Andersons pediatric cardiology 1696

Therapeutic Options for Patients With Cancer Treatment-Related Cardiotoxicity Some practitioners in the field of cardio-oncology support the notion that all patients exposed to cancer treatment should be considered American College of Cardiology/American Heart Association stage A heart failure, with the goal being to prevent progression to stages B to D.15 Medical Therapy Adults should receive standard guideline-directed heart failure therapy,76 supplemented by cardio-oncology–specific guidelines that include recommendations for therapy in response to changes in imaging and serum biomarkers, symptomatic heart failure, and directed by specific chemotherapy exposures.16 Although CTC is not covered specifically, there are now pediatric guidelines for management of cardiomyopathy and heart failure.77 Advanced Heart Failure Therapy When standard oral therapies are insufficient to manage heart failure, patients with CTC may progress to the need for inotropic or mechanical support or even consideration of heart transplantation Active neoplasm and ongoing chemotherapy and/or radiotherapy are contraindications to transplantation at most centers Transplantation can be considered if recurrence of the tumor is deemed to be low, there is a negative work up for the presence of metastases, and other considerations that include tumor type and response to therapy.78 There is no objective time after therapy required before listing for transplantation Reports of heart transplantation to treat CTC in children extend back 20 years,79 and a recent review of data from the Pediatric Heart Transplant Study show that, for appropriately selected patients, there is no difference in long-term graft survival when compared with other forms of dilated cardiomyopathy.80 For patients unable to wait, or for whom it is not appropriate to list for transplantation, mechanical circulatory support may be offered If the mechanism of dysfunction is believed to be temporary or reversible, short- or medium-term support strategies can bridge through recovery.81 If long-term survival, separate from cardiac disease, is otherwise high, then bridge to heart transplantation may be considered In adults treated with mechanical circulatory support related to CTC, survival is similar to other patients although the need for early postoperative right ventricular support is greater.82 Implantable Cardiac Defibrillators and Cardiac Resynchronization Therapy Indications for implantable cardiac defibrillators and cardiac resynchronization therapy are similar in CTC to other disease processes However, no specific guidelines exist for the cancer patient population, and care should be individualized Interestingly, there is evidence that adults with CTC are less likely to receive an implantable defibrillator or resynchronization therapy than in other causes of heart failure, at least partly because specific data are lacking on the efficacy of resynchronization therapy in CTC.83 Conclusion CTC is an important part of patient care before, during, and after therapy Many chemotherapeutic agents lead to a wide variety of cardiovascular pathologies that can manifest within hours of administration, or decades later The field of cardio-oncology is focused on prevention, surveillance, and treatment of CTC Given that any single center has a limited number of patients with CTC, multiinstitutional efforts will be required to advance the field and improve patient care