Neha Bansal

Chemotherapy-induced cardiotoxicity in children

ABSTRACT Introduction: With advances in clinical oncology, the burden of morbidity and mortality for cancer survivors due to the cardiac side effects of the chemotherapy is steadily increasing. Treatment-related cardiac damage is progressive and often irreversible. Primary prevention of cardiotoxicity during treatment is possible with strategies like limiting the cumulative anthracycline dose, the use of anthracycline structural analogs, and especially cardioprotective agents. Areas covered: This review covers the various cardiotoxic chemotherapeutic agents, the pathophysiology of cardiotoxicity due to anthracyclines, and the clinical and subclinical presentations and progression of childhood anthracycline cardiotoxicity. We also discuss preventive measures and strategies, especially the cardioprotectant agent dexrazoxane where there is strong evidence-based support for its use with anthracycline chemotherapy. However, there is a paucity of evidence-based recommendations for diagnosing and treating cancer therapy-induced cardiovascular complications. Finally, we discuss the potential of cardio-oncology. Expert opinion: There is no ‘safe’ anthracycline dose if the goal is normal long-term cardiovascular status but higher lifetime cumulative doses of anthracyclines, higher dose rates, female sex, longer follow-up, younger age at anthracycline treatment, pre-existing cardiovascular disease, and cardiac irradiation are associated with more severe cardiotoxicity. With deeper understanding of the mechanisms of the adverse cardiac effects and identification of driver mutations causing these effects, personalized cancer therapy to limit cardiotoxic effects can be achieved, such as with the cardioprotectant dexrazoxane.

Ten-Year Clinical Experience with the Lumenless, Catheter-Delivered, 4.1-Fr Diameter Pacing Lead in Patients with and without Congenital Heart: 4.1FR PACING LEAD AFTER 10 YEARS

Patients with congenital heart defects (CHD) often present more challenges to pacing therapy due to anatomy than those without CHD. The lumenless, 4.1Fr diameter M3830 pacing lead (Medtronic, Inc., Minneapolis, MN, USA), approved for use in 2005, has, to date, reported to have excellent short‐term (<6 years) lead performance. Unfortunately, very long‐term performance is unknown, especially among CHD patients and with implants at alternate pacing (AP) sites. This study reports a 10‐year clinical experience with the M3830 lead.

Purulent Pericarditis Due to Paronychia in a 16-Month-Old Child: A Nail-Biting Story

Purulent pericarditis is a rare infectious disease with significant mortality, even in the modern antibiotic era. The presenting signs can often be subtle and patients can deteriorate rapidly with cardiac tamponade. We report a previously healthy 16-month-old female who developed purulent pericarditis associated with paronychia and sepsis caused by methicillin-sensitive Staphylococcus aureus. In addition to antibiotic treatment, she required emergent pericardiocentesis for cardiac tamponade, followed by two surgical interventions including full median sternotomy incision and partial pericardiectomy. At 4-month follow-up, she did well with no evidence of constrictive pericarditis on echocardiogram.

When is early septal myectomy in children with hypertrophic cardiomyopathy justified

Pediatric cardiomyopathy is a debilitating disease that leads to pump failure and sudden death; in fact, it is the leading cause of heart failure in children (1). Cardiomyopathy and heart failure in infants and children remain serious population health crises for children and their families and confer a great cost burden on society (2-5). In the United States, the estimated annual incidence of congenital cardiovascular malformations or cardiomyopathy in infants, children, and adolescents less than 19 years old is between 12,000 and 35,000 (6).

Pulmonary damage following right ventricular outflow tachycardia ablation in a child: When electroanatomical mapping isn't good enough

A 14‐year‐old female was referred for severe pulmonary valve insufficiency after undergoing radiofrequency ablation for a right ventricular outflow tract tachycardia that originated in the proximal pulmonary artery at 10 years of age. Clinical records indicated that ablation was guided solely by electrograms and electroanatomical mapping. Due to myocardial tissue extensions, mapping failed to identify the level of the pulmonary valve annulus, which resulted in delivery of energy on the valve proper and into the pulmonary artery. She developed severe pulmonary valve insufficiency and moderate proximal pulmonary artery stenosis necessitating intravascular stent placement 4 years later with an associated transcatheter valve. Although the nonfluoroscopic approach during ablation has gained wide acceptance for use in children, this report highlights the benefits of adjunctive imaging to identify the precise location of the pulmonary valve when ablation therapy is contemplated in the right ventricle outflow tract.

Child with Heart Transplant: Unique Immunologic and Hemodynamic Issues and Their Management

Heart transplant is indicated in children with heart failure secondary to dilated cardiomyopathy refractory to standard medical therapy, in children with congenital heart disease that is not amenable to surgical repair, and in children with failed palliation of congenital heart disease. Heart transplant recipients can pose a unique challenge to emergency room physicians with regard to clinical presentation, diagnostic testing, and therapeutic interventions warranted. The ER physician is the first to identify and possibly initiate treatment for the common complications seen after heart transplantation. The most common posttransplant complications are acute allograft rejection, life-threatening infections, adverse reactions to immunosuppressants, as well as certain malignancies, such as posttransplant lymphoproliferative disease (PTLD). In this chapter, we discuss the presentation and initial diagnostic and therapeutic steps in the management of patients with acute allograft rejection and infections—two most common indications for heart transplant recipients to present to the emergency room. Ultimately, it is important to have a high index of suspicion for the common complications of heart transplant as timely initiation of treatment is essential to decrease morbidity and mortality in this population. To achieve favorable outcomes, close consultation with the primary heart transplant team is essential for management of these complex and fragile patients.

Chapter 32 – Heart Failure in Pediatric Oncologic Disease

Abstract Children diagnosed with cancer are now living longer, thanks to advances in treatment. However, though cured of cancer, they are at risk for chronic health conditions. Cardiovascular diseases are among the most common cause of morbidity and mortality after recurrence and secondary malignancies. Cardiotoxicity is associated with certain cancer treatments, such as anthracyclines and radiation, and if left undetected or untreated can lead to heart failure, heart transplant, or death. This chapter will provide the latest evidence on risk factors, preventative strategies, screening, and treatment of cardiotoxicity in childhood cancer survivors. Though advances have been made, particularly in prevention by use of the cardioprotectant dexrazoxane, there is still much to be done to find a balance between oncologic efficacy and cardiotoxic late effects.

Bilateral branch pulmonary artery valve implantation in repaired tetralogy of fallot

Transcatheter, bilateral branch pulmonary artery (PA) valve implantation is a novel treatment for patients with severe pulmonary insufficiency and oversized right ventricle (RV) outflow tract. There is scarce data on efficacy and safety of this approach.

Coronary artery spasm in a neonate with transposition of great arteries: a rare complication and reason for heart transplant

Arterial switch operation has become the standard of care for d-transposition of great arteries and has excellent short- and long-term outcomes. We report the case of a newborn with a diagnosis of d-transposition of great arteries with intact ventricular septum and a low-risk coronary artery anatomy who developed coronary artery vasospasm while coming off bypass following arterial switch operation in the operating room. The coronary artery spasm led to severe biventricular dysfunction and need for extracorporeal membranous oxygenation support. Despite extracorporeal membranous oxygenation and inotropic support, there was no improvement in the left ventricular function, and cardiac transplantation was performed after 8 days. The explanted heart showed extensive infarction of both ventricles. Both the coronary ostei were patent with no evidence of thrombus, suggesting coronary artery vasospasm rather than embolus or thrombus formation. This is the first case of coronary artery vasospasm in a neonate with d-transposition of great arteries leading to cardiac transplantation. We speculate that early identification of patients who are at a high risk for coronary vasospasm and prophylactic or timely infusion of papaverine directly into the coronary arteries may be beneficial in this condition.

Junctional tachycardia in a child with non-rheumatic fever streptococcal pharyngitis

Accelerated junctional rhythm has been reported in children in the setting of acute rheumatic fever; however, we describe a hitherto unreported case of isolated junctional tachycardia in a child with streptococcal pharyngitis, not meeting revised Jones criteria for rheumatic fever. A previously healthy, 9-year-old girl presented to the emergency department with complaints of sore throat, low-grade fever, and intermittent chest pain. She was found to have a positive rapid streptococcal antigen test. The initial electrocardiogram showed junctional tachycardia with atrioventricular dissociation in addition to prolonged and aberrant atrioventricular conduction. An echocardiogram revealed normal cardiac anatomy with normal biventricular function. The patient responded to treatment with amoxicillin for streptococcal pharyngitis. The junctional tachycardia and other electrocardiogram abnormalities resolved during follow-up.