Chimeric antigen receptor T (CAR-T) cell therapy has been shown to have substantial efficacy against refractory hematopoietic malignancies. However, it frequently causes cytokine release syndrome (CRS) as a treatment-specific adverse event. Although cardiovascular events associated with CAR-T cell therapy have been increasingly reported recently, pericardial disease is a rare complication and its clinical course is not well characterized. Here, we report a case of acute pericardial effusion with cardiac tamponade after CAR-T cell therapy.A 59-year-old man with refractory diffuse large B-cell lymphoma underwent CAR-T cell therapy. Grade 2 CRS was observed on day 0; it progressed to grade 4 on day 7 and was accompanied by a fever over 39°C, hypoxia requiring intubation, hypotension requiring the use of a vasopressor agent, and supraventricular tachycardia. Although cardiac function was preserved, marked pericardial effusion with the collapse of the right heart was detected on echocardiography. Since pericardiocentesis was considered to have a high complication risk due to severe myelosuppression, medications for CRS were prioritized. Tocilizumab, an interleukin-6 inhibitor, and high-dose methylprednisolone (1 g/day for 3 days) were administered for the management of severe CRS. On day 8, the pericardial effusion decreased, and the hemodynamic status markedly stabilized. CRS did not exacerbate after the steroid dose was reduced. Further, lymphoma size reduced after the induction of CAR-T cell therapy, and tumor regrowth was not noted at 3 months after CAR-T cell infusion.Interleukin-6 pathway inhibitors and corticosteroid therapy should be considered in the context of CRS for significant pericardial effusion after CAR-T cell therapy in the acute phase.
A 51-year-old man with a resuscitation episode was referred to our hospital. Coronary angiography revealed a focal spasm overlapped with organic stenosis where a bare metal stent was implanted. Acetylcholine (ACh) provocation test did not induce chest pain. It revealed no discernible ST-T changes but unmasked a J wave at the end of the QRS complex, which was associated with short-coupled repetitive premature ventricular beats. A J wave reportedly appears immediately before the onset of ventricular fibrillation caused by vasospastic angina. However, a J wave observed newly after a coronary spasm provocation test using ACh without ST-T changes is informative when considering the mechanisms of the J wave.
Rationale: Neurogenic shock is generally typified by spinal injury due to bone metastases in cancer patients, but continuous disturbance of the vagus nerve controlling the aortic arch baroreceptor can cause shock by a reflex response through the medulla oblongata. Patient concerns: A 43-year-old woman with dysphagia presented to our hospital. Computed tomography showed a primary tumor adjacent to and surrounding half the circumference of the descending aorta, and multiple cervical lymph node metastases, including a 55 × 35-mm lymph node overlapping the root of the left vagus nerve. Squamous esophageal cancer (T4bN3M1, stage IV) was diagnosed. Whereas shock status initially appeared soon after left cervical pain, suggesting pain-induced neutrally-mediated syncope, sustained bradycardia and hypotension occurred even after alleviation of pain by opioids. Diagnosis: Disturbance of the left vagus nerve associated with the aortic arch baroreceptor by a large left cervical lymph node metastasis was considered as the cause of shock, pathologically mimicking the baroreceptor reflex. Interventions: Systemic steroid administration was performed, and radiotherapy for both the primary site and lymph node metastasis was started 2 days after initiating steroid treatment. Outcomes: Four days after initiating steroid administration, hypotension and bradycardia were improved and stable. Lessons: Disturbance of the vagus nerve controlling the aortic arch baroreceptor should be kept in mind as a potential cause of neurogenic shock in cancer patients, through a pathological reflex mimicking the baroreceptor reflex.
A 75-year-old woman presented with a right atrial tumor with pericardial dissemination.However, an examination of the pericardial fluid and forceps-obtained tumor samples did not detect malignant cells.We retried tumor biopsy using a sheath-wedge aspiration biopsy (SABx) technique.When the forceps were retracted into the sheath, the sheath moved forward slightly in an action-reaction motion and wedged it into the tumor tissue (Picture A).Next, the sheath was aspirated under the echocardiographic observation.Echocardiography detected a tumor defect at the sheath entry site,
Malignant primary cardiac tumors require multimodal approaches including surgery, chemotherapy and radiotherapy, but these treatments can be associated with cardiovascular complications. However, few reports have described the cardiovascular complications related to primary cardiac tumor treatment because of their rarity.
Aims: Atherosclerosis is associated with oxidative stress and fatty acid composition plays a critical role in vascular endothelial dysfunction and injury leading to the coronary atherosclerotic progression. However, the correlation between the fatty acid profile and coronary atherosclerosis is debatable. The goal of this study is to assess the erythrocyte membrane and plasma fatty acid composition in patients with coronary heart disease.
Methods: The erythrocyte membrane and plasma distributions of fatty acids were quantified in patients with coronary heart disease (n = 30, group A) which needs both intensive medication and elective percutaneous coronary intervention and age-matched controls (n = 38, group B) using high-performance liquid chromatography combined with evaporative light scattering detection method. Baseline data were extracted from medical records.
Results: Logistic regression analysis demonstrated that hypoalbuminemia (p = 0.010) and HbA1c (p = 0.005) are associated with required percutaneous coronary intervention. Although appropriate logistic regression model for percutaneous coronary intervention could not be obtained by incorporating fatty acid components, percutaneous coronary intervention was correlated mostly to the increased oleic acid and decreased stearic acid in both erythrocyte membrane and plasma in receiver-operating characteristic analysis.
Conclusion: This single-center, cross-sectional study indicated that erythrocyte membrane and plasma fatty acids have a potential impact on the coronary atherosclerotic progression which requires coronary intervention. Longitudinal studies are necessary to clarify the clinical role of fatty acids distribution as a novel atherogenic marker.
Left ventricular assist device (LVAD) is essential for patients with severe heart failure, but there is a risk of thrombus formation on the aortic root and cusps, leading to coronary artery occlusion. Even with the narrowing of the echo-window due to LVAD, careful observation of coronary flow by transthoracic echocardiography can evaluate the patency of coronary flow non-invasively and immediately.
