The development of immune checkpoint inhibitors (ICIs) has revolutionized the treatment of patients with advanced stage cancers. However, immune-related adverse events are frequently observed. Cardiac toxicity from ICI therapy can range from asymptomatic troponin-I elevations to conduction abnormalities of the heart and even fulminant myocarditis. Although rare, myocarditis is a potentially fatal adverse effect of ICI therapy. We present a series of five cases of ICI-related cardio-toxicity diagnosed and managed at Roswell Park Comprehensive Cancer Center along with a review of published case reports in the literature. Our series highlights the importance of high clinical suspicion, early diagnosis of myocarditis, and prompt initiation of immunosuppressive therapy.

Improved cancer survival in patients treated with thoracic ionizing radiation (XRT) has resulted in unanticipated surge of aortic stenosis. Transcatheter aortic valve replacement (TAVR) has revolutionized the management of severe aortic stenosis. However, long-term clinical outcomes in radiation-exposed cohorts undergoing TAVR are unknown. We compared the all-cause mortality and major adverse cardiac events (MACE) in patients with prior chest XRT (C-XRT) undergoing TAVR. This is an observational cohort study in subjects who underwent TAVR for symptomatic severe aortic stenosis from 2012 to 2017 in a tertiary care referral center. We examined the all-cause mortality and MACE using cox proportional hazard analysis to identify the clinical predictors of survival in the cohort of patients who had a history of prior C-XRT for malignancy. Of the 610 patients who underwent TAVR for symptomatic severe aortic stenosis, 75 had prior C-XRT. The majority of C-XRT patients had prior breast cancer (44%) followed by Hodgkin’s lymphoma (31%), with the median time from XRT to TAVR of 19.0 years. During a mean follow up of 17.1 months after TAVR, all-cause mortality was 17%. Those with prior C-XRT had higher all-cause mortality (XRT: 29%; non-XRT:15%, p < 0.01) and MACE (XRT: 57%; non-XRT: 27%, p < 0.001) after TAVR. Patients with prior XRT had a higher incidence of atrial fibrillation (XRT: 48%; non-XRT: 2.4%, p < 0.01) and high-grade heart block (XRT: 20%; non-XRT: 9.1%, p = 0.007) requiring pacemaker implant after TAVR. On multivariate cox proportional hazard analysis, prior XRT (HR: 2.07, p = 0.003), poor renal function (HR: 1.29, p < 0.001) and post-operative anemia requiring transfusion (HR: 1.16, p:0.001) were the strongest predictors of reduced survival. Cancer survivors with prior C- XRT have higher incidence of all-cause mortality and MACE after TAVR. Careful patient selection and follow-up strategies are needed to improve outcomes.

Spontaneous coronary artery dissection is a rare, life-threatening cause of acute myocardial infarction that must always be considered in the differential diagnosis, particularly in young, healthy women with a paucity of typical risk factors for heart disease. We present a case of a 39-year-old White woman, three months postpartum, presenting with severe epigastric chest pain radiating to her neck. Subsequent workup using coronary angiography revealed spontaneous dissection of the distal left anterior descending artery. The patient was successfully managed by conservative treatment using low dose aspirin, metoprolol, and captopril, highlighting that hemodynamically stable patients with lesions in distal branches of coronary arteries and single-vessel disease can be successfully managed in a conservative fashion, without the need for surgical or percutaneous revascularization.