17, 18 While current expert consensus suggests the diagnosis of LV cardiotoxicity based on LV systolic assessment, the same consensus recommends the assessment of RV chamber sizes and function in case of possible RV involvement, without going into further details regarding necessary parameters, reference, or diagnosis values. 13- 16Īssessment of right ventricular (RV) function is of emerging importance in patients undergoing chemotherapies, radiotherapies, or immunotherapies.
12 While ICI-related fulminant myocarditis was described to be relatively rare, preclinical evidence also indicates a risk for left ventricular (LV) dysfunction during ICI even in the absence of manifest myocarditis particularly with ICI therapies. 9- 11 The most severe cardiac complication is immune-related myocarditis. 8 Because of an increasing use of ICI therapy, different aspects of cardiovascular irAEs have been identified ranging from myocardial infarction, ischaemic stroke, and pericardial disease to venous thrombo-embolism. 6 Cardiac immune-related complications are relatively rare but considerably life-threatening. The most common irAEs are immune-related colitis, immune-related hepatitis, skin-related immune reactions, and immune-related thyroiditis and hypophysitis. 5 irAEs often occur within the early phase of therapy (≤12 weeks of therapy in combination therapies consisting of ipilimumab and nivolumab), 6, 7 which results in the need for very premature clinical follow-up visitations. Immune checkpoint inhibitor therapy has the risk of serious side effects, the so-called immune-related adverse events (irAEs). The CTLA-4 inhibitor ipilimumab and the PD-1 inhibitors nivolumab and pembrolizumab or combinations of these agents are applied in patients with advanced melanoma. 1 ICI therapies typically target cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) or programmed death-1 (PD-1)/ligand-1. Over the past 10 years, immune checkpoint inhibitor (ICI) therapy has revolutionized the therapeutic concept in advanced malignant melanoma. Alterations in RV and RA strain could be early signs of cardiotoxicity and therefore should be assessed in patients undergoing ICI therapy. ConclusionsĪnalysis of RV and RA strain shows alterations even in a short-term follow-up, while changes in RV function are not visible by conventional RV parameters.
Conventional parameters including tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and pulmonary artery systolic pressure were not different between the two time points (TAPSE 26 ± 5 vs. Short-term ICI therapy caused a reduction of RV-LSFW (−25.5 ± 6.4% vs.
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Two-dimensional echocardiography with assessment of RV longitudinal strain of the free wall (RV-LSFW) and assessment of right atrial (RA) strain from speckle tracking was performed at baseline and after the start of ICI therapy. We retrospectively examined 30 patients (40% women, age 59 ± 13 years) with advanced melanoma (stage III/IV) before and 4 weeks after the start of ICI therapy (follow-up at 39 ± 15 days) n = 15 of the patients received nivolumab, and n = 15 received the combination therapy nivolumab/ipilimumab. We aimed to assess RV function in melanoma patients undergoing ICI therapy using conventional echocardiographic and strain imaging techniques. Right ventricular (RV) dysfunction negatively impacts the outcomes in cardiovascular diseases and may be an early sign for overall cardiotoxicity. While immune checkpoint inhibitor (ICI) therapy significantly improves survival rates in advanced melanoma, ICI can evoke severe immune-related cardiovascular adverse events.
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