Advanced Heart Failure Therapies for Patients With Chemotherapy-Induced Cardiomyopathy

Continual advances in antineoplastic therapies have produced better cancer outcomes with 13.7 million cancer survivors in the United States in 20131. However, a significant number of survivors may develop cardiac disease as a result of cancer treatment, whether chemotherapy, radiation, or a combination of both.2 Although radiation can cause significant heart disease3 both alone and with chemotherapy, this review will only address cardiomyopathy induced by chemotherapy agents, especially anthracyclines, commonly used to treat pediatric and adult cancers. Whereas anthracyclines remain the most common cause of chemotherapy-induced cardiomyopathy (CCMP), recently developed targeted therapies can also cause cardiac dysfunction.4–6 Newer drugs that target survival pathways in cancer cells, such as the HER-2 (human epidermal growth factor 2) and vascular endothelial growth factor inhibitors, have been directly implicated in left ventricular (LV) systolic dysfunction7,8 through off-target effects. Because cancer and heart cells share many of the same survival pathways, it is likely that newer targeted therapies will continue to cause off-target impairment of cardiomyocyte survival and heart failure (HF).9 However, whereas LV dysfunction associated with targeted therapies seems reversible,10 anthracyclines remain the only agents that seem capable to cause end-stage HF.11 In this review, we critically appraise the data available to support the use of advanced HF therapies in this patients with CCMP and end-stage HF. Specifically, we review treatments indicated for American College of Cardiology/American Heart Association stages C-D HF, including implantable cardiac defibrillators, cardiac resynchronization therapy (CRT), mechanical circulatory support devices, and orthotopic heart transplantation (OHT). Herein defined as cardiomyopathy caused by anthracycline damage with or without exposure to other cardiotoxic agents,12 CCMP has been described in 1% to 5% of cancer survivors13,14 and arguably portends the worst survival among cardiomyopathies.15 Unlike any …