nevertheless, the price to pay is a concomitant increase in cardiovascular (CV) morbidity and mortality in this population. Increased inflammation and disturbances of the immune system are shared by both cancer and CV diseases. Immunological effects of anti-cancer treatments occur with both conventional chemotherapy and, to a greater extent, with novel biological therapies such as immunotherapy. For these reasons, there is growing interest in the immune system and its potential role at the molecular level in determining cardiotoxicity. Early recognition of these detrimental effects could help in identifying patients at risk and improve their oncological management. Non-invasive imaging already plays a key role in evaluating baseline CV risk and in detecting even subclinical cardiac dysfunction during surveillance. The aim of this review is to highlight the role of advanced cardiovascular imaging techniques in the detection and management of cardiovascular complications related to cancer treatment.
Collapse
Affiliation(s)
- Isabella Leo
- Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK; (I.L.)
- Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy
| | - Mahesh Vidula
- Division of Cardiovascular Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA (P.E.B.)
- Divisions of Nuclear Medicine and Cardiothoracic Imaging, Department of Radiology, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Giandomenico Bisaccia
- Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK; (I.L.)
- Department of Neuroscience, Imaging and Clinical Sciences, “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
| | - Maria Cristina Procopio
- Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK; (I.L.)
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy
| | - Roberto Licordari
- Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK; (I.L.)
- Department of Biomedical and Dental Sciences and of Morphological and Functional Images, University of Messina, 98122 Messina, Italy
| | - Maria Perotto
- Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK; (I.L.)
| | - Giulia La Vecchia
- Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK; (I.L.)
- Department of Cardiovascular and Pulmonary Science, Catholic University of Sacred Heart, 00168 Rome, Italy
| | - Nikolaos Miaris
- Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK; (I.L.)
| | - Paco E. Bravo
- Division of Cardiovascular Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA (P.E.B.)
- Divisions of Nuclear Medicine and Cardiothoracic Imaging, Department of Radiology, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Chiara Bucciarelli-Ducci
- Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK; (I.L.)
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King’s College London, London WC2R 2LS, UK
| |
Collapse
|
14
|
Bucciarelli V, Bianco F, Di Blasio A, Morano T, Tuosto D, Mucedola F, Di Santo S, Cimini A, Napolitano G, Bucci I, Di Baldassarre A, Cianchetti E, Gallina S. Cardiometabolic Profile, Physical Activity, and Quality of Life in Breast Cancer Survivors after Different Physical Exercise Protocols: A 34-Month Follow-Up Study. J Clin Med 2023; 12:4795. [PMID: 37510910 PMCID: PMC10381308 DOI: 10.3390/jcm12144795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 07/15/2023] [Accepted: 07/17/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Breast cancer (BC) and cardiovascular (CV) disease share many risk factors associated with worse outcomes, in terms of cancer relapse, CV events, and quality of life (QoL), that could be counteracted by physical exercise (PE). We aimed to assess the impact of a 12-week differential PE protocol on cardiometabolic profile, QoL, CV- and BC-related long-term outcomes, and physical activity (PA) in a cohort of BC survivors (BCS) not treated with chemotherapy. METHODS 57 BCS participated in a 12-week PE protocol [aerobic exercise training (AET) or resistance exercise training (RET)]. Anthropometric and CV evaluation, health-related (HR)-QoL, daily PA, cortisol, and dehydroepiandrosterone sulfate (DHEA-S) levels were assessed before (T0) and after (T1) PE. We assessed BC and CV outcomes, HR-QoL, CV-QoL, and PA at the follow-up. RESULTS RET improved waist circumference, DHEA-S, cortisol/DHEA-S, systolic and mean blood pressure, and ventricular/arterial coupling; AET ameliorated sagittal abdomen diameter and pulse wave velocity. Regarding HR-QoL, physical function improved only in AET group. At a mean 34 ± 3.6-month follow-up, we documented no significant differences in CV-QoL, HR-QoL, and PA or CV and BC outcomes. CONCLUSIONS AET and RET determine specific, positive adaptations on many parameters strongly related to CV risk, CV and BC outcomes, and QoL, and should be included in any cardio-oncology rehabilitation program.
Collapse
Affiliation(s)
- Valentina Bucciarelli
- Cardiovascular Sciences Department-Azienda Ospedaliero-Universitaria delle Marche, 60126 Ancona, Italy
- Department of Neurosciences, Imaging and Clinical Sciences, "G. d'Annunzio" University, 66100 Chieti, Italy
| | - Francesco Bianco
- Cardiovascular Sciences Department-Azienda Ospedaliero-Universitaria delle Marche, 60126 Ancona, Italy
- Department of Neurosciences, Imaging and Clinical Sciences, "G. d'Annunzio" University, 66100 Chieti, Italy
| | - Andrea Di Blasio
- Department of Medicine and Aging Sciences, "G. d'Annunzio" University, 66100 Chieti, Italy
| | - Teresa Morano
- Department of Medicine and Aging Sciences, "G. d'Annunzio" University, 66100 Chieti, Italy
| | - Desiree Tuosto
- Department of Neurosciences, Imaging and Clinical Sciences, "G. d'Annunzio" University, 66100 Chieti, Italy
| | - Francesco Mucedola
- Department of Neurosciences, Imaging and Clinical Sciences, "G. d'Annunzio" University, 66100 Chieti, Italy
| | - Serena Di Santo
- Department of Medicine and Aging Sciences, "G. d'Annunzio" University, 66100 Chieti, Italy
| | - Alessandra Cimini
- Eusoma Breast Centre, "G. Bernabeo" Hospital, ASL02 Lanciano-Vasto-Chieti, 66026 Ortona, Italy
| | - Giorgio Napolitano
- Department of Medicine and Aging Sciences, "G. d'Annunzio" University, 66100 Chieti, Italy
| | - Ines Bucci
- Center for Advanced Studies and Technology (CAST), "G. d'Annunzio" University of Chieti-Pescara, 66100 Chieti, Italy
| | - Angela Di Baldassarre
- Department of Medicine and Aging Sciences, "G. d'Annunzio" University, 66100 Chieti, Italy
| | - Ettore Cianchetti
- Eusoma Breast Centre, "G. Bernabeo" Hospital, ASL02 Lanciano-Vasto-Chieti, 66026 Ortona, Italy
| | - Sabina Gallina
- Department of Neurosciences, Imaging and Clinical Sciences, "G. d'Annunzio" University, 66100 Chieti, Italy
| |
Collapse
|
15
|
Uwase E, Caru M, Curnier D, Abasq Meng M, Andelfinger G, Krajinovic M, Laverdière C, Sinnett D, Périé D. Cardiac Mechanical Performance Assessment at Different Levels of Exercise in Childhood Acute Lymphoblastic Leukemia Survivors. J Pediatr Hematol Oncol 2023; 45:247-255. [PMID: 37278566 DOI: 10.1097/mph.0000000000002682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 03/31/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND There is a shortage of relevant studies interested in cardiac mechanical performance. Thus, it is clinically relevant to study the impact of cancer treatments on survivors' cardiac mechanical performance to improve our knowledge. The first objective of this study is to assess survivors' cardiac mechanical performance during a cardiopulmonary exercise test (CPET) using both ventricular-arterial coupling (VAC) and cardiac work efficiency (CWE) from cardiac magnetic resonance (CMR) acquisitions. The second objective is to assess the impact of doxorubicin and dexrazoxane (DEX) treatments. METHODS A total of 63 childhood acute lymphoblastic leukemia survivors underwent a CMR at rest on a 3T magnetic resonance imaging system, followed by a CPET on ergocycle. The CircAdapt model was used to study cardiac mechanical performance. At different levels of exercise, arterial elastance, end-systolic elastance, VAC, and CWE were estimated. RESULTS We observed significant differences between the different levels of exercise for both VAC ( P <0.0001) and CWE parameters ( P =0.001). No significant differences were reported between prognostic risk groups at rest and during the CPET. Nevertheless, we observed that survivors in the SR group had a VAC value slightly lower than heart rate (HR)+DEX and HR groups throughout the CPET. Moreover, survivors in the SR group had a CWE parameter slightly higher than HR+DEX and HR groups throughout the CPET. CONCLUSIONS This study reveals that the combination of CPET, CMR acquisitions and CircAdapt model was sensitive enough to observe slight changes in the assessment of VAC and CWE parameters. Our study contributes to improving survivors' follow-up and detection of cardiac problems induced by doxorubicin-related cardiotoxicity.
Collapse
Affiliation(s)
- Egidie Uwase
- Department of Mechanical Engineering, Polytechnique
| | - Maxime Caru
- Department of Mechanical Engineering, Polytechnique
- Sainte-Justine University Health Center, Research Center
| | - Daniel Curnier
- Sainte-Justine University Health Center, Research Center
- School of Kinesiology and Physical Activity Sciences, Faculty of Medicine, University of Montreal, Montreal, QC, Canada
| | | | - Gregor Andelfinger
- Sainte-Justine University Health Center, Research Center
- Department of Pediatrics, University of Montreal
| | - Maja Krajinovic
- Sainte-Justine University Health Center, Research Center
- Department of Pediatrics, University of Montreal
| | - Caroline Laverdière
- Sainte-Justine University Health Center, Research Center
- Department of Pediatrics, University of Montreal
| | - Daniel Sinnett
- Sainte-Justine University Health Center, Research Center
- Department of Pediatrics, University of Montreal
| | - Delphine Périé
- Department of Mechanical Engineering, Polytechnique
- Sainte-Justine University Health Center, Research Center
| |
Collapse
|
16
|
Alexandraki A, Papageorgiou E, Zacharia M, Keramida K, Papakonstantinou A, Cipolla CM, Tsekoura D, Naka K, Mazzocco K, Mauri D, Tsiknakis M, Manikis GC, Marias K, Marcou Y, Kakouri E, Konstantinou I, Daniel M, Galazi M, Kampouroglou E, Ribnikar D, Brown C, Karanasiou G, Antoniades A, Fotiadis D, Filippatos G, Constantinidou A. New Insights in the Era of Clinical Biomarkers as Potential Predictors of Systemic Therapy-Induced Cardiotoxicity in Women with Breast Cancer: A Systematic Review. Cancers (Basel) 2023; 15:3290. [PMID: 37444400 PMCID: PMC10340234 DOI: 10.3390/cancers15133290] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/09/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023] Open
Abstract
Cardiotoxicity induced by breast cancer therapies is a potentially serious complication associated with the use of various breast cancer therapies. Prediction and better management of cardiotoxicity in patients receiving chemotherapy is of critical importance. However, the management of cancer therapy-related cardiac dysfunction (CTRCD) lacks clinical evidence and is based on limited clinical studies. AIM To provide an overview of existing and potentially novel biomarkers that possess a promising predictive value for the early and late onset of CTRCD in the clinical setting. METHODS A systematic review of published studies searching for promising biomarkers for the prediction of CTRCD in patients with breast cancer was undertaken according to PRISMA guidelines. A search strategy was performed using PubMed, Google Scholar, and Scopus for the period 2013-2023. All subjects were >18 years old, diagnosed with breast cancer, and received breast cancer therapies. RESULTS The most promising biomarkers that can be used for the development of an alternative risk cardiac stratification plan for the prediction and/or early detection of CTRCD in patients with breast cancer were identified. CONCLUSIONS We highlighted the new insights associated with the use of currently available biomarkers as a standard of care for the management of CTRCD and identified potentially novel clinical biomarkers that could be further investigated as promising predictors of CTRCD.
Collapse
Affiliation(s)
- Alexia Alexandraki
- A.G. Leventis Clinical Trials Unit, Bank of Cyprus Oncology Centre, 32 Acropoleos Avenue, Nicosia 2006, Cyprus; (E.P.); (M.Z.)
| | - Elisavet Papageorgiou
- A.G. Leventis Clinical Trials Unit, Bank of Cyprus Oncology Centre, 32 Acropoleos Avenue, Nicosia 2006, Cyprus; (E.P.); (M.Z.)
| | - Marina Zacharia
- A.G. Leventis Clinical Trials Unit, Bank of Cyprus Oncology Centre, 32 Acropoleos Avenue, Nicosia 2006, Cyprus; (E.P.); (M.Z.)
| | - Kalliopi Keramida
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece;
- Cardiology Department, General Anti-Cancer Oncological Hospital, Agios Savvas, 11522 Athens, Greece
| | - Andri Papakonstantinou
- Department of Oncology-Pathology, Karolinska Institute, 17176 Stockholm, Sweden;
- Department for Breast, Endocrine Tumours and Sarcoma, Karolinska University Hospital, 17176 Stockholm, Sweden
| | - Carlo M. Cipolla
- Cardioncology and Second Opinion Division, European Institute of Oncology (IEO), IRCCS, Via Ripamonti 435, 20141 Milan, Italy;
| | - Dorothea Tsekoura
- 2nd Department of Surgery, Aretaieio University Hospital, National and Kapodistrian University of Athens, 76 Vas. Sofias Av., 11528 Athens, Greece; (D.T.); (E.K.)
| | - Katerina Naka
- 2nd Cardiology Department, University of Ioannina Medical School, 45110 Ioannina, Greece;
| | - Ketti Mazzocco
- Applied Research Division for Cognitive and Psychological Science, European Institute of Oncology IRCCS, 20139 Milan, Italy;
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
| | - Davide Mauri
- Department of Medical Oncology, University of Ioannina, 45110 Ioannina, Greece;
| | - Manolis Tsiknakis
- Department of Electrical and Computer Engineering, Hellenic Mediterranean University, 71410 Heraklion, Greece; (M.T.); (K.M.)
- Computational BioMedicine Laboratory (CBML), Institute of Computer Science, Foundation for Research and Technology Hellas (FORTH), 70013 Heraklion, Greece;
| | - Georgios C. Manikis
- Computational BioMedicine Laboratory (CBML), Institute of Computer Science, Foundation for Research and Technology Hellas (FORTH), 70013 Heraklion, Greece;
| | - Kostas Marias
- Department of Electrical and Computer Engineering, Hellenic Mediterranean University, 71410 Heraklion, Greece; (M.T.); (K.M.)
- Computational BioMedicine Laboratory (CBML), Institute of Computer Science, Foundation for Research and Technology Hellas (FORTH), 70013 Heraklion, Greece;
| | - Yiola Marcou
- Department of Medical Oncology, Bank of Cyprus Oncology Centre, 32 Acropoleos Avenue, Nicosia 2006, Cyprus; (Y.M.); (E.K.); (I.K.); (M.G.)
| | - Eleni Kakouri
- Department of Medical Oncology, Bank of Cyprus Oncology Centre, 32 Acropoleos Avenue, Nicosia 2006, Cyprus; (Y.M.); (E.K.); (I.K.); (M.G.)
| | - Ifigenia Konstantinou
- Department of Medical Oncology, Bank of Cyprus Oncology Centre, 32 Acropoleos Avenue, Nicosia 2006, Cyprus; (Y.M.); (E.K.); (I.K.); (M.G.)
| | - Maria Daniel
- Department of Radiation Oncology, Bank of Cyprus Oncology Centre, 32 Acropoleos Avenue, Nicosia 2006, Cyprus;
| | - Myria Galazi
- Department of Medical Oncology, Bank of Cyprus Oncology Centre, 32 Acropoleos Avenue, Nicosia 2006, Cyprus; (Y.M.); (E.K.); (I.K.); (M.G.)
| | - Effrosyni Kampouroglou
- 2nd Department of Surgery, Aretaieio University Hospital, National and Kapodistrian University of Athens, 76 Vas. Sofias Av., 11528 Athens, Greece; (D.T.); (E.K.)
| | - Domen Ribnikar
- Division of Medical Oncology, Institute of Oncology Ljubljana, Faculty of Medicine, University of Ljubljana, Zaloska Cesta 2, 1000 Ljubljana, Slovenia;
| | - Cameron Brown
- Translational Medicine, Stremble Ventures Ltd., 59 Christaki Kranou, Limassol 4042, Cyprus;
| | - Georgia Karanasiou
- Biomedical Research Institute, Foundation for Research and Technology, Hellas, 45500 Ioannina, Greece;
| | - Athos Antoniades
- Research and Development, Stremble Ventures Ltd., 59 Christaki Kranou, Limassol 4042, Cyprus;
| | - Dimitrios Fotiadis
- Unit of Medical Technology and Intelligent Information Systems, Department of Materials Science and Engineering, University of Ioannina, 45110 Ioannina, Greece;
| | - Gerasimos Filippatos
- Cardio-Oncology Clinic, Heart Failure Unit, Department of Cardiology, National and Kapodistrian University of Athens Medical School, Athens University Hospital Attikon, 11527 Athens, Greece;
| | - Anastasia Constantinidou
- Department of Medical Oncology, Bank of Cyprus Oncology Centre, 32 Acropoleos Avenue, Nicosia 2006, Cyprus; (Y.M.); (E.K.); (I.K.); (M.G.)
- School of Medicine, University of Cyprus, Panepistimiou 1, Aglantzia, Nicosia 2408, Cyprus
| |
Collapse
|
17
|
Rasouli R, Baranger J, Slorach C, Hui W, Venet M, Nguyen MB, Henry M, Gopaul J, Nathan PC, Mertens L, Villemain O. Local arterial stiffness measured by ultrafast ultrasound imaging in childhood cancer survivors treated with anthracyclines. Front Cardiovasc Med 2023; 10:1150214. [PMID: 37346288 PMCID: PMC10279856 DOI: 10.3389/fcvm.2023.1150214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/23/2023] [Indexed: 06/23/2023] Open
Abstract
Background There is conflicting literature regarding the long-term effect of anthracycline treatment on arterial stiffness. This study assessed local arterial stiffness using ultrafast ultrasound imaging (UUI) in anthracycline treated childhood cancer survivors, at rest and during exercise. Methods 20 childhood cancer survivors (mean age 21.02 ± 9.45 years) treated with anthracyclines (mean cumulative dose 200.7 ± 126.80 mg/m2) and 21 healthy controls (mean age 26.00 ± 8.91 years) were included. Participants completed a demographic survey, fasting bloodwork for cardiovascular biomarkers, and performed a submaximal exercise test on a semi-supine bicycle. Pulse wave velocity (PWV) was measured in the left common carotid artery by direct pulse wave imaging using UUI at rest and submaximal exercise. Both PWV at the systolic foot (PWV-SF) and dicrotic notch (PWV-DN) were measured. Central (carotid-femoral) PWV was obtained by applanation tonometry. Carotid measurements were taken by conventional ultrasound. Measures were compared using two-tailed Students t-test or Chi-squared test, as appropriate. Results There was no statistically significant difference (p > 0.05) between childhood cancer survivors and healthy controls in demographic parameters (age, sex, weight, height, BMI), blood biomarkers (total cholesterol, triglycerides, LDL-c, HDL-c, hs-CRP, fasting glucose, insulin, Hb A1c), cardiovascular parameters (intima media thickness, systolic and diastolic blood pressure, heart rate, carotid diameters, distensibility) or PWV measured by UUI at rest or at exercise. There was also no difference in the cardiovascular adaptation between rest and exercise in the two groups (p > 0.05). Multivariate analysis revealed age (p = 0.024) and LDL-c (p = 0.019) to be significant correlates of PWV-SF in childhood cancer survivors, in line with previously published data. Conclusion We did not identify a significant impact of anthracycline treatment in young survivors of childhood cancer on local arterial stiffness in the left common carotid artery as measured by UUI.
Collapse
Affiliation(s)
- Rahna Rasouli
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Jerome Baranger
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Cameron Slorach
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Wei Hui
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Maelys Venet
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Minh B. Nguyen
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Matthew Henry
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Josh Gopaul
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Paul C. Nathan
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Luc Mertens
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Olivier Villemain
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
18
|
Camilli M, Birritella L, Delogu AB, Lamendola P, De Vita A, Melita V, Romano A, Ruggiero A, Attinà G, Lanza GA, Massetti M, Crea F, Lombardo A. Left Ventricular-Arterial Coupling and Vascular Function in Childhood Cancer Survivors Exposed to Anthracycline Chemotherapy. Rev Cardiovasc Med 2023; 24:124. [PMID: 39076269 PMCID: PMC11273053 DOI: 10.31083/j.rcm2404124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 12/30/2022] [Accepted: 01/04/2023] [Indexed: 10/10/2023] Open
Abstract
Background Cardiovascular (CV) diseases are a cause of increased long-term morbidity and mortality in childhood cancer survivors (CCSs) treated with anthracyclines. These drugs may affect not only the heart, but also the vascular system. Left ventricular-arterial coupling (LVAC) represents a reliable parameter of altered ventricular and vascular performance, with validated prognostic value and never investigated in this setting. Aim of this study was to assess, in CCSs and matched controls, LVAC changes, performed with different echocardiographic modalities, and their relationship with endothelial function. Methods Twenty survivors treated with anthracyclines for childhood malignancies and a matched control group of 20 healthy subjects were enrolled. Arterial elastance (Ea), end-systolic elastance (Ees), Ea/Ees ratio, as well as three-dimensional (3D) LVAC (assessed by measurement of End Systolic Volume [ESV]/Stroke Volume [SV] ratio) were performed at rest. Endothelial function was evaluated by measurement of flow-mediated dilatation (FMD) of the brachial artery. Results 3D SV and 3D ESV/SV ratio resulted respectively significantly lower and higher in CCSs than in controls, while Ea, Ees and Ea/Ees ratio were not different among groups. A positive correlation between 3D ESV/SV ratio and cumulative anthracycline doses, as well as with time after drug exposure were also found. Mean FMD was similar in CCSs and controls (8.45 ± 1.79 versus 9.41 ± 3.41, p = 0.34). Conclusions In conclusion, conventional LVAC parameters were not shown to be significantly different between CCSs and controls; however, 3D SV and LVAC were significantly impaired in our population. In these patients, endothelial function was comparable to controls. Larger validation studies are therefore needed.
Collapse
Affiliation(s)
- Massimiliano Camilli
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Lisa Birritella
- Catholic University of The Sacred Heart, 00168 Rome, Italy
- Unit of Pediatrics, Pediatric Cardiology, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Angelica Bibiana Delogu
- Catholic University of The Sacred Heart, 00168 Rome, Italy
- Unit of Pediatrics, Pediatric Cardiology, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Priscilla Lamendola
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Antonio De Vita
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Veronica Melita
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Alberto Romano
- Catholic University of The Sacred Heart, 00168 Rome, Italy
- Pediatric Oncology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Antonio Ruggiero
- Catholic University of The Sacred Heart, 00168 Rome, Italy
- Pediatric Oncology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Giorgio Attinà
- Catholic University of The Sacred Heart, 00168 Rome, Italy
- Pediatric Oncology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Gaetano Antonio Lanza
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Massimo Massetti
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Antonella Lombardo
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy
| |
Collapse
|
19
|
Mihalcea D, Memis H, Mihaila S, Vinereanu D. Cardiovascular Toxicity Induced by Vascular Endothelial Growth Factor Inhibitors. Life (Basel) 2023; 13:life13020366. [PMID: 36836722 PMCID: PMC9965690 DOI: 10.3390/life13020366] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 01/26/2023] [Accepted: 01/27/2023] [Indexed: 01/31/2023] Open
Abstract
Cardiotoxicity is an important side effect of vascular endothelial growth factor (VEGF) inhibitors therapy used in the treatment of various malignancies, leading to increased morbidity and mortality. Arterial hypertension, cardiac ischemia with the acceleration of atherosclerosis, arrhythmias, myocardial dysfunction and thromboembolic disease are the most feared cardiovascular adverse reactions due to VEGF inhibitors. Susceptibility for the occurrence of VEGF inhibitors-induced cardiotoxicity has multifactorial determinants, with a significant inter-individual variation. Baseline cardiovascular risk assessment of the patient, type and stage of cancer, dose and duration of VEGF inhibitors treatment and adjuvant chemotherapy or radiotherapy are the main predictors for cardiotoxicity. The role of the cardio-oncology team becomes essential for achieving maximum therapeutic anti-angiogenic effects with minimum cardiovascular side effects. This review will summarize the incidence, risk factors, mechanisms, management and treatment of VEGF inhibitors-induced cardiovascular toxicity.
Collapse
Affiliation(s)
- Diana Mihalcea
- Cardiology and Cardiovascular Surgery Department, University of Medicine and Pharmacy Carol Davila, Splaiul Independentei 169, 050098 Bucharest, Romania
- Cardiology Department, University and Emergency Hospital, 050098 Bucharest, Romania
| | - Hayat Memis
- Cardiology and Cardiovascular Surgery Department, University of Medicine and Pharmacy Carol Davila, Splaiul Independentei 169, 050098 Bucharest, Romania
| | - Sorina Mihaila
- Cardiology and Cardiovascular Surgery Department, University of Medicine and Pharmacy Carol Davila, Splaiul Independentei 169, 050098 Bucharest, Romania
- Cardiology Department, University and Emergency Hospital, 050098 Bucharest, Romania
| | - Dragos Vinereanu
- Cardiology and Cardiovascular Surgery Department, University of Medicine and Pharmacy Carol Davila, Splaiul Independentei 169, 050098 Bucharest, Romania
- Cardiology Department, University and Emergency Hospital, 050098 Bucharest, Romania
- Correspondence: ; Tel./Fax: +40-21-3180576
| |
Collapse
|
20
|
Longitudinal Right Ventricular Systolic Function Changes in Breast Cancer Patients Treated With Cardiotoxic Cancer Therapy. JACC: CARDIOONCOLOGY 2022; 4:552-554. [DOI: 10.1016/j.jaccao.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
21
|
Lyon AR, López-Fernández T, Couch LS, Asteggiano R, Aznar MC, Bergler-Klein J, Boriani G, Cardinale D, Cordoba R, Cosyns B, Cutter DJ, de Azambuja E, de Boer RA, Dent SF, Farmakis D, Gevaert SA, Gorog DA, Herrmann J, Lenihan D, Moslehi J, Moura B, Salinger SS, Stephens R, Suter TM, Szmit S, Tamargo J, Thavendiranathan P, Tocchetti CG, van der Meer P, van der Pal HJH. 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS). Eur Heart J 2022; 43:4229-4361. [PMID: 36017568 DOI: 10.1093/eurheartj/ehac244] [Citation(s) in RCA: 797] [Impact Index Per Article: 398.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
|
22
|
Ky B, Wilcox NS. Myocardial Strain Is Not in Vain: Predicting Cardiovascular Risk in Checkpoint Inhibitor Myocarditis. JACC Cardiovasc Imaging 2022; 15:1897-1899. [PMID: 36357132 DOI: 10.1016/j.jcmg.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 08/09/2022] [Accepted: 08/10/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Bonnie Ky
- Division of Cardiology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Nicholas S Wilcox
- Division of Cardiology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
23
|
Heshmat-Ghahdarijani K, Najafian J, Vafaei Z, Mostafavi S, Mohammadifard N, Mansourian M, Ashrafi F, Sharifi M, Khosravifarsani M, Darakhshandeh A, Mohammad Hassan E, Shaghayegh Haghjooy J, Sarrafzadegan N. Rational, Design and Preliminary Results of a Cohort Study on Breast and Colorectal Cancer to Develop a Risk Assessment Model to Predict Future Cardiovascular Events. "Cardio Vascular Events in Breast and Colorectal Cancers (CIBC) Study". Curr Probl Cardiol 2022; 47:100958. [PMID: 34358588 DOI: 10.1016/j.cpcardiol.2021.100958] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 07/30/2021] [Indexed: 11/19/2022]
Abstract
Breast cancer (BC) and colorectal cancer (CRC) are among the most common cancers in Iran. We aimed to develop a risk assessment model to predict the development of cardiovascular events in these patients by performing a 5 year prospective cohort study on a newly diagnosed patients with BC or CRC before they receive any treatment. A multi-center prospective cohort study of 2700 newly diagnosed BC and CRC patients has been started in Iran since 2019 and will be continued until 2024. Demographics, socioeconomic status, life style behaviors, psychological characteristics and type of cancer treatments will be collected by standard questionnaires and blood pressure, obesity indices will be measured. Blood sampling, ECG, and echocardiography will be done in all patients at base line, 6 and 12 months, then at annual basis for five years. Incidence of heart failure, acute coronary syndrome, stroke and CVD related death are the primary outcome of this study. In this preliminary analysis, 70 patients with BC and 30 patients with CRC were enrolled in this study from April 2019 to November 2019. Mean age of BC and CRC patients was 48 ± 10.5 and 61 ± 13.2 respectively. 98.6% of patients in BC group and 60% of CRC groups were female. This study will be a platform for other cancers to develop CVD risk assessment charts that can cover other cancers. Patients who lie in the high risk category according to the newly developed risk assessment chart, should receive special management and preventive interventions.
Collapse
Affiliation(s)
- Kiyan Heshmat-Ghahdarijani
- Interventional Cardiology Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Jamshid Najafian
- Hypertension Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Zamaneh Vafaei
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Samaneh Mostafavi
- Heart Failure Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Noushin Mohammadifard
- Pediatric Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Marjan Mansourian
- Department of Epidemiology and Biostatistics, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Farzaneh Ashrafi
- Cardio-Oncology Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Science, Tehran, Iran
| | - Mehran Sharifi
- Department of Internal Medicine, School of Medicine Cancer Prevention Research Center Seyyed AlShohada Hospital Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Ali Darakhshandeh
- Department of Medical Oncology- Hematology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Emami Mohammad Hassan
- Poursina Hakim Research and Therapeutic Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Javanmard Shaghayegh Haghjooy
- Applied Physiology Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Nizal Sarrafzadegan
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran.
| |
Collapse
|
24
|
Lyon AR, López-Fernández T, Couch LS, Asteggiano R, Aznar MC, Bergler-Klein J, Boriani G, Cardinale D, Cordoba R, Cosyns B, Cutter DJ, de Azambuja E, de Boer RA, Dent SF, Farmakis D, Gevaert SA, Gorog DA, Herrmann J, Lenihan D, Moslehi J, Moura B, Salinger SS, Stephens R, Suter TM, Szmit S, Tamargo J, Thavendiranathan P, Tocchetti CG, van der Meer P, van der Pal HJH. 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS). Eur Heart J Cardiovasc Imaging 2022; 23:e333-e465. [PMID: 36017575 DOI: 10.1093/ehjci/jeac106] [Citation(s) in RCA: 98] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
|
25
|
Wei X, Lin L, Zhang G, Zhou X. Cardiovascular Magnetic Resonance Imaging in the Early Detection of Cardiotoxicity Induced by Cancer Therapies. Diagnostics (Basel) 2022; 12:1846. [PMID: 36010197 PMCID: PMC9406931 DOI: 10.3390/diagnostics12081846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/21/2022] [Accepted: 07/26/2022] [Indexed: 11/16/2022] Open
Abstract
The significant progress in cancer treatment, including chemotherapy, immunotherapy, radiotherapy, and combination therapies, has led to higher long-term survival rates in cancer patients, while the cardiotoxicity caused by cancer treatment has become increasingly prominent. Cardiovascular magnetic resonance (CMR) is a non-invasive comprehensive imaging modality that provides not only anatomical information, but also tissue characteristics and cardiometabolic and energetic assessment, leading to its increased use in the early identification of cardiotoxicity, and is of major importance in improving the survival rate of cancer patients. This review focused on CMR techniques, including myocardial strain analysis, T1 mapping, T2 mapping, and extracellular volume fraction (ECV) calculation in the detection of early myocardial injury induced by cancer therapies. We summarized the existing studies and ongoing clinical trials using CMR for the assessment of subclinical ventricular dysfunction and myocardial changes at the tissue level. The main focus was to explore the potential of clinical and preclinical CMR techniques for continuous non-invasive monitoring of myocardial toxicity associated with cancer therapy.
Collapse
Affiliation(s)
| | | | - Guizhi Zhang
- Department of Radiology, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen 518036, China; (X.W.); (L.L.)
| | - Xuhui Zhou
- Department of Radiology, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen 518036, China; (X.W.); (L.L.)
| |
Collapse
|
26
|
Upshaw JN, Mohanty S, Rastogi A. Cardioprotection of High-Risk Individuals. Heart Fail Clin 2022; 18:385-402. [PMID: 35718414 PMCID: PMC10984350 DOI: 10.1016/j.hfc.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Targeting cardioprotective strategies to patients at the highest risk for cardiac events can help maximize therapeutic benefits. Dexrazoxane, liposomal formulations, continuous infusions, and neurohormonal antagonists may be useful for cardioprotection for anthracycline-treated patients at the highest risk for heart failure. Prevalent cardiovascular disease is a risk factor for cardiac events with many cancer therapies, including anthracyclines, anti-human-epidermal growth factor receptor-2 therapy, radiation, and BCR-Abl tyrosine kinase inhibitors, and may be a risk factor for cardiac events with other therapies. Although evidence for cardioprotective strategies is sparse for nonanthracycline therapies, optimizing cardiac risk factors and prevalent cardiovascular disease may improve outcomes.
Collapse
Affiliation(s)
- Jenica N Upshaw
- Division of Cardiology, Tufts Medical Center, 800 Washington St, Boston, MA 02111, USA.
| | - Sharanya Mohanty
- Division of Cardiology, Tufts Medical Center, 800 Washington St, Boston, MA 02111, USA
| | - Akash Rastogi
- Division of Cardiology, Tufts Medical Center, 800 Washington St, Boston, MA 02111, USA
| |
Collapse
|
27
|
|
28
|
Esmaeilzadeh M, Urzua Fresno CM, Somerset E, Shalmon T, Amir E, Fan CPS, Brezden-Masley C, Thampinathan B, Thevakumaran Y, Yared K, Koch CA, Abdel-Qadir H, Woo A, Yip P, Marwick TH, Chan R, Wintersperger BJ, Thavendiranathan P. A Combined Echocardiography Approach for the Diagnosis of Cancer Therapy-Related Cardiac Dysfunction in Women With Early-Stage Breast Cancer. JAMA Cardiol 2022; 7:330-340. [PMID: 35138325 PMCID: PMC8829754 DOI: 10.1001/jamacardio.2021.5881] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 12/08/2021] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Diagnosis of cancer therapy-related cardiac dysfunction (CTRCD) remains a challenge. Cardiovascular magnetic resonance (CMR) provides accurate measurement of left ventricular ejection fraction (LVEF), but access to repeated scans is limited. OBJECTIVE To develop a diagnostic model for CTRCD using echocardiographic LVEF and strain and biomarkers, with CMR as the reference standard. DESIGN, SETTING, AND PARTICIPANTS In this prospective cohort study, patients were recruited from University of Toronto-affiliated hospitals from November 2013 to January 2019 with all cardiac imaging performed at a single tertiary care center. Women with human epidermal growth factor receptor 2 (HER2)-positive early-stage breast cancer were included. The main exclusion criterion was contraindication to CMR. A total of 160 patients were recruited, 136 of whom completed the study. EXPOSURES Sequential therapy with anthracyclines and trastuzumab. MAIN OUTCOMES AND MEASURES Patients underwent echocardiography, high-sensitivity troponin I (hsTnI), B-type natriuretic peptide (BNP), and CMR studies preanthracycline and postanthracycline every 3 months during and after trastuzumab therapy. Echocardiographic measures included 2-dimensional (2-D) LVEF, 3-D LVEF, peak systolic global longitudinal strain (GLS), and global circumferential strain (GCS). LVEF CTRCD was defined using the Cardiac Review and Evaluation Committee Criteria, GLS or GCS CTRCD as a greater than 15% relative change, and abnormal hsTnI and BNP as greater than 26 pg/mL and ≥ 35 pg/mL, respectively, at any follow-up point. Combinations of echocardiographic measures and biomarkers were examined to diagnose CMR CTRCD using conditional inference tree models. RESULTS Among 136 women (mean [SD] age, 51.1 [9.2] years), CMR-identified CTRCD occurred in 37 (27%), and among those with analyzable images, in 30 of 131 (23%) by 2-D LVEF, 27 of 124 (22%) by 3-D LVEF, 53 of 126 (42%) by GLS, 61 of 123 (50%) by GCS, 32 of 136 (24%) by BNP, and 14 of 136 (10%) by hsTnI. In isolation, 3-D LVEF had greater sensitivity and specificity than 2-D LVEF for CMR CTRCD while GLS had greater sensitivity than 2-D or 3-D LVEF. Regression tree analysis identified a sequential algorithm using 3-D LVEF, GLS, and GCS for the optimal diagnosis of CTRCD (area under the receiver operating characteristic curve, 89.3%). The probability of CTRCD when results for all 3 tests were negative was 1.0%. When 3-D LVEF was replaced by 2-D LVEF in the model, the algorithm still performed well; however, its primary value was to rule out CTRCD. Biomarkers did not improve the ability to diagnose CTRCD. CONCLUSIONS AND RELEVANCE Using CMR CTRCD as the reference standard, these data suggest that a sequential approach combining echocardiographic 3-D LVEF with 2-D GLS and 2-D GCS may provide a timely diagnosis of CTRCD during routine CTRCD surveillance with greater accuracy than using these measures individually. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02306538.
Collapse
Affiliation(s)
- Maryam Esmaeilzadeh
- Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, Division of Cardiology, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Camila M. Urzua Fresno
- Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, Division of Cardiology, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Emily Somerset
- Rogers Computational Program, Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Tamar Shalmon
- Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, Division of Cardiology, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Eitan Amir
- Princess Margaret Cancer Center, Division of Medical Oncology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Chun-Po Steve Fan
- Rogers Computational Program, Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Christine Brezden-Masley
- Division of Medical Oncology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Babitha Thampinathan
- Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, Division of Cardiology, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Yobiga Thevakumaran
- Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, Division of Cardiology, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kibar Yared
- Division of Cardiology, Scarborough Health Network, Toronto, Ontario, Canada
| | - C. Anne Koch
- Radiation Medicine Program, Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Husam Abdel-Qadir
- Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, Division of Cardiology, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Women’s College Hospital, Toronto, Ontario, Canada
| | - Anna Woo
- Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, Division of Cardiology, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Paul Yip
- Division of Laboratory Medicine and Pathobiology, University Health Network, University of Toronto, Ontario, Canada
| | | | - Rosanna Chan
- Joint Department of Medical Imaging, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Bernd J. Wintersperger
- Joint Department of Medical Imaging, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Paaladinesh Thavendiranathan
- Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, Division of Cardiology, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Joint Department of Medical Imaging, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
29
|
Evaluation of Risk Prediction Models to Identify Cancer Therapeutics Related Cardiac Dysfunction in Women with HER2+ Breast Cancer. J Clin Med 2022; 11:jcm11030847. [PMID: 35160296 PMCID: PMC8836544 DOI: 10.3390/jcm11030847] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/23/2022] [Accepted: 01/31/2022] [Indexed: 12/10/2022] Open
Abstract
Cancer-therapeutics-related cardiac dysfunction (CTRCD) is an important concern in women receiving trastuzumab therapy for HER2+ breast cancer. However, the ability to assess CTRCD risk remains limited. In this retrospective cohort study, we apply three published risk prediction models (Ezaz et al., NSABP-31 cardiac risk scores (CRS), and HFA-ICOS trastuzumab proforma) to 629 women (mean age 52.4 ± 10.9 years) with Stage I-III HER2+ breast cancer treated with trastuzumab ± anthracyclines to assess their performance to identify CTRCD during or immediately post treatment. Using these models, patients were classified into CTRCD risk categories according to the pre-treatment characteristics. With NSABP-31 CRS and HFA-ICOS proformas, patients in the highest risk category had a 1.7-to-2.4-fold higher relative risk of CTRCD than the low-risk category (p = 0.010 and 0.005, respectively). However, with all three risk models, those in the low-risk category had a high absolute risk of CTRCD (15.5–25.5%). The discrimination of the models for CTRCD (AUC 0.51–0.60) and their calibration was limited. NSAP-31 CRS and HFA-ICOS proformas can identify relative differences in CTRCD risk between patients, but when considering absolute risk, they are only able to identify the highest risk patients. There remains an ongoing need for accurate CTRCD risk prediction models in women with HER2+ breast cancer.
Collapse
|
30
|
Viswanathan T, Lang CC, Petty RD, Baxter MA. Cardiotoxicity and Chemotherapy-The Role of Precision Medicine. Diseases 2021; 9:90. [PMID: 34940028 PMCID: PMC8699963 DOI: 10.3390/diseases9040090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 11/25/2021] [Accepted: 11/28/2021] [Indexed: 11/16/2022] Open
Abstract
Cancer and cardiovascular disease are the leading causes of death in the United Kingdom. Many systemic anticancer treatments are associated with short- and long-term cardiotoxicity. With improving cancer survival and an ageing population, identifying those patients at the greatest risk of cardiotoxicity from their cancer treatment is becoming a research priority and has led to a new subspecialty: cardio-oncology. In this concise review article, we discuss cardiotoxicity and systemic anticancer therapy, with a focus on chemotherapy. We also discuss the challenge of identifying those at risk and the role of precision medicine as we strive for a personalised approach to this clinical scenario.
Collapse
Affiliation(s)
- Thyla Viswanathan
- Dundee School of Medicine, Ninewells Hospital, University of Dundee, Dundee DD2 1SY, UK;
| | - Chim C. Lang
- Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee DD2 1SY, UK; (C.C.L.); (R.D.P.)
- UKM Medical Molecular Biology Institute (UMBI), Jalan Yaacob Latif, Cheras, Kuala Lumpur 56000, Malaysia
| | - Russell D. Petty
- Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee DD2 1SY, UK; (C.C.L.); (R.D.P.)
- Tayside Cancer Centre, Ninewells Hospital and Medical School, NHS Tayside, Dundee DD2 1SY, UK
| | - Mark A. Baxter
- Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee DD2 1SY, UK; (C.C.L.); (R.D.P.)
- Tayside Cancer Centre, Ninewells Hospital and Medical School, NHS Tayside, Dundee DD2 1SY, UK
| |
Collapse
|
31
|
Visseren FLJ, Mach F, Smulders YM, Carballo D, Koskinas KC, Bäck M, Benetos A, Biffi A, Boavida JM, Capodanno D, Cosyns B, Crawford C, Davos CH, Desormais I, Di Angelantonio E, Franco OH, Halvorsen S, Hobbs FDR, Hollander M, Jankowska EA, Michal M, Sacco S, Sattar N, Tokgozoglu L, Tonstad S, Tsioufis KP, van Dis I, van Gelder IC, Wanner C, Williams B. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur J Prev Cardiol 2021; 29:5-115. [PMID: 34558602 DOI: 10.1093/eurjpc/zwab154] [Citation(s) in RCA: 211] [Impact Index Per Article: 70.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | | | | | | | | | | | | | - Alessandro Biffi
- European Federation of Sports Medicine Association (EFSMA).,International Federation of Sport Medicine (FIMS)
| | | | | | | | | | | | | | | | | | | | - F D Richard Hobbs
- World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA) - Europe
| | | | | | | | | | | | | | | | | | | | | | - Christoph Wanner
- European Renal Association - European Dialysis and Transplant Association (ERA-EDTA)
| | | | | |
Collapse
|
32
|
Visseren FLJ, Mach F, Smulders YM, Carballo D, Koskinas KC, Bäck M, Benetos A, Biffi A, Boavida JM, Capodanno D, Cosyns B, Crawford C, Davos CH, Desormais I, Di Angelantonio E, Franco OH, Halvorsen S, Hobbs FDR, Hollander M, Jankowska EA, Michal M, Sacco S, Sattar N, Tokgozoglu L, Tonstad S, Tsioufis KP, van Dis I, van Gelder IC, Wanner C, Williams B. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J 2021; 42:3227-3337. [PMID: 34458905 DOI: 10.1093/eurheartj/ehab484] [Citation(s) in RCA: 2345] [Impact Index Per Article: 781.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | - Alessandro Biffi
- European Federation of Sports Medicine Association (EFSMA)
- International Federation of Sport Medicine (FIMS)
| | | | | | | | | | | | | | | | | | | | - F D Richard Hobbs
- World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA) - Europe
| | | | | | | | | | | | | | | | | | | | | | - Christoph Wanner
- European Renal Association - European Dialysis and Transplant Association (ERA-EDTA)
| | | |
Collapse
|
33
|
Narezkina A, Narayan HK, Zemljic-Harpf AE. Molecular mechanisms of anthracycline cardiovascular toxicity. Clin Sci (Lond) 2021; 135:1311-1332. [PMID: 34047339 PMCID: PMC10866014 DOI: 10.1042/cs20200301] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 05/07/2021] [Accepted: 05/11/2021] [Indexed: 12/21/2022]
Abstract
Anthracyclines are effective chemotherapeutic agents, commonly used in the treatment of a variety of hematologic malignancies and solid tumors. However, their use is associated with a significant risk of cardiovascular toxicities and may result in cardiomyopathy and heart failure. Cardiomyocyte toxicity occurs via multiple molecular mechanisms, including topoisomerase II-mediated DNA double-strand breaks and reactive oxygen species (ROS) formation via effects on the mitochondrial electron transport chain, NADPH oxidases (NOXs), and nitric oxide synthases (NOSs). Excess ROS may cause mitochondrial dysfunction, endoplasmic reticulum stress, calcium release, and DNA damage, which may result in cardiomyocyte dysfunction or cell death. These pathophysiologic mechanisms cause tissue-level manifestations, including characteristic histopathologic changes (myocyte vacuolization, myofibrillar loss, and cell death), atrophy and fibrosis, and organ-level manifestations including cardiac contractile dysfunction and vascular dysfunction. In addition, these mechanisms are relevant to current and emerging strategies to diagnose, prevent, and treat anthracycline-induced cardiomyopathy. This review details the established and emerging data regarding the molecular mechanisms of anthracycline-induced cardiovascular toxicity.
Collapse
Affiliation(s)
- Anna Narezkina
- Department of Medicine, Division of Cardiovascular Medicine, UCSD Cardiovascular Institute, University of California, San Diego
| | - Hari K. Narayan
- Department of Pediatrics, Division of Cardiology, University of California, San Diego
| | - Alice E. Zemljic-Harpf
- Veterans Affairs San Diego Healthcare System, San Diego, USA
- Department of Anesthesiology, University of California San Diego, La Jolla, California, USA
| |
Collapse
|
34
|
de Baat EC, Naaktgeboren WR, Leiner T, Teske AJ, Habets J, Grotenhuis HB. Update in imaging of cancer therapy-related cardiac toxicity in adults. Open Heart 2021; 8:openhrt-2020-001506. [PMID: 33863836 PMCID: PMC8055139 DOI: 10.1136/openhrt-2020-001506] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/08/2021] [Accepted: 02/22/2021] [Indexed: 12/19/2022] Open
Abstract
Over the past decades, prognosis of patients with cancer has strongly improved and the number of cancer survivors is rapidly growing. Despite this success, cancer treatment is associated with development of serious cardiovascular diseases including left ventricular (LV) systolic dysfunction, heart failure, valvular disease, myocardial infarction, arrhythmias or pericardial diseases. Serial non-invasive cardiac imaging is an important tool to detect early signs of cardiotoxicity, to allow for timely intervention and provide optimal circumstances for long-term prognosis. Currently, echocardiographic imaging is the method of choice for the evaluation of myocardial function during and after cancer therapy. However, 2D echocardiography may fail to detect subtle changes in myocardial function, potentially resulting in a significant delay of therapeutic intervention to impede advanced cardiac disease states with more overt systolic dysfunction. Strain imaging is a promising method for early detection of myocardial dysfunction and may predict future changes in LV ejection fraction. The use of three-dimensional echocardiography may overcome the limitations of 2D echocardiography with more precise and reproducible measurements of LV performance. Cardiac MRI is the gold standard for volumetric assessment and can also be used to perform myocardial tissue characterisation. Visualisation of oedema and fibrosis may provide insights into the degree and disease course of cardiotoxicity and underlying pathophysiological mechanisms. There is growing body of literature regarding the promising role of these advanced imaging modalities in early detection of cardiotoxicity. With this overview paper, new insights and recent results in literature regarding echocardiographic and cardiac magnetic resonance imaging of cancer therapy-related cardiac dysfunction in post-cancer therapy adults will be highlighted.
Collapse
Affiliation(s)
- Esmée C de Baat
- Pediatric Oncology, Princess Maxima Center, Utrecht, The Netherlands
| | - Willeke R Naaktgeboren
- Psychosocial Research and Epidemiology, Antoni van Leeuwenhoek Netherlands Cancer Institute, Amsterdam, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Tim Leiner
- Radiology, University Medical Center Utrecht Imaging Division, Utrecht, The Netherlands
| | - Arco J Teske
- Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jesse Habets
- Radiology, University Medical Center Utrecht Imaging Division, Utrecht, The Netherlands
- Radiology, University Medical Center Nijmegen, Nijmegen, The Netherlands
| | - Heynric B Grotenhuis
- Pediatric Cardiology, Wilhelmina Children's Hospital University Medical Centre, Utrecht, The Netherlands
| |
Collapse
|
35
|
Barbosa MF, Fusco DR, Gaiolla RD, Werys K, Tanni SE, Fernandes RA, Ribeiro SM, Szarf G. Characterization of subclinical diastolic dysfunction by cardiac magnetic resonance feature-tracking in adult survivors of non-Hodgkin lymphoma treated with anthracyclines. BMC Cardiovasc Disord 2021; 21:170. [PMID: 33845778 PMCID: PMC8040217 DOI: 10.1186/s12872-021-01996-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/07/2021] [Indexed: 01/19/2023] Open
Abstract
Background The use of anthracycline-based chemotherapy is associated with the development of heart failure, even years after the end of treatment. Early detection of cardiac dysfunction could identify a high-risk subset of survivors who would eventually benefit from early intervention. Cardiac magnetic resonance feature-tracking (CMR-FT) analysis offers a practical and rapid method to calculate systolic and diastolic strains from routinely acquired cine images. While early changes in systolic function have been described, less data are available about late effects of chemotherapy in diastolic parameters by CMR-FT. The main goal of this study was to determine whether left ventricular (LV) early diastolic strain rates (GDSR-E) by CMR-FT are impaired in long-term adult survivors of non-Hodgkin lymphoma (NHL). Our secondary objective was to analyze associations between GDSR-E with cumulative anthracycline dose, systolic function parameters and myocardial tissue characteristics.
Methods This is a single center cross-sectional observational study of asymptomatic patients in remission of NHL who previously received anthracycline therapy. All participants underwent their CMR examination on a 3.0-T scanner, including cines, T2 mapping, T1 mapping and late gadolinium enhancement imaging. Derived myocardial extracellular volume fraction was obtained from pre- and post-contrast T1 maps. CMR-FT analysis was performed using Trufi Strain software. The data obtained were compared between anthracycline group and volunteers without cardiovascular disease or neoplasia. Results A total of 18 adult survivors of NHL, 14 (77.8%) males, at mean age of 57.6 (± 14.7) years-old, were studied 88.2 (± 52.1) months after exposure to anthracycline therapy (median 400 mg/m2). Compared with controls, anthracycline group showed impaired LV global early diastolic circumferential strain rate (GCSR-E) [53.5%/s ± 19.3 vs 72.2%/s ± 26.7, p = 0.022], early diastolic longitudinal strain rate (GLSR-E) [40.4%/s ± 13.0 vs 55.9%/s ± 17.8, p = 0.006] and early diastolic radial strain rate (GRSR-E) [− 114.4%/s ± 37.1 vs − 170.5%/s ± 48.0, p < 0.001]. Impaired LV GCSR-E, GLSR-E and GRSR-E correlated with increased anthracycline dose and decreased systolic function. There were no correlations between GDSR-E and myocardial tissue characteristics. Conclusions Left ventricular early diastolic strain rates by CMR-FT are impaired late after anthracycline chemotherapy in adult survivors of non-Hodgkin lymphoma.
Collapse
Affiliation(s)
- Maurício Fregonesi Barbosa
- Department of Diagnostic Imaging, Universidade Federal de São Paulo (UNIFESP), Rua Napoleão de Barros 800, Vila Clementino, São Paulo, 04024-002, Brazil. .,Department of Tropical Diseases and Diagnostic Imaging, Universidade Estadual Paulista (UNESP), Botucatu, Brazil.
| | - Daniéliso Renato Fusco
- Cardiology Division, Internal Medicine Department, Universidade Estadual Paulista (UNESP), Botucatu, Brazil
| | - Rafael Dezen Gaiolla
- Hematology Division, Internal Medicine Department, Universidade Estadual Paulista (UNESP), Botucatu, Brazil
| | - Konrad Werys
- University of Oxford Centre for Clinical Magnetic Resonance Research (OCMR), University of Oxford, Oxford, UK
| | - Suzana Erico Tanni
- Pneumology Division, Internal Medicine Department, Universidade Estadual Paulista (UNESP), Botucatu, Brazil
| | - Rômulo Araújo Fernandes
- Department of Physical Education, Universidade Estadual Paulista (UNESP), Presidente Prudente, Brazil
| | - Sergio Marrone Ribeiro
- Department of Tropical Diseases and Diagnostic Imaging, Universidade Estadual Paulista (UNESP), Botucatu, Brazil
| | - Gilberto Szarf
- Department of Diagnostic Imaging, Universidade Federal de São Paulo (UNIFESP), Rua Napoleão de Barros 800, Vila Clementino, São Paulo, 04024-002, Brazil.,Hospital Israelita Albert Einstein, São Paulo, Brazil
| |
Collapse
|
36
|
Gomes-Santos IL, Jordão CP, Passos CS, Brum PC, Oliveira EM, Chammas R, Camargo AA, Negrão CE. Exercise Training Preserves Myocardial Strain and Improves Exercise Tolerance in Doxorubicin-Induced Cardiotoxicity. Front Cardiovasc Med 2021; 8:605993. [PMID: 33869297 PMCID: PMC8047409 DOI: 10.3389/fcvm.2021.605993] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 03/01/2021] [Indexed: 12/25/2022] Open
Abstract
Doxorubicin causes cardiotoxicity and exercise intolerance. Pre-conditioning exercise training seems to prevent doxorubicin-induced cardiac damage. However, the effectiveness of the cardioprotective effects of exercise training concomitantly with doxorubicin treatment remains largely unknown. To determine whether low-to-moderate intensity aerobic exercise training during doxorubicin treatment would prevent cardiotoxicity and exercise intolerance, we performed exercise training concomitantly with chronic doxorubicin treatment in mice. Ventricular structure and function were accessed by echocardiography, exercise tolerance by maximal exercise test, and cardiac biology by histological and molecular techniques. Doxorubicin-induced cardiotoxicity, evidenced by impaired ventricular function, cardiac atrophy, and fibrosis. Exercise training did not preserve left ventricular ejection fraction or reduced fibrosis. However, exercise training preserved myocardial circumferential strain alleviated cardiac atrophy and restored cardiomyocyte cross-sectional area. On the other hand, exercise training exacerbated doxorubicin-induced body wasting without affecting survival. Finally, exercise training blunted doxorubicin-induced exercise intolerance. Exercise training performed during doxorubicin-based chemotherapy can be a valuable approach to attenuate cardiotoxicity.
Collapse
Affiliation(s)
- Igor L Gomes-Santos
- Faculdade de Medicina, Heart Institute (InCor), Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Camila P Jordão
- Faculdade de Medicina, Heart Institute (InCor), Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Clevia S Passos
- Faculdade de Medicina, Heart Institute (InCor), Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Patricia C Brum
- School of Physical Education and Sport, Universidade de São Paulo, São Paulo, Brazil
| | - Edilamar M Oliveira
- School of Physical Education and Sport, Universidade de São Paulo, São Paulo, Brazil
| | - Roger Chammas
- Faculdade de Medicina, Cancer Institute of the State of São Paulo (ICESP), Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Anamaria A Camargo
- Centro de Oncologia Molecular, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Carlos E Negrão
- Faculdade de Medicina, Heart Institute (InCor), Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil.,School of Physical Education and Sport, Universidade de São Paulo, São Paulo, Brazil
| |
Collapse
|
37
|
Clasen SC, Shou H, Freedman G, Plastaras JP, Taunk NK, Kevin Teo BK, Smith AM, Demissei BG, Ky B. Early Cardiac Effects of Contemporary Radiation Therapy in Patients With Breast Cancer. Int J Radiat Oncol Biol Phys 2021; 109:1301-1310. [PMID: 33340602 PMCID: PMC11237872 DOI: 10.1016/j.ijrobp.2020.12.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 12/02/2020] [Accepted: 12/07/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE To characterize the early changes in echocardiographically derived measures of cardiac function with contemporary radiation therapy (RT) in breast cancer and to determine the associations with radiation dose-volume metrics, including mean heart dose (MHD). METHODS AND MATERIALS In a prospective longitudinal cohort study of 86 patients with breast cancer treated with photon or proton thoracic RT, clinical and echocardiographic data were assessed at 3 time points: within 4 weeks before RT initiation (T0), within 3 days before 6 weeks after the end of RT (T1), and 5 to 9 months after RT completion (T2). Associations between MHD and echocardiographically derived measures of cardiac function were assessed using generalized estimating equations to define the acute (T0 to T1) and subacute (T0 to T2) changes in cardiac function. RESULTS The median estimates of MHD were 139 cGy (interquartile range, 99-249 cGy). In evaluating the acute changes in left ventricular ejection fraction (LVEF) from T0 to T1, and accounting for the time from RT, age, race, preexisting cardiovascular disease, and an interaction term with anthracycline or trastuzumab exposure and MHD, there was a modest decrease in LVEF of borderline significance (0.22%; 95% confidence interval [CI], -0.44% to 0.01%; P = .06) per 30-day interval for every 100 cGy increase of MHD. Similarly, there was a modest worsening in longitudinal strain (0.19%; 95% CI, -0.01% to 0.39%; P = .06) per 30-day interval for each 100 cGy increase in MHD. We did not find significant associations between MHD and changes in circumferential strain or diastolic function. CONCLUSIONS With modern radiation planning techniques, there are modest subclinical changes in measures of cardiac function in the short-term. Longer-term follow-up studies are needed to determine whether these early changes are associated with the development of overt cardiac disease.
Collapse
Affiliation(s)
- Suparna C Clasen
- Krannert Institute of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Haochang Shou
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gary Freedman
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John P Plastaras
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Neil K Taunk
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Boon-Keng Kevin Teo
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amanda M Smith
- Department of Medicine, Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Biniyam G Demissei
- Department of Medicine, Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Bonnie Ky
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Medicine, Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| |
Collapse
|
38
|
Demissei BG, Fan Y, Qian Y, Cheng HG, Smith AM, Shimamoto K, Vedage N, Narayan HK, Scherrer-Crosbie M, Davatzikos C, Ky B. Left ventricular segmental strain and the prediction of cancer therapy-related cardiac dysfunction. Eur Heart J Cardiovasc Imaging 2021; 22:418-426. [PMID: 33206976 PMCID: PMC7984733 DOI: 10.1093/ehjci/jeaa288] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/12/2020] [Indexed: 01/02/2023] Open
Abstract
AIMS We aimed to determine the early changes and predictive value of left ventricular (LV) segmental strain measures in women with breast cancer receiving doxorubicin. METHODS AND RESULTS In a cohort of 237 women with breast cancer receiving doxorubicin with or without trastuzumab, 1151 echocardiograms were prospectively acquired over a median (Q1-Q3) of 7 (2-24) months. LV ejection fraction (LVEF) and 36 segmental strain measures were core lab quantified. A supervised machine learning (ML) model was then developed using random forest regression to identify segmental strain measures predictive of nadir LVEF post-doxorubicin completion. Cancer therapy-related cardiac dysfunction (CTRCD) was defined as a ≥10% absolute LVEF decline pre-treatment to a value <50%. Median (Q1-Q3) baseline age was 48 (41-57) years. Thirty-five women developed CTRCD, and eight of these developed symptomatic heart failure. From pre-treatment to doxorubicin completion, longitudinal strain worsened across the basal and mid-LV segments but not in the apical segments; circumferential strain worsened primarily in the septum; radial strain worsened uniformly and transverse strain remained unchanged across all LV segments. In the ML model, anterolateral and inferoseptal circumferential strain were the most predictive features; longitudinal and transverse strain in the basal inferoseptal, anterior, basal anterolateral, and apical lateral segments were also top predictive features. The addition of predictive segmental strain measures to a model including age, cancer therapy regimen, hypertension, and LVEF increased the area under the curve (AUC) from 0.70 (95% confidence interval (CI) 0.60-0.80) to 0.87 (95% CI 0.81-0.92), ΔAUC = 0.18 (95% CI 0.08-0.27) for the prediction of CTRCD. CONCLUSION Our findings suggest that segmental strain measures can enhance cardiotoxicity risk prediction in women with breast cancer receiving doxorubicin.
Collapse
Affiliation(s)
- Biniyam G Demissei
- Division of Cardiology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Yong Fan
- Department of Radiology, Center for Biomedical Image Computing and Analytics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Yiwen Qian
- Division of Cardiology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Henry G Cheng
- Division of Cardiology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Amanda M Smith
- Division of Cardiology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Kelsey Shimamoto
- Division of Cardiology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Natasha Vedage
- Department of Internal Medicine, Temple University Hospital, Philadelphia, PA, USA
| | - Hari K Narayan
- Department of Pediatrics, Division of Cardiology, Rady Children’s Hospital San Diego, The University of California San Diego, San Diego, CA, USA
| | - Marielle Scherrer-Crosbie
- Division of Cardiology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Christos Davatzikos
- Department of Radiology, Center for Biomedical Image Computing and Analytics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Bonnie Ky
- Division of Cardiology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
39
|
Levine L, Arany Z, Kern-Goldberger A, Koelper N, Lewey J, Sammel MD, Elovitz MA, Ky B. Soluble Flt1 levels are associated with cardiac dysfunction in Black women with and without severe preeclampsia. Hypertens Pregnancy 2020; 40:44-49. [PMID: 33345653 DOI: 10.1080/10641955.2020.1861462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Background: We evaluate soluble fms-like tyrosine kinase-1 (sFlt-1) levels and cardiac function during pregnancy and postpartum among Black women with and without preeclampsia. Study design: Prospective longitudinal cohort study from 2015 to 2017 of Black women with preterm severe preeclampsia and normotensive pregnant controls.We obtained echocardiograms and sFlt-1 levels during pregnancy and postpartum. Results: 93 Black women were included (43 cases, 50 controls). Higher sFlt1 levels were correlated with worse longitudinal strain, diastolic dysfunction, decreased ventricular-arterial coupling, and increased chamber and arterial elastance at the time of preeclampsia diagnosis and postpartum. Conclusions: Higher sFlt1 levels are associated with cardiovascular dysfunction during pregnancy and postpartum.
Collapse
Affiliation(s)
- Lisa Levine
- Maternal and Child Health Research Center, Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine , Philadelphia, PA, USA
| | - Zolt Arany
- Cardiovascular Institute, University of Pennsylvania Perelman School of Medicine , Philadelphia, PA, USA.,Division of Cardiology, University of Pennsylvania Perelman School of Medicine , Philadelphia, PA, USA
| | - Adina Kern-Goldberger
- Maternal and Child Health Research Center, Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine , Philadelphia, PA, USA
| | - Nathanael Koelper
- Center for Research on Reproduction and Women's Health, Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine , Philadelphia, PA, USA
| | - Jennifer Lewey
- Division of Cardiology, University of Pennsylvania Perelman School of Medicine , Philadelphia, PA, USA
| | - Mary D Sammel
- Center for Integrative Design and Analysis (CIDA, Colorado School of Public Health , Denver, Colorado, USA
| | - Michal A Elovitz
- Maternal and Child Health Research Center, Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine , Philadelphia, PA, USA
| | - Bonnie Ky
- Cardiovascular Institute, University of Pennsylvania Perelman School of Medicine , Philadelphia, PA, USA.,Division of Cardiology, University of Pennsylvania Perelman School of Medicine , Philadelphia, PA, USA.,Department of Biostatistics, Epidemiology and Informatics, Center for Clinical Epidemiology and Biostatistics, and Women's Health Clinical Research Center, University of Pennsylvania Perelman School of Medicine , Philadelphia, PA, USA
| |
Collapse
|
40
|
McGregor PC, Moura FA, Banchs J, Aragam JR. Role of myocardial strain imaging in surveillance and management of cancer therapeutics-related cardiac dysfunction: A systematic review. Echocardiography 2020; 38:314-328. [PMID: 33277729 DOI: 10.1111/echo.14944] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/27/2020] [Accepted: 11/15/2020] [Indexed: 12/18/2022] Open
Abstract
Transthoracic echocardiography is the primary cardiac imaging modality for the detection of Cancer Therapeutics-Related Cardiac Dysfunction (CTRCD) through evaluation of serial changes in left ventricular ejection fraction (LVEF). However, LVEF assessment by standard methods including 3D Echo has important limitations including the fact that reduction in LVEF occurs late in the process of CTRCD. In contrast, by detecting early myocardial change, myocardial strain or deformation imaging has evolved to be a preferred parameter for detecting CTRCD. Peak systolic global longitudinal strain (GLS) by speckle-tracking echocardiography (STE) has become an important prechemotherapy parameter that can independently predict subsequent adverse cardiac events as these abnormalities typically precede reduction in LVEF. While an absolute GLS measurement may be informative, a 10%-15% early reduction in GLS by STE appears to be the most useful prognosticator for cardiotoxicity while on therapy. In this paper, we present a current systematic literature review of application of myocardial strain imaging in cancer patients performed following PRISMA guidelines using electronic databases from MEDLINE, Embase, and SCOPUS Library from their inception until June 11th 2020. This review demonstrates the incremental value of myocardial deformation imaging over traditional LVEF in detection and its clinical implication in management of CTRCD.
Collapse
Affiliation(s)
- Pei-Chun McGregor
- Department of Cardiology, Boston Veterans Affairs Healthcare System, West Roxbury, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Filipe A Moura
- Harvard Medical School, Boston, MA, USA.,Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jose Banchs
- Department of Cardiology, MD Anderson Cancer Center, Houston, TX, USA
| | - Jayashri R Aragam
- Department of Cardiology, Boston Veterans Affairs Healthcare System, West Roxbury, MA, USA.,Harvard Medical School, Boston, MA, USA
| |
Collapse
|
41
|
3D echocardiography, arterial stiffness, and biomarkers in early diagnosis and prediction of CHOP-induced cardiotoxicity in non-Hodgkin's lymphoma. Sci Rep 2020; 10:18473. [PMID: 33116212 PMCID: PMC7595195 DOI: 10.1038/s41598-020-75043-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 10/07/2020] [Indexed: 12/13/2022] Open
Abstract
CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) represents standard chemotherapy in non-Hodgkin's lymphoma (NHL) with risk of cardiotoxicity. To define new parameters, such as 3D myocardial deformation, arterial stiffness, and biomarkers for early diagnosis and prediction of cardiotoxicity. 110 NHL patients with LVEF > 50%, scheduled for CHOP, were evaluated at baseline, after third cycle and chemotherapy completion. 3DE assessed LVEF and myocardial deformation: longitudinal (LS), radial, circumferential, area strain. Echo-tracking analysed arterial stiffness: PWV, β index, wave intensity. Troponin I and NT-pro-BNP were measured. After chemotherapy completion, 18 patients (16%) (group I) developed cardiotoxicity (LVEF decrease < 50%, with > 10% from baseline); 92 patients (group II) did not. Significant reduction of 3D LV deformation and increase of arterial stiffness developed starting with third cycle, with greater changes in group I. LS reduction and PWV increase after third cycle were the best independent predictors for LVEF decrease; the association of LS decrease by > 19% and PWV increase by > 27% after third cycle predicted cardiotoxicity after chemotherapy completion (90% sensitivity and 81% specificity). 3D LS and PWV can detect early chemotherapy-induced cardiotoxicity and predict LVEF decline. These parameters should be incorporated in clinical protocols to monitor cardiovascular function during chemotherapy and early intervention.
Collapse
|
42
|
Impact of hypertension on left ventricular function in patients after anthracycline chemotherapy for malignant lymphoma. Int J Cardiol 2020; 323:126-132. [PMID: 32800904 DOI: 10.1016/j.ijcard.2020.08.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 07/05/2020] [Accepted: 08/07/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Hypertension is considered an important risk factors for cancer therapeutics-related cardiac dysfunction (CTRCD) as well as heart failure. However, the impact of hypertension and left ventricular (LV) hypertrophy (LVH), which is associated with hypertension, on LV function in patients treated with anthracycline chemotherapy for malignant lymphoma remains uncertain. METHOD We studied 92 patients with malignant lymphoma and with preserved LV ejection fraction (LVEF). Echocardiography was performed before and two-month after anthracycline chemotherapy. CTRCD was defined as the presence of an absolute decrease in LVEF ≥10% to a final value <53%. LVH was defined as concentric hypertrophy, which was determined as relative wall thickness ≥ 0.42 and LV mass index >95 g/m2 for females and > 115 g/m2 for males. RESULTS Relative decrease in LVEF after anthracycline chemotherapy in patients with hypertension (n = 23) was significantly higher than that in patients without hypertension (n = 69) (-5.8% [-9.4, -1.3]) vs. (-1.1% [-4.1, 2.5]); P = .005). Moreover, the prevalence of CTRCD in patients with hypertension tended to be higher than in those without hypertension (17% vs. 5%, p = .09). A sequential logistic model for predicting CTRCD, based on baseline clinical variables including major clinical risk factors, was improved by the addition of the complication of hypertension (P = .049), and further improved by the addition of the presence of LVH (P = .023). CONCLUSIONS Hypertension, especially when complicated by LVH, was found to be associated with LV dysfunction after anthracycline chemotherapy in patients with malignant lymphoma and preserved LVEF. Watchful observation or early therapeutic intervention may thus be needed for such patients by the addition of the presence of LVH.
Collapse
|
43
|
Abstract
OPINION STATEMENT Moderate-level evidence suggests that cardiac troponin and natriuretic peptides are useful for risk stratification and early identification of anthracycline cardiotoxicity; however, many of these studies used older chemotherapy regimens, and thus, the applicability to current anthracycline treatment regimens is uncertain. Further research is needed to determine optimal timing and thresholds for troponin and natriuretic peptides in anthracycline-treated patients and evaluate these and other promising biomarkers for anti-HER2 therapies, thoracic radiation, anti-VEGF therapy, and fluoropyrimidine therapy-related cardiotoxicity. Risk tools that combine cardiac risk factors, cancer treatment variables, biomarkers, and imaging parameters are most likely to accurately identify individuals at highest risk for cancer therapy cardiotoxicity. Clinical trials focusing cardioprotective strategies on high-risk individuals are more likely to result in clinically significant results compared with primary prevention cardioprotective approaches.
Collapse
Affiliation(s)
- Jenica N Upshaw
- Division of Cardiology, Tufts Medical Center, 800 Washington St, Box 5931, Boston, MA, 02111, USA.
| |
Collapse
|
44
|
Cardiac Monitoring for Thoracic Radiation Therapy: Survey of Practice Patterns in the United States. Am J Clin Oncol 2020; 43:249-256. [PMID: 31972567 DOI: 10.1097/coc.0000000000000666] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The American Society of Clinical Oncology (ASCO) 2017 guidelines on cardiac monitoring during cancer treatments identified patients receiving thoracic radiation (TRT) ≥30 Gy (heart in field) at increased risk for developing radiation-induced heart disease (RIHD). ASCO encouraged clinicians to actively screen and monitor for baseline modifiable cardiac risk factors and therapy-induced cardiotoxicity in this high-risk population. Coronary artery calcium (CAC) is an independent risk factor for adverse cardiac events that can be mitigated with preventative medical therapy. It is unclear whether radiation oncologists (ROs) are aware of ASCO guidelines or the implications of CAC observed on computed tomographic scans. We report on practice patterns, perceptions, and experiences of cardiac monitoring for patients receiving definitive TRT, excluding breast patients. MATERIALS AND METHODS A 28-question survey was emailed to United States ROs 3 times from September 2018 to January 2019. RESULTS There were 162 respondents from 42 states, 51% in academic practice. Most ROs (81%) were not aware of the ASCO guidelines. Only 24% agreed with the guidelines, only 27% believed symptomatic RIHD could manifest within 2 years of TRT, and 69% thought there was a lack of strong evidence for type and timing of cardiac monitoring tests. If CAC was evident on computed tomographic scans, 40% took no further action to inform the patient or referring doctor. CONCLUSIONS This survey highlights a critical gap in knowledge about cardiac monitoring and potentially life-saving opportunities for preventive cardiac medical management. Future studies focusing on timing and detection of RIHD may elucidate the utility of cardiac monitoring for TRT patients.
Collapse
|
45
|
Oikonomou EK, Kokkinidis DG, Kampaktsis PN, Amir EA, Marwick TH, Gupta D, Thavendiranathan P. Assessment of Prognostic Value of Left Ventricular Global Longitudinal Strain for Early Prediction of Chemotherapy-Induced Cardiotoxicity: A Systematic Review and Meta-analysis. JAMA Cardiol 2020; 4:1007-1018. [PMID: 31433450 DOI: 10.1001/jamacardio.2019.2952] [Citation(s) in RCA: 197] [Impact Index Per Article: 49.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Importance Echocardiographic left ventricular global longitudinal strain (GLS) detects early subclinical ventricular dysfunction and can be used in patients receiving potentially cardiotoxic chemotherapy. A meta-analysis of the prognostic value of GLS for cancer therapy-related cardiac dysfunction (CTRCD) has not been performed, to our knowledge. Objective To explore the prognostic value of GLS for the prediction of CTRCD. Data Sources Systematic search of the MEDLINE, Embase, Scopus, and the Cochrane Library databases from database inception to June 1, 2018. Study Selection Cohort studies assessing the prognostic or discriminatory performance of GLS before or during chemotherapy for subsequent CTRCD. Data Extraction and Synthesis Random-effects meta-analysis and hierarchical summary receiver operating characteristic curves (HSROCs) were used to summarize the prognostic and discriminatory performance of different GLS indices. Publication bias was assessed using the Egger test, and meta-regression was performed to assess sources of heterogeneity. Main Outcomes and Measures The primary outcome was CTRCD, defined as a clinically significant change in left ventricular ejection fraction with or without new-onset heart failure symptoms. Results Analysis included 21 studies comprising 1782 patients with cancer, including breast cancer, hematologic malignancies, or sarcomas, treated with anthracyclines with or without trastuzumab. The incidence of CTRCD ranged from 9.3% to 43.8% over a mean follow-up of 4.2 to 23.0 months (pooled incidence, 21.0%). For active treatment absolute GLS (9 studies), the high-risk cutoff values ranged from -21.0% to -13.8%, with worse GLS associated with a higher CTRCD risk (odds ratio, 12.27; 95% CI, 7.73-19.47; area under the HSROC, 0.86; 95% CI, 0.83-0.89). For relative changes vs a baseline value (9 studies), cutoff values ranged from 2.3% to 15.9%, with a greater decrease linked to a 16-fold higher risk of CTRCD (odds ratio, 15.82; 95% CI, 5.84-42.85; area under the HSROC, 0.86; 95% CI, 0.83-0.89). Both indices showed significant publication bias. Meta-regression identified differences in sample size and CTRCD definition but not GLS cutoff value as significant sources of interstudy heterogeneity. Conclusions and Relevance In this meta-analysis, measurement of GLS after initiation of potentially cardiotoxic chemotherapy with anthracyclines with or without trastuzumab had good prognostic performance for subsequent CTRCD. However, risk of bias in the original studies, publication bias, and limited data on the incremental value of GLS and its optimal cutoff values highlight the need for larger prospective multicenter studies.
Collapse
Affiliation(s)
- Evangelos K Oikonomou
- Department of Internal Medicine, Yale New Haven Hospital, Yale School of Medicine, New Haven, Connecticut
| | - Damianos G Kokkinidis
- Department of Internal Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, New York, New York
| | - Polydoros N Kampaktsis
- Department of Cardiology, New York Presbyterian Hospital, Weill Cornell Medical College, New York
| | - Eitan A Amir
- Division of Medical Oncology, Princess Margaret Cancer Center, University of Toronto, Toronto, Ontario, Canada
| | - Thomas H Marwick
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Dipti Gupta
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Paaladinesh Thavendiranathan
- Peter Munk Cardiac Centre, Ted Rogers Program in Cardiotoxicity Prevention, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
46
|
Upshaw JN. Cardioprotective Strategies to Prevent Cancer Treatment-Related Cardiovascular Toxicity: a Review. Curr Oncol Rep 2020; 22:72. [DOI: 10.1007/s11912-020-00923-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
|
47
|
Non-Invasive Quantification of Ventricular Contractility, Arterial Elastic Function and Ventriculo-Arterial Coupling from a Single Diagnostic Encounter Using Simultaneous Arterial Tonometry and Magnetic Resonance Imaging. Cardiovasc Eng Technol 2020; 11:283-294. [DOI: 10.1007/s13239-020-00462-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 04/07/2020] [Indexed: 12/31/2022]
|
48
|
Makavos G, Ikonomidis I, Palios J, Rigopoulos A, Katogiannis K, Parissis J, Paraskevaidis I, Noutsias M. Cardiac imaging in cardiotoxicity: a focus on clinical practice. Heart Fail Rev 2020; 26:1175-1187. [PMID: 32306221 DOI: 10.1007/s10741-020-09952-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Cancer therapeutics induced cardiotoxicity has emerged as an important factor of long-term adverse cardiovascular outcomes in survivors of various malignant diseases. Early detection of myocardial injury in the setting of cancer treatment is important for the initiation of targeted cardioprotective therapy, in order to prevent irreversible cardiac dysfunction and heart failure, while not withholding a potentially life-saving cancer therapy. Cardiac imaging techniques including echocardiography, cardiac magnetic resonance, and nuclear cardiac imaging are the main tools for the identification of cardiotoxicity. There is also growing evidence for the detection of subclinical cardiac dysfunction in cancer patients by speckle tracking echocardiography. In this review article, we focus on current and emerging data regarding the role of cardiac imaging for the detection of changes in myocardial function related with cancer treatment in clinical practice.
Collapse
Affiliation(s)
- George Makavos
- 2nd Department of Cardiology, "Attikon" Hospital, National and Kapodistrian University of Athens Medical School, Rimini 1, Haidari, 12462, Athens, Greece.
| | - Ignatios Ikonomidis
- 2nd Department of Cardiology, "Attikon" Hospital, National and Kapodistrian University of Athens Medical School, Rimini 1, Haidari, 12462, Athens, Greece
| | - John Palios
- 2nd Department of Cardiology, "Attikon" Hospital, National and Kapodistrian University of Athens Medical School, Rimini 1, Haidari, 12462, Athens, Greece
| | - Angelos Rigopoulos
- Mid-German Heart Center, Department of Internal Medicine III, Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Strasse 40, 06120, Halle (Saale), Germany
| | - Konstantinos Katogiannis
- 2nd Department of Cardiology, "Attikon" Hospital, National and Kapodistrian University of Athens Medical School, Rimini 1, Haidari, 12462, Athens, Greece
| | - John Parissis
- 2nd Department of Cardiology, "Attikon" Hospital, National and Kapodistrian University of Athens Medical School, Rimini 1, Haidari, 12462, Athens, Greece
| | - Ioannis Paraskevaidis
- Department of Clinical Therapeutics, "Alexandra" Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Michel Noutsias
- Mid-German Heart Center, Department of Internal Medicine III, Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Strasse 40, 06120, Halle (Saale), Germany
| |
Collapse
|
49
|
Demissei BG, Hubbard RA, Zhang L, Smith AM, Sheline K, McDonald C, Narayan V, Domchek SM, DeMichele A, Shah P, Clark AS, Fox K, Matro J, Bradbury AR, Knollman H, Getz KD, Armenian SH, Januzzi JL, Tang WHW, Liu P, Ky B. Changes in Cardiovascular Biomarkers With Breast Cancer Therapy and Associations With Cardiac Dysfunction. J Am Heart Assoc 2020; 9:e014708. [PMID: 31959034 PMCID: PMC7033834 DOI: 10.1161/jaha.119.014708] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background We examined the longitudinal associations between changes in cardiovascular biomarkers and cancer therapy–related cardiac dysfunction (CTRCD) in patients with breast cancer treated with cardotoxic cancer therapy. Methods and Results Repeated measures of high‐sensitivity cardiac troponin T (hs‐cTnT), NT‐proBNP (N‐terminal pro‐B‐type natriuretic peptide), myeloperoxidase, placental growth factor, and growth differentiation factor 15 were assessed longitudinally in a prospective cohort of 323 patients treated with anthracyclines and/or trastuzumab followed over a maximum of 3.7 years with serial echocardiograms. CTRCD was defined as a ≥10% decline in left ventricular ejection fraction to a value <50%. Associations between changes in biomarkers and left ventricular ejection fraction were evaluated in repeated‐measures linear regression models. Cox regression models assessed the associations between biomarkers and CTRCD. Early increases in all biomarkers occurred with anthracycline‐based regimens. hs‐cTnT levels >14 ng/L at anthracycline completion were associated with a 2‐fold increased CTRCD risk (hazard ratio, 2.01; 95% CI, 1.00–4.06). There was a modest association between changes in NT‐proBNP and left ventricular ejection fraction in the overall cohort; this was most pronounced with sequential anthracycline and trastuzumab (1.1% left ventricular ejection fraction decline [95% CI, −1.8 to –0.4] with each NT‐proBNP doubling). Increases in NT‐proBNP were also associated with CTRCD (hazard ratio per doubling, 1.56; 95% CI, 1.32–1.84). Increases in myeloperoxidase were associated with CTRCD in patients who received sequential anthracycline and trastuzumab (hazard ratio per doubling, 1.28; 95% CI, 1.04–1.58). Conclusions Cardiovascular biomarkers may play an important role in CTRCD risk prediction in patients with breast cancer who receive cardiotoxic cancer therapy, particularly in those treated with sequential anthracycline and trastuzumab therapy. Clinical Trial Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01173341.
Collapse
Affiliation(s)
- Biniyam G Demissei
- Department of Medicine Division of Cardiology Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Rebecca A Hubbard
- Department of Biostatistics, Epidemiology & Informatics Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Liyong Zhang
- Division of Cardiology University of Ottawa Heart Institute Ottawa Ontario Canada
| | - Amanda M Smith
- Department of Medicine Division of Cardiology Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Karyn Sheline
- Department of Medicine Division of Cardiology Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Caitlin McDonald
- Department of Medicine Division of Cardiology Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Vivek Narayan
- Abramson Cancer Center Perelman School of Medicine at the University of Pennsylvania Philadelphia PA.,Department of Medicine Division of Hematology and Oncology University of Pennsylvania Philadelphia PA
| | - Susan M Domchek
- Abramson Cancer Center Perelman School of Medicine at the University of Pennsylvania Philadelphia PA.,Department of Medicine Division of Hematology and Oncology University of Pennsylvania Philadelphia PA
| | - Angela DeMichele
- Abramson Cancer Center Perelman School of Medicine at the University of Pennsylvania Philadelphia PA.,Department of Medicine Division of Hematology and Oncology University of Pennsylvania Philadelphia PA
| | - Payal Shah
- Abramson Cancer Center Perelman School of Medicine at the University of Pennsylvania Philadelphia PA.,Department of Medicine Division of Hematology and Oncology University of Pennsylvania Philadelphia PA
| | - Amy S Clark
- Abramson Cancer Center Perelman School of Medicine at the University of Pennsylvania Philadelphia PA.,Department of Medicine Division of Hematology and Oncology University of Pennsylvania Philadelphia PA
| | - Kevin Fox
- Abramson Cancer Center Perelman School of Medicine at the University of Pennsylvania Philadelphia PA.,Department of Medicine Division of Hematology and Oncology University of Pennsylvania Philadelphia PA
| | - Jennifer Matro
- Abramson Cancer Center Perelman School of Medicine at the University of Pennsylvania Philadelphia PA.,Department of Medicine Division of Hematology and Oncology University of Pennsylvania Philadelphia PA
| | - Angela R Bradbury
- Abramson Cancer Center Perelman School of Medicine at the University of Pennsylvania Philadelphia PA.,Department of Medicine Division of Hematology and Oncology University of Pennsylvania Philadelphia PA
| | - Hayley Knollman
- Abramson Cancer Center Perelman School of Medicine at the University of Pennsylvania Philadelphia PA.,Department of Medicine Division of Hematology and Oncology University of Pennsylvania Philadelphia PA
| | - Kelly D Getz
- Division of Oncology The Children's Hospital of Philadelphia PA
| | | | - James L Januzzi
- Division of Cardiovascular Medicine Massachusetts General Hospital Boston MA
| | - W H Wilson Tang
- Division of Cardiovascular Medicine Cleveland Clinic Cleveland OH
| | - Peter Liu
- Division of Cardiology University of Ottawa Heart Institute Ottawa Ontario Canada
| | - Bonnie Ky
- Department of Medicine Division of Cardiology Perelman School of Medicine at the University of Pennsylvania Philadelphia PA.,Department of Biostatistics, Epidemiology & Informatics Perelman School of Medicine at the University of Pennsylvania Philadelphia PA.,Abramson Cancer Center Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| |
Collapse
|
50
|
Steingart RM, Chandrashekhar Y, Marwick TH. Imaging in Cardio-Oncology: Where Are We and Where Should We Be Going? JACC Cardiovasc Imaging 2019; 11:1209-1211. [PMID: 30092977 DOI: 10.1016/j.jcmg.2018.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
| | - Y Chandrashekhar
- Division of Cardiology, University of Minnesota and Veterans Affairs Medical Center, Minneapolis, Minnesota.
| | - Thomas H Marwick
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| |
Collapse
|