Andersons pediatric cardiology 1696
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TherapeuticOptionsforPatientsWith
CancerTreatment-RelatedCardiotoxicity
Somepractitionersinthefieldofcardio-oncologysupportthenotionthatall
patientsexposedtocancertreatmentshouldbeconsideredAmericanCollegeof
Cardiology/AmericanHeartAssociationstageAheartfailure,withthegoal
beingtopreventprogressiontostagesBtoD.15
MedicalTherapy
Adultsshouldreceivestandardguideline-directedheartfailuretherapy,76
supplementedbycardio-oncology–specificguidelinesthatinclude
recommendationsfortherapyinresponsetochangesinimagingandserum
biomarkers,symptomaticheartfailure,anddirectedbyspecificchemotherapy
exposures.16AlthoughCTCisnotcoveredspecifically,therearenowpediatric
guidelinesformanagementofcardiomyopathyandheartfailure.77
AdvancedHeartFailureTherapy
Whenstandardoraltherapiesareinsufficienttomanageheartfailure,patients
withCTCmayprogresstotheneedforinotropicormechanicalsupportoreven
considerationofhearttransplantation.Activeneoplasmandongoing
chemotherapyand/orradiotherapyarecontraindicationstotransplantationat
mostcenters.Transplantationcanbeconsideredifrecurrenceofthetumoris
deemedtobelow,thereisanegativeworkupforthepresenceofmetastases,and
otherconsiderationsthatincludetumortypeandresponsetotherapy.78Thereis
noobjectivetimeaftertherapyrequiredbeforelistingfortransplantation.
ReportsofhearttransplantationtotreatCTCinchildrenextendback20
years,79andarecentreviewofdatafromthePediatricHeartTransplantStudy
showthat,forappropriatelyselectedpatients,thereisnodifferenceinlong-term
graftsurvivalwhencomparedwithotherformsofdilatedcardiomyopathy.80For
patientsunabletowait,orforwhomitisnotappropriatetolistfor
transplantation,mechanicalcirculatorysupportmaybeoffered.Ifthe
mechanismofdysfunctionisbelievedtobetemporaryorreversible,short-or
medium-termsupportstrategiescanbridgethroughrecovery.81Iflong-term
survival,separatefromcardiacdisease,isotherwisehigh,thenbridgetoheart
transplantationmaybeconsidered.Inadultstreatedwithmechanicalcirculatory
supportrelatedtoCTC,survivalissimilartootherpatientsalthoughtheneedfor
earlypostoperativerightventricularsupportisgreater.82
ImplantableCardiacDefibrillatorsandCardiac
ResynchronizationTherapy
Indicationsforimplantablecardiacdefibrillatorsandcardiacresynchronization
therapyaresimilarinCTCtootherdiseaseprocesses.However,nospecific
guidelinesexistforthecancerpatientpopulation,andcareshouldbe
individualized.Interestingly,thereisevidencethatadultswithCTCareless
likelytoreceiveanimplantabledefibrillatororresynchronizationtherapythanin
othercausesofheartfailure,atleastpartlybecausespecificdataarelackingon
theefficacyofresynchronizationtherapyinCTC.83
Conclusion
CTCisanimportantpartofpatientcarebefore,during,andaftertherapy.Many
chemotherapeuticagentsleadtoawidevarietyofcardiovascularpathologies
thatcanmanifestwithinhoursofadministration,ordecadeslater.Thefieldof
cardio-oncologyisfocusedonprevention,surveillance,andtreatmentofCTC.
GiventhatanysinglecenterhasalimitednumberofpatientswithCTC,
multiinstitutionaleffortswillberequiredtoadvancethefieldandimprove
patientcare.
