Pregnancy-associated cardiomyopathy in survivors of childhood cancer

Abstract

Purpose Current information regarding pregnancy-associated cardiomyopathy among women treated for childhood cancer is insufficient to appropriately guide counseling and patient management. This study aims to characterize its prevalence within a large cohort of females exposed to cardiotoxic therapy. Methods Retrospective cohort study of female cancer survivors treated at St. Jude Children’s Research Hospital between 1963 and 2006, at least 5 years from diagnosis, ≥ 13 years old at last follow-up, and with at least one successful pregnancy. Pregnancy-associated cardiomyopathy was defined as shortening fraction < 28% or ejection fraction < 50% or treatment for cardiomyopathy during or up to 5 months after completion of pregnancy. Results Among 847 female cancer survivors with 1554 completed pregnancies only 3 (0.3%) developed pregnancy-associated cardiomyopathy, 40 developed non-pregnancy-associated cardiomyopathy either 5 months post-partum (n=14), or prior to pregnancy (n=26). Among those with cardiomyopathy prior to pregnancy (n=26), cardiac function deteriorated during pregnancy in 8 patients (3 patients with normalization of cardiac function prior to pregnancy, 3 with persistently abnormal cardiac function, and 2 for whom resolution of cardiomyopathy was unknown prior to pregnancy). Patients that developed cardiomyopathy recevied a higher median dose of anthracyclines compared to those that did not (321 mg/m2 versus 164 mg/m2; p< 0.01). Conclusions Pregnancy-associated cardiomyopathy in childhood cancer survivors is rare. Implications for cancer survivors Most female childhood cancer survivors will have no cardiac complications during or after childbirth, however those with a history of cardiotoxic therapies should be followed carefully during pregnancy particularly those with a history of anthracycline exposures and if they had documented previous or current subclinical or symptomatic cardiomyopathy. Female childhood cancer survivors with a history of cardiotoxic therapies should be followed carefully during pregnancy particularly those with a history of anthracycline exposures and if they had documented previous or current subclinical or symptomatic cardiomyopathy.

Regional practice norms for the care of childhood cancer survivors at risk for cardiomyopathy: A Delphi study

“…However, a few panelists did indicate limited provider expertise as a rationale for referral to cardiology for recommended screening and cardiovascular risk reduction. All panelists recognized pregnancy as a risk factor for heart failure in anthracycline‐treated CCS and endorsed consultation with maternal–fetal medicine as part of obstetrical care. Reciprocally, a sampling of obstetricians in the New England region also supported that recommendation.…”

“…The incidence of ALVD in CCS is as high as 50% to 60% and the incidence of symptomatic left ventricular dysfunction is between <5% and 30% depending on treatment intensity. Risk factors for cardiomyopathy include higher cumulative anthracycline dose (≥250 mg/m 2 ), thoracic radiation involving the heart (≥35 Gy), combination therapy with anthracyclines and thoracic radiation (≥100 mg/m 2 + ≥ 15 Gy), younger age at diagnosis (age < 5 years), longer duration of follow‐up, and pregnancy . In addition, traditional cardiac risk factors including hypertension, diabetes, hyperlipidemia, and tobacco use also likely contribute to CCS risk for cardiomyopathy .…”

“…therapy with anthracyclines and thoracic radiation (≥100 mg/m 2 + ≥ 15 Gy), younger age at diagnosis (age < 5 years), longer duration of follow-up, 2 and pregnancy. 6 In addition, traditional cardiac risk factors including hypertension, diabetes, hyperlipidemia, and tobacco use also likely contribute to CCS risk for cardiomyopathy. 7 Of note, late-onset myocardial fibrosis, coronary artery disease, valvular abnormalities, and conduction system abnormalities are also seen with higher doses of thoracic radiation, >35 Gy, and there is evidence that anthracyclines contribute to that risk.…”

Adolescent survivor of childhood Acute Myeloid Leukaemia undertakes pregnancy with a severe anthracycline induced cardiomyopathy and risk taking behaviours

“…Anthracycline induced cardiomyopathies existing prior to pregnancy are also at risk of deteriorating during this time. [9] Hines et al conducted a retrospective study looking at pregnancy-associated cardiomyopathy in females treated with cardiotoxic therapy for childhood cancer between 1963-2006. Of the women who had a pre existing diagnosis of anthracycline induced cardiomyopathy prior to pregnancy (N = 26), 8 women had deterioration in their cardiac function during pregnancy.…”

“…Of the women who had a pre existing diagnosis of anthracycline induced cardiomyopathy prior to pregnancy (N = 26), 8 women had deterioration in their cardiac function during pregnancy. [9] Van Dalen et al conducted a cohort study in 53 female childhood cancer survivors exposed to anthracycline and neither of the 2 subjects with cardiomyopathy prior to pregnancy deteriorated to peripartum CCF. [10] Therefore further research regarding cardiovascular outcomes during pregnancy for females with anthracycline induced cardiomyopathies are needed to help guide patient counseling and management.…”