Case Report
Early Extracorporeal Membrane Oxygenation Support for 5‑Fluorouracil‑induced Acute Heart Failure with Cardiogenic Shock Robert Höllriegel, Julia Fischer, Gerhard Schuler Department of Internal Medicine/Cardiology, University of Leipzig - Heart Center, Leipzig, Germany
ABSTRACT A 50‑year‑old man with no previous history of cardiovascular disease or risk factors was admitted for syncope and orthopnea. Importantly, he underwent recent chemotherapy with 5‑fluorouracil (5‑FU) until 1 day before his acute presentation. In the emergency room, patient developed asystole and was successfully resuscitated for 2 min. At coronary angiography, no signs of coronary artery disease were detectable, but transthoracic echocardiography showed a severely decreased left‑ventricular systolic function. Due to the progressive cardiogenic shock, an extracorporeal membrane oxygenation (ECMO) support was used as bridge-to-recovery and to avoid the use of sympathomimetics with their known disadvantages. On ECMO support, hemodynamic stabilization was evident and medical heart failure treatment was commenced. Left‑ventricular function recovered to normal values within a short period of time. Cardiac complications after chemotherapy with 5‑FU are not rare and should be taken into consideration even in acute heart failure with cardiogenic shock. ECMO as the most potent form of acute cardiorespiratory support enables complete relief of cardiac workload and therefore recovery of cardiac function.
Key words: Acute heart failure, cardiogenic shock, extracorporeal membrane oxygenation support, 5‑fluorouracil How to cite this article: Höllriegel R, Fischer J, Schuler G. Early extracorporeal membrane oxygenation support for 5-fluorouracil-induced acute heart failure with cardiogenic shock. Heart Views 2014;15:26-8. © Gulf Heart Association 2014.
INTRODUCTION
5
‑fluorouracil (5‑FU) is a widely used chemotherapeutic drug and cardiac complications are not rare. [1] Angina is the most common clinical presentation. However myocardial infarction, Tako‑Tsubo‑like syndrome and cardiogenic shock are also described.[1‑3]
CASE REPORT A 50‑year‑old man (weight 70 kg, height 180 cm) was admitted to a primary care hospital following an episode of syncope. He reported acute orthopnea and an attack of sweating at night accompanied by nausea and vomiting before loss of consciousness for 1 min. Angina pectoris was denied by patient. In the emergency room, patient developed asystole and was immediately and successfully resuscitated for 2 min. Afterwards, he was fully oriented without any neurological dysfunction. Consequently, he was Address for correspondence: Dr. Robert Höllriegel,
Department of Internal Medicine/Cardiology, University of Leipzig - Heart Center, Struempellstrasse 39, 04289 Leipzig, Germany. E-mail: [email protected]
HEART VIEWS Jan-Mar 14 Issue 1 / Vol 15
transferred to our heart center for further diagnostic work‑up and therapy. Importantly, patient had no previous history of cardiovascular disease or risk factors, but was diagnosed with colorectal cancer (cT3 N1 M0) and underwent recent neoadjuvant chemotherapy with 5‑FU (9500 mg by continuous infusion over a period of 120 h) until 1 day before his acute presentation. His physical examination revealed hypotensive blood pressures (89/58 mmHg) and heart rate at rest of 95 bpm. There was distension of the jugular veins with normal heart sounds. The electrocardiogram documented sinus rhythm at 95 bpm with non‑significant ST‑elevation in leads II, III, aVF. High‑sensitive troponin T (60 ng/L; upper reference value 14 ng/L) and creatine kinase‑MB fraction (0.74 µmol/L*s; upper reference Access this article online Quick Response Code:
Website: www.heartviews.org DOI: 10.4103/1995-705X.132144
26
Höllriegel, et al.: 5-fluorouracil-induced acute heart failure
hemodynamic stabilization was evident and medical heart failure treatment including angiotensin‑converting enzyme‑inhibitor, diuretics and spironolactone was commenced. After 4 days with ECMO therapy, left‑ventricular ejection fraction improved to 45% and lactate levels were in normal ranges (
Early Extracorporeal Membrane Oxygenation Support for 5‑Fluorouracil‑induced Acute Heart Failure with Cardiogenic Shock Robert Höllriegel, Julia Fischer, Gerhard Schuler Department of Internal Medicine/Cardiology, University of Leipzig - Heart Center, Leipzig, Germany
ABSTRACT A 50‑year‑old man with no previous history of cardiovascular disease or risk factors was admitted for syncope and orthopnea. Importantly, he underwent recent chemotherapy with 5‑fluorouracil (5‑FU) until 1 day before his acute presentation. In the emergency room, patient developed asystole and was successfully resuscitated for 2 min. At coronary angiography, no signs of coronary artery disease were detectable, but transthoracic echocardiography showed a severely decreased left‑ventricular systolic function. Due to the progressive cardiogenic shock, an extracorporeal membrane oxygenation (ECMO) support was used as bridge-to-recovery and to avoid the use of sympathomimetics with their known disadvantages. On ECMO support, hemodynamic stabilization was evident and medical heart failure treatment was commenced. Left‑ventricular function recovered to normal values within a short period of time. Cardiac complications after chemotherapy with 5‑FU are not rare and should be taken into consideration even in acute heart failure with cardiogenic shock. ECMO as the most potent form of acute cardiorespiratory support enables complete relief of cardiac workload and therefore recovery of cardiac function.
Key words: Acute heart failure, cardiogenic shock, extracorporeal membrane oxygenation support, 5‑fluorouracil How to cite this article: Höllriegel R, Fischer J, Schuler G. Early extracorporeal membrane oxygenation support for 5-fluorouracil-induced acute heart failure with cardiogenic shock. Heart Views 2014;15:26-8. © Gulf Heart Association 2014.
INTRODUCTION
5
‑fluorouracil (5‑FU) is a widely used chemotherapeutic drug and cardiac complications are not rare. [1] Angina is the most common clinical presentation. However myocardial infarction, Tako‑Tsubo‑like syndrome and cardiogenic shock are also described.[1‑3]
CASE REPORT A 50‑year‑old man (weight 70 kg, height 180 cm) was admitted to a primary care hospital following an episode of syncope. He reported acute orthopnea and an attack of sweating at night accompanied by nausea and vomiting before loss of consciousness for 1 min. Angina pectoris was denied by patient. In the emergency room, patient developed asystole and was immediately and successfully resuscitated for 2 min. Afterwards, he was fully oriented without any neurological dysfunction. Consequently, he was Address for correspondence: Dr. Robert Höllriegel,
Department of Internal Medicine/Cardiology, University of Leipzig - Heart Center, Struempellstrasse 39, 04289 Leipzig, Germany. E-mail: [email protected]
HEART VIEWS Jan-Mar 14 Issue 1 / Vol 15
transferred to our heart center for further diagnostic work‑up and therapy. Importantly, patient had no previous history of cardiovascular disease or risk factors, but was diagnosed with colorectal cancer (cT3 N1 M0) and underwent recent neoadjuvant chemotherapy with 5‑FU (9500 mg by continuous infusion over a period of 120 h) until 1 day before his acute presentation. His physical examination revealed hypotensive blood pressures (89/58 mmHg) and heart rate at rest of 95 bpm. There was distension of the jugular veins with normal heart sounds. The electrocardiogram documented sinus rhythm at 95 bpm with non‑significant ST‑elevation in leads II, III, aVF. High‑sensitive troponin T (60 ng/L; upper reference value 14 ng/L) and creatine kinase‑MB fraction (0.74 µmol/L*s; upper reference Access this article online Quick Response Code:
Website: www.heartviews.org DOI: 10.4103/1995-705X.132144
26
Höllriegel, et al.: 5-fluorouracil-induced acute heart failure
hemodynamic stabilization was evident and medical heart failure treatment including angiotensin‑converting enzyme‑inhibitor, diuretics and spironolactone was commenced. After 4 days with ECMO therapy, left‑ventricular ejection fraction improved to 45% and lactate levels were in normal ranges (
