Heart Transplantation in Short Term after Chemotherapy

Patients with a history of cancer are considered high-risk candidates for solid organ transplantation because of concerns about potential adverse effects or recurrence with posttransplant immunosuppression. Furthermore, heart transplantation is not often considered an option in children who have been cancer free for fewer than 5 years. Now doctors, led by Kenneth R. Knecht, MD, from the Department of Pediatrics, Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, have reported a case of orthotopic heart transplantation for anthracycline-induced dilated cardiomyopathy (DCM) in the short term after completion of chemotherapy treatment.

The child described in the case study was less than 3 years old and was diagnosed with acute myeloid leukemia (AML); she also had Down syndrome (DS).

She underwent chemotherapy including the POG 9421 standard arm protocol, which included 3 doses of 45 mg/m² of daunomucin, systemic and intrathecal Ara-C, etoposide, and 8 doses of 10 mg/m² mitoxantrone. Her total anthracycline dose was 432.455 mg/m². She did not receive a cardioprotectant. The patient completed chemotherapy 6 months after her AML diagnosis. Two months later, she was readmitted to the hospital with respiratory distress and was diagnosed with heart failure, and her symptoms were not controllable by aggressive medical therapy, including high-dose IV inodilator and pressor support.

Heart transplantation was considered but concerns about the possibility of recurrent leukemia were raised. After extensive discussion, and in consideration of the severity of her cardiac symptoms, the decision was made to use a ventricular assist device and heart transplantation. Right and left ventricular assist devices were placed 2 weeks after the diagnosis of cardiomyopathy; the patient tolerated the placement and support well. Twenty-seven days later, a suitable heart became available and the patient underwent orthotopic heart transplantation. Immunosuppression was administered using tacrolimus, mycophenylate, and corticosteroids.

The patient’s initial posttransplant catheterization and biopsy at 3 weeks indicated normal filling pressures and cardiac output. Initial and subsequent endomyocardial biopsy results were 0R and C4D negative, showing no evidence of cellular or humoral rejection. One year later, the case reported success with the transplant.

The authors concluded that patients such as the one described in the case study should be considered for organ (including heart) transplantation, even for near-term postchemotherapy.