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Special Considerations for the Management of Cancer Patients in the Cath Lab Konstantinos Marmagkiolis MD, MBA, FACC, FSCAI STEMI Medical Director Citizens Memorial Hospital, Heart and Vascular Institute, Bolivar, MO Clinical Assistant Professor of Medicine, University of Missouri, Columbia, MO Presentation Outline Introduction Chemotherapy - induced vascular toxicity Radiation – induced vascular toxicity Special considerations for thrombocytopenic patients ACS in cancer patients Vascular access for cancer patients Optimizing PCI results in cancer patients Non-coronary cardiac interventions in cancer patients Introduction 14.5 million cancer survivors expected to increase to 20 million by 2020 Chemotherapy toxicity Radiotherapy toxicity Traditional cardiovascular risk factors Cancer patients have been excluded from most PCI registries and RCTs Chemotherapy-induced Vascular Toxicity (Mechanisms) Abnormal vasoreactivity (5-FU) Severe vasospasm resulting in ACS (Paclitaxel and Docetaxel) Acute coronary thrombosis, even in multiple territories (Cisplatin) Endothelial dysfunction (Bleomycin) Endothelial apoptosis (Vinblastine) Prinzmetal’s angina (Cyclophosphamide) Accelerated atherosclerosis (nilotinib and ponatinib) Takotsubo cardiomyopathy Radiation therapy - induced Vascular Toxicity (Mechanism) 50% of cancer patients receive radiation Oxidative stress and inflammation Cholesterol plaques formation and thrombosis can appear within days Fibrosis in all three layers of the vessel wall Radiation therapy – induced coronary toxicity Extensive mantle radiation (HL or esophageal cancer) => ostial and multivessel stenoses. 10 years after RTX for Hodgkin severe stenosis of the LM or RCA ostium in 30% without symptoms Radiation therapy – induced coronary toxicity Focal radiation (i.e. breast cancer) => focal disease in the mid to distal LAD (left breast), => proximal RCA (right breast). Radiation – Induced PAD Type of Radiation Peripheral Arterial Disease Head and Neck radiation CVA/TIA, carotid arterial disease Supraclavicular&mediastinal radiation CVA/TIA, carotid & subclavian arterial disease Abdominal and pelvic Renal arterial disease, lower extremity PAD Cancer patients with thrombocytopenia 10% of cancer patients have platelet counts <100,000/mm3 Most cancer patients become thrombocytopenic during therapy Traditional Approach for cancer patient with ACS - “Cannot start dual antiplatelet therapy or anticoagulation due to thrombocytopenia” - “Cannot send the patient to the cath lab due to thrombocytopenia” - “Let’s give some morphine” SCAI Consensus Recommendations ASA only when platelet count > 10,000/ml DAPT with clopidogrel only when platelet count > 30,000/ml 30-50 U/kg Unfractionated heparin dose is the initial recommended dose for thrombocytopenic patients with platelets < 50,000/ml undergoing PCI We recommend against the use of prasugrel, ticagrelor and IIB-IIIA inhibitors in patients with platelet count < 50,000 ACS in cancer patients The presenting symptoms of ACS in cancer patients are: Dyspnea (44%) Chest pain (30.3%) Hypotension (23%). ACS in cancer patients Case series (465 patients): Cancer patients with ACS treated conservatively -> 1-year survival 26% Case series: STEMI in patients with recent cancer diagnosis (<6 months) treated with PCI -> 3x increased mortality NHLBI registry: in ACS patients undergoing PCI , cancer was one of the strongest independent predictors of in hospital death ( OR 3.2; CI 1.12-9.4) and one year mortality (OR 2.15; 1.3-3.4)173. Velders MA, Boden H, Hofma SH, Osanto S, van der Hoeven BL, Heestermans AA, et al. Outcome after ST elevation myocardial infarction in patients with cancer treated with primary percutaneous coronary intervention. Am J Cardiol 2013;112(12):1867-72. Yusuf SW, Daraban N, Abbasi N, Lei X, Durand JB, Daher IN. Treatment and outcomes of acute coronary syndrome in the cancer population. Clin Cardiol 2012;35(7):443-50. General considerations before cath There is not a low platelet threshold for coronary angiogram If expected survival is < 1 year, PCI should only be done for STEMI or high risk NSTEMI With chemotherapy, DAPT may need to be extended due to the delayed re-endothelialization of the stent Some cancer and chemotherapy may increase the risk of stent thrombosis In GI tumors the post PCI GI bleed increases from 2.4% to 5.8%. Staged intervention (POBA and later stent) may be considered Vascular Access Considerations Femoral preferred in: Abnormal Allen’s test Multiple radial procedures or a-lines Dialysis or pre-dialysis patients Bilateral mastectomy When a complex intervention is anticipated Micropuncture, smaller sheaths, frequent sheath flush, angiogram after access, early ambulation Decision making in the cath lab Before PCI: FFR is recommended When PCI is indicated: a. POBA in cancer patients who are not candidates for DAPT (Platelets < 30,000/ml) or when a non-cardiac procedure or surgery is necessary as soon as possible. b. BMS is recommended in patients with platelet count > 30,000/ml needing a non-cardiac procedure or surgery which can be postponed for >4 weeks. c. Third-generation DES is recommended in patients with platelet count > 30,000/ml who are not in immediate need for a non-cardiac procedure or surgery. After PCI: OCT/IVUS is recommended to assure optimal apposition and absence of complications Right Heart Cath Left ventricular systolic or diastolic heart failure Restriction or constriction physiology Valvular dysfunction 5F (French) Swan catheter from the right forearm may be preferred to reduce the risk of bleeding complications Endomyocardial Biopsy Unexplained ventricular dysfunction with suspected anthracycline cardiomyopathy (IIa, Level of evidence C) Fulminant myocarditis Pericardiocentesis We recommend that pericardiocentesis should be performed in the catheterization laboratory under fluoroscopic AND echocardiographic guidance. Micro-puncture access is encouraged 2/3 of the malignant effusions reaccumulate within 24 – 48 hours The pericardial drain should be maintained for a minimum of 3 days (optimally 5 days). BAV/TAVR A 6-patient case series showed the feasibility of BAV in cancer patients as a bridge to SAVR Surgeons are reluctant to operated due to mediastinal fibrosis, lung disease, porcelain aorta, and prior thoracic surgeries TAVR? Key points Cancer patients should be referred to the CCL due to their atypical presentation, increased ACS mortality and acceptable bleeding risk There NO low platelet threshold for a diagnostic cath OK for ASA if PLT>10K, DAPT if PLT>30K FFR before stent and OCT/IVUS after stent because DAPT may need to de discontinued early Thank you