Yann Ancedy

Clinical Features, Management, and Outcomes of Immune Checkpoint Inhibitor–Related Cardiotoxicity

Immune checkpoint inhibitors (ICIs) represent a major advance in the treatment of cancer. Although clinical trials reported a low incidence of immune-related cardiovascular adverse events,1 the number of published life-threatening cases of cardiotoxicity is increasing.2 In this descriptive observational analysis, we aimed to describe the clinical manifestations, management, and outcomes of patients who developed ICI-related cardiotoxicity. The medical records of patients with a clinical suspicion of ICI-related cardiotoxicity were reviewed from the databases of 2 cardio-oncology units between March 2015 and April 2017. The patients are managed according to similar protocols. Because no specific follow-up had previously been established for patients receiving ICIs during the study period, the oncologists referred patients receiving ICIs only on the basis of their clinical suspicion of cardiovascular events. These patients had a standardized evaluation including clinical consultation, ECG, transthoracic echocardiography, and measurement of brain natriuretic peptide and troponin I serum levels. The management of cardiotoxicity was left to the physician’s discretion. The study was approved by our institutional review board, and informed consent has been obtained from the subjects. To create a pooled analysis, we also searched PubMed for English articles reporting cases of ICI-related cardiotoxicity until April 2017. We selected …

Takotsubo-Like Syndrome in Cancer Patients Treated With Immune Checkpoint Inhibitors

Takotsubo syndrome (TTS) is defined as an acute, reversible, left ventricular (LV) systolic dysfunction that can mimic acute coronary syndrome. In patients with TTS, the prevalence of patients with a history of cancer can be as high as 29% [(1)][1]. Several drugs and particularly chemotherapy are

Stratégie de dépistage précoce de la toxicité cardiaque secondaire aux anthracyclines et thérapies moléculaires ciblées

Anthracyclines and molecular targeted agents have improved prognosis of patients undergoing chemotherapeutics for malignancy. However, the use of these therapies is limited because of risk of cardiac toxicity. The severity of the cardiomyopathy can range from an asymptomatic left ventricular (LV) dysfunction to a severe congestive heart failure. Cardiomyopathy can be reversible or irreversible according to the type of chemotherapy, modality of administration and patients characteristics. Several studies aimed to early detection and the evaluation of tools to characterize patients at risk to develop cardiac side effects in order to prevent severe LV dysfunction. According to this literature, it is recommended that initial assessment and follow-up of patients undergoing these chemotherapies be performed using troponin dosage, assessment of left ventricle ejection fraction and evaluation of LV myocardial deformation assessing LV global longitudinal strain.

Is von Willebrand factor associated with stroke and death at mid-term in patients with non-valvular atrial fibrillation?

BACKGROUND Heart failure and atrial fibrillation share common mechanisms that may contribute to hypercoagulability and thrombotic risk. Elevated von Willebrand factor (vWF) concentration has been associated with increased risk of thromboembolism and cardiovascular events. AIM To investigate whether increased vWF plasma concentration predicts occurrence of a composite endpoint (all-cause death and stroke) in patients with non-valvular atrial fibrillation (NVAF). METHODS We prospectively studied 122 patients (mean age 70±14years; 46% men) hospitalized with NVAF, and followed over a median (interquartile range) of 5.4 (2.3-9.0)years. Cox proportional models were used to estimate the association of vWF concentration with time to stroke and death. RESULTS Forty-three patients (35%) had at least a stroke or died during the 5-year follow-up. Kaplan-Meier curves using vWF plasma concentration tertiles (≤191IU/dL;>191 to≤295IU/dL;>295IU/dL) showed that vWF plasma concentrations discriminated groups of patients with higher cardiovascular event rates (log-rank P=0.01). In the multivariable analysis, higher vWF concentrations (middle tertile hazard ratio [HR] 4.59, 95% confidence interval [CI] 1.55-13.50 [P=0.006]; upper tertile HR 4.10, 95% CI 1.43-11.75 [P=0.009]), age≥75years (HR 5.02, 95% CI 1.53-16.49; P=0.008), heart failure (HR 2.05, 1.01-4.19; P=0.048), C-reactive protein, log2 per unit increase (HR 1.29, 95% CI 1.04-1.61; P=0.021), no warfarin at discharge (HR 4.96, 95% CI 2.02-12.20; P<0.0001) and no aspirin at discharge (HR 4.41, 95% CI 1.71-11.97; P=0.002) were independently associated with an increased risk of stroke and all-cause death, whereas female sex was a protective factor (HR 0.35, 0.16-0.78; P=0.01). CONCLUSIONS High vWF plasma concentrations may discriminate patients with NVAF at greater risk of stroke or all-cause death.

Multilayer global longitudinal strain in patients with cancer: A comparison of two vendors

BACKGROUND Global longitudinal strain (GLS) has several sources of variation. Strain multilayer tracking is a new tool that has not yet been validated in clinical practice. AIM The purpose of this study was to investigate intervendor variability when measuring multilayer strain in patients receiving chemotherapy for cancer. METHODS Patients receiving chemotherapy for cancer, who were referred for echocardiography, were included prospectively. First, the same operator performed two-dimensional echocardiography on each patient using the Vivid E9™ (General Electric, Fairfield, CT, USA) and the ACUSON SC2000™ (Siemens, Munich, Germany) ultrasound systems. Second, we assessed myocardial deformation by using their respective speckle-tracking software. Third, we compared absolute values of GLS for the two vendors in each apical view (four-, three- and two-chamber) and for each layer (endocardial, mid-myocardial and epicardial). RESULTS Eighty patients with cancer were included prospectively between February and June 2015. For a given vendor, GLS values decreased from the endocardial layer to the epicardial layer. For a given view, GLS values obtained with the ACUSON SC2000 platform were systematically lower than those obtained with the Vivid E9 platform (P<0.0001). We observed a significant difference between the two platforms, irrespective of the layer, interlayer gradient or chamber view considered (P<0.0001). CONCLUSIONS There was poor agreement for layer-specific strain evaluation between the Vivid E9 and ACUSON SC2000 platforms, using their dedicated software for strain multilayer assessment. These results suggest that, in clinical practice, the same system and software from the same vendor should be used for longitudinal follow-up.

0554 : Right ventricle 2D strain derived from speckle tracking imaging might help to identify patients with pulmonary embolism at low risk

Background We sought to investigate whether right ventricular deformation parameters as assessed with two-dimensional (2D) speckle tracking imaging (STI) could help in identifying patients at low risk according to the ESC guidelines. Methods From February 2015 to September 2015 all consecutive patients with a PE confirmed by thoracic computed tomography scan or by ventilation/ perfusion scintigraphy were included in the study. 2D Echocardiography was performed at admission. STI Longitudinal strain for the RV free wall and septal wall. We defined as intermediate-to-high risk PE patients with RV systolic dysfunction on echocardiography (defined as RV/LV ratio>0.9) and/or troponin I >0.04 μg/L and/or brain natriuretic peptide >100 pg/mL. When none of these criteria were present, patients were considered at low risk. Results Fifty-eight patients (mean age 66.1 ± 18.5 years, 55% male) were prospectively included. None of these patients exhibit hemodynamic instability. Twenty-three patients (40%) showed a RV/LV ratio > 0.9, 25 patients (43%) an elevated BNP levels (mean: 454±494 pg/mL) and 17 patients (29%) an elevated troponin levels (mean: 0.36±0.46 μg/L). According to the ESC guidelines, 14 patients (24%) were classified at low risk PE, and 44 (76%) at intermediate-to-high risk. Global 2D RV strain differed significantly between the 2 groups (23.0% vs. 19.3%, p=0.0035), as did RV strain of the free wall (26.9% vs. 21.1%, p=0.0038). However, 2D RV strain of the septal wall did not differ significantly in the 2 groups (20.0% vs. 18.5%, p=0.12). ROC curves were determined to evaluate the ability of RV strain parameters derived from STI to identify low risk patients. The best performance was obtained with global 2D RV strain and a cut off value of 23.0%. Conclusion Global longitudinal 2D strain is significantly reduced in patients with intermediate-to-high risk PE compared with low risk PE. A cut off value of 23% allowed to identify PE patients at low risk. Download : Download full-size image Figure . Comparative receiver operative character The author hereby declares no conflict of interest

0553 : Assessment of myocardial deformation using multi-layer speckle tracking in patients undergoing chemotherapy: a comparison of two vendors

Background The purpose of this study was to investigate intervendor variability when measuring multilayer strain in cancer patients treated with oral chemotherapy. Methods Patients enrolled to receive oral chemotherapy were prospectively included. Firstly, a same operator performed a 2 dimensional echocardiography within a delay of 10 minutes using Vivid 9 (Vendor A) and SC 2000 Siemens (Vendor B) ultrasound systems for each patient. Thereafter, we assessed myocardial deformation by using their respective speckle tracking softwares for strain multilayer measurement. Thus, we compared GLS multilayer values for the 2 vendors in each apical view (4c, 3c and 2c) and for each layer (endocardial, mid and epicardial layer). Comparisons between the 2 vendors were evaluated using intra class correlation coefficient. Results Eighty patients planned to receive chemotherapy were prospectively included between February and June 2015. Mean age was 55.3±16.3 years and 61% were female. Median left ventricular ejection fraction was 62% (57-66). Results of GLS multilayer values according to vendor, incidence, layer and their comparison are summarized in Table 1 There was a poor agreement between GLS multilayer as measured with GE system and Siemens system, whatever the layers, the incidence and the vendor. Conclusion We found a poor agreement for layer specific strain evaluation between GE and Siemens system using their dedicated softwares for strain multilayer assessment. These results suggest that in patient receiving chemotherapy the same system and software from the same vendor should be used for a longitudinal follow-up. The author hereby declares no conflict of interest Table. Values of GLS according to vendor, layer and views Vendor A Vendor B ICC±SD 4c GLS endo 20.7 (18.5-23.5) 18.8 (17.1-21.0) 0.315±0.089 4c GLS mid 18.2 (16.1-20.5) 15.5 (13.6-17.2) 0.222±0.075 4c GLS epi 15.9 (14.1-17.9) 11.8 (10.6-14.2) 0.125±0.055 3c GLS endo 22.2 (19.8-25.7) 18.5 (16.6-21.4) 0.310±0.078 3c GLS mid 19.2 (17.3-22.3) 15.1 (13.6-17.5) 0.291±0.061 3c GLS epi 16.9 (15.2-14.2) 12.0 (9.6-13.5) 0.189±0.045 2c GLS endo 21.7 (19.0-24.1) 18.0 (16.7-20.9) 0.234±0.075 2c GLS mid 19.3 (17.0-21.8) 15.3 (13.2-17.1) 0.180±0.057 2c GLS epi 17.3 (15.1-19.4) 12.0 (10.3-14.0) 0.042±0.040 GLS: Global longitudinal strain, 4c: 4 chamber view, 3c: 3 chamber view, 2c: 2 chamber view, endo: endocardial layer, mid: mid layer, epi: epicardial layer, ICC: intraclass correlation coefficient, SD: Standard deviation. Full-size table Table options View in workspace Download as CSV