Hemalatha Narayanasamy
Mayo Clinic, United States
Abstract Title:
Cardio-Oncology Guided Revascularization Enabling Resumption of Cancer Therapy in a Patient with Metastatic Renal Cell Carcinoma and HFrEF
Biography:
Background: Cardiovascular complications frequently limit cancer treatment options,
especially when potentially cardiotoxic therapies represent the final available oncologic
strategy. Cardio-oncology plays a critical role in distinguishing treatment-related cardiotoxicity
from alternative cardiac etiologies and guiding individualized management.
Case Presentation: A 75‑year‑old man with a history of atrial flutter status post ablation,
dual-chamber pacemaker implantation for high-grade atrioventricular block, and prior right
ventricular pacing–induced cardiomyopathy presented with newly reduced left ventricular
ejection fraction (LVEF) of 36% and heart failure hospitalization. His LVEF had previously
improved from 45% to 60% after upgrade to biventricular pacing.
The patient was diagnosed with renal cell carcinoma and underwent left nephrectomy. After
development of metastatic disease, he received lenvatinib and pembrolizumab. Lenvatinib was
discontinued because of severe inflammatory arthritis, while pembrolizumab monotherapy
initially stabilized disease for few months before progression occurred. Cabozantinib was
subsequently initiated.
Following hospitalization for heart failure with reduced ejection fraction, cabozantinib
was discontinued because of concern for chemotherapy-related cardiotoxicity. Coronary
angiography demonstrated hemodynamically significant proximal left anterior descending
artery disease by fractional flow reserve assessment and chronic total occlusion of the mid
right coronary artery with collateral circulation. Due to uncertainty regarding the etiology of
cardiomyopathy and limited remaining oncologic options, palliative and hospice care were
recommended.
The patient was referred for cardio-oncology evaluation. After multidisciplinary review,
cabozantinib-induced cardiomyopathy was considered less likely, and coronary revascularization
was recommended. The patient underwent successful percutaneous coronary intervention of
the proximal left anterior descending artery. Follow-up echocardiography several weeks later
demonstrated improvement in LVEF to 48%, allowing resumption of cabozantinib.
This case highlights the importance of cardio-oncology collaboration in identifying reversible
causes of left ventricular dysfunction and facilitating continuation of potentially life-prolonging
cancer therapy in complex patients.
