scholarly journals Immunotherapy for Metastatic Melanoma with Right Atrial Involvement in a Patient with Rheumatoid Arthritis

2017 ◽  
Vol 2017 ◽  
pp. 1-4 ◽  
Author(s):  
Zachary Benson ◽  
Sarah Gordon ◽  
Patricia Nicolato ◽  
Andrew Poklepovic
Keyword(s):  
Rheumatoid Arthritis ◽  
Heart Failure ◽  
Surgical Treatment ◽  
Autoimmune Disease ◽  
Adverse Events ◽  
Metastatic Melanoma ◽  
Response To Therapy ◽  
Right Atrial ◽  
Durable Response ◽  
Life Threatening

Prognosis for metastatic melanoma has improved significantly with the use of immune checkpoint inhibitors. Given improvements in survival, aggressive surgical treatment may be considered in patients with life-threatening complications from their disease that would not otherwise be considered in advanced disease. Patients with preexisting autoimmune diseases or prior immune-related adverse events from therapy are largely excluded from clinical trials. Concerns exist that immunotherapy in these patients could worsen autoimmune disease or increase the risk of developing additional immune-related adverse events on therapy. We present a case of a patient with rheumatoid arthritis that presented with obstructive heart failure secondary to melanoma that had metastasized to the right atrium. After aggressive surgical resection to stabilize him from his life-threatening heart failure, he was treated with ipilimumab, which was stopped due to an immune-related adverse event. He was then started on pembrolizumab and had a durable response to therapy. Aggressive surgical treatment should be considered in patients with a cancer that may respond to immunotherapy. Furthermore, some patients with preexisting autoimmune disease may be safely treated with checkpoint inhibition therapy, and patients with a severe immune toxicity from one class may successfully be treated with an alternate class.

scholarly journals Multimodality imaging can shift the clinical approach and prognosis of a patient: from heart failure and angina to cardiac amyloidosis

2021 ◽  
Vol 31 (1) ◽  
pp. 103-110
Author(s):  
Alexandra Maria Chitroceanu ◽  
Alina Ioana Nicula ◽  
Roxana Cristina Rimbas ◽  
Mihaela Andreescu ◽  
Cristina Popp ◽  
...  
Keyword(s):  
Heart Failure ◽  
Cardiac Amyloidosis ◽  
Multimodality Imaging ◽  
Clinical Status ◽  
Decompensated Heart Failure ◽  
Response To Therapy ◽  
Al Amyloidosis ◽  
Clinical Approach ◽  
Non Invasive ◽  
Life Threatening

AL (light chain) amyloidosis is a life threatening disease. Untreated patients with involvement of the heart, a condition known as cardiac amyloidosis (CA), tend to have the most rapid disease progression and worst prognosis. Therefore, it is essential to early recognize the signs of symptoms of CA, and to identify the affected individuals with readily available non-invasive tests, as timely therapy can prolong life. Different imaging tests are used to diagnose and stratify the risk of the disease noninvasively, and to follow-up of the disease course and response to therapy. In this light, we present a case of a woman with cardiovascular risk factors, initially admitted for typical angina and decompensated heart failure (HF), who was later diagnosed with AL amyloidosis with cardiac involvement, by using multimodality imaging assessment in a step-by-step fashion. This changed completely the prognosis of the patient. Timely chemotherapy and stem cell transplantation led to an improvement in clinical status, biomarkers, and in a regression of amyloid myocardial infi ltration showed by imaging.

scholarly journals 565 Impact of right atrial physiology on heart failure and adverse events after myocardial infarction

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
A Schuster ◽  
S J Backhaus ◽  
J L Navarra ◽  
T Stiermaier ◽  
K P Rommel ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Heart Failure ◽  
Adverse Events ◽  
Systolic Function ◽  
Risk Groups ◽  
Right Atrial ◽  
Volume Index ◽  
Cardiac Events ◽  
St Elevation ◽  
Booster Pump

Abstract Background Right ventricular (RV) function is a known predictor of adverse events in heart failure and following acute myocardial infarction (AMI). While right atrial (RA) involvement is well characterized in pulmonary arterial hypertension, its relative contributions to adverse events following AMI especially in patients with heart failure and congestion needs further evaluation. Methods 1235 MI patients underwent CMR after primary percutaneous coronary intervention (PCI) in 15 centers across Germany (n = 795 with ST-elevation MI and 440 with non ST-elevation MI). Right atrial (RA) performance was evaluated using cardiac magnetic resonance myocardial feature tracking (CMR-FT) for the assessment of RA reservoir (total strain εs), conduit (passive strain εe), booster pump function (active strain εa) and associated strain rates (SR) in a blinded core-laboratory. The primary clinical endpoint was the occurrence of major adverse cardiac events (MACE) 12 months post MI. Results RA reservoir (εs p = 0.061, SRs p = 0.049) and conduit functions (εe p = 0.006, SRe p = 0.030) were impaired in patients with MACE as opposed to RA booster pump (εa p = 0.579, SRa p = 0.118) and RA volume index (p = 0.866). RA conduit function was associated with clinical onset of heart failure and MACE independently of RV systolic function (multi-variable analysis HR 0.95, 95% CI 0.91-0.99, p = 0.006) while RV systolic function was no independent prognosticator (HR 0.98, 95% CI 0.96-1.00, p = 0.055). Furthermore, RA conduit strain identified low- and high-risk groups within patients with relatively preserved and reduced RV and LV systolic functions (p < 0.019 on log rank testing). Conclusions Right atrial impairment is a distinct feature and independent risk factor in patients following AMI and can be easily assessed using CMR-FT derived quantification of RA strain.

Experience of immune-related adverse events associated with ipilimumab and nivolumab in a single center.

2017 ◽  
Vol 35 (7_suppl) ◽  
pp. 91-91 ◽  
Author(s):  
Bernardo Leon Rapoport ◽  
Teresa Smit ◽  
Ronwyn van Eeden
Keyword(s):  
Adverse Events ◽  
Metastatic Melanoma ◽  
Performance Status ◽  
Death Receptor ◽  
Endocrine System ◽  
Organ Systems ◽  
Anti Cancer ◽  
Life Threatening ◽  
Prompt Diagnosis ◽  
Cell Death Receptor

91 Background: Anti-programmed cell death receptor-1 (PD-1) and anti-CTLA4 antibodies represent an effective anti-cancer. Ipilimumab and nivolumab can induce immune-related adverse events (IrAEs). These IrAEs affect skin, gastrointestinal tract, liver, endocrine system and other organ systems. Life-threatening and fatal irAEs have been reported; adequate diagnosis and management are essential. Methods: A retrospective review of data from 40 patients (pts) records were used to describe the IrAE’s associated with 15 pts treated with ipilimumab and 25 pts treated with nivolumab. Results: A total of 40 pts (25 males and 15 females) were included in the analysis. The median age was 63 years (range 30 - 85 years). The performance status (PS) ranged from 0 to 2, with a median PS of 1. In total, 3 pts with metastatic melanoma, 18 with non small cell lung cancer (NSCLC), 2 with renal cell carcinoma and 2 with Hodgkin’s disease were treated with nivolumab and 15 with metastatic melanoma received ipilimumab. A total of 167 cycles of nivolumab (median = 4, range 1-16) and 60 cycles of ipilimumab (median = 4 cycles, range 1-4 cycles) were administered. Seven IrAEs are described in 19 pts treated with ipilimumab. These include endocrinopathy in 3 pts (hypophysitis in pt and hyphothyroidsm in 2 pts), colitis in 3 pts (1 required infliximab) and hepatitis in 1 pt. Among the pts treated with nivolumab 7 IrAEs were documented. These included pneumonitis in 2 pts, skin rash in 3 pts, mild diarrhea in 1 pt and mild uveitis in 1 pt. Additionally, 3 chest infections were documented including a case of pulmonary tuberculosis in a pt with NSCLC. Conclusions: Anti-PD1 and anti-CTLA4 antibodies can induce a plethora of irAEs. Colitis was more common with ipilimumab while pneumonitis more common with nivolumab. The knowledge of IrAE’s will allow prompt diagnosis and improve the management resulting in decreased morbidity.

Giant Right Atrial Aneurysm: Antenatal Diagnosis and Surgical Treatment

2016 ◽  
Vol 9 (4) ◽  
pp. 459-462 ◽  
Author(s):  
Laurynas Bezuska ◽  
Frances A. Bu’Lock ◽  
Robert H. Anderson ◽  
Simone Speggiorin ◽  
Antonio F. Corno
Keyword(s):  
Heart Failure ◽  
Prenatal Diagnosis ◽  
Surgical Treatment ◽  
Natural History ◽  
Antenatal Diagnosis ◽  
Right Atrial ◽  
Right Atrial Aneurysm ◽  
Early Preparation

Giant congenital right atrial aneurysms are rare, with their natural history complicated by death, heart failure, arrhythmias, and thrombosis. Prenatal diagnosis of the defect is feasible and allows an early preparation of a plan for management. We present details of a patient diagnosed prenatally with a giant right atrial aneurysm, which was successfully treated surgically as soon as the patient became symptomatic.

scholarly journals Influence of physical rehabilitation on oxygen and lactate status in "inotrope-dependent" patients with chronic heart failure in class III–IV

2021 ◽  
Vol 12 (3) ◽  
pp. 147-157
Author(s):  
Maria A. Bortsova ◽  
Elena A. Demchenko ◽  
Andrey E. Bautin ◽  
Petr A. Fedotov ◽  
Aleksandr O. Marichev ◽  
...  
Keyword(s):  
Heart Failure ◽  
Chronic Heart Failure ◽  
Adverse Events ◽  
Blood Lactate ◽  
Physical Rehabilitation ◽  
Inotropic Support ◽  
Left Ventricular Ejection ◽  
Research Centre ◽  
Central Venous ◽  
Life Threatening

Aim. To assess the effect of physical rehabilitation on dynamics of oxygen and lactate status indicators in inotrope-dependent patients with stable chronic heart failure (CHF) of IIIIV functional class (FC). Material and methods. A randomized prospective study included 120 men, aged 1865, hospitalized at Almazov National Medical Research Centre due to CHF IIIIV FC, left ventricular ejection fraction (LVEF) 30%; with blood pressure (BP)90/60 mm Hg. Patients who received dobutamine or dopamine for 2 weeks were randomized into 3 groups: 1st participating in the program of physical training (PPT), 2nd not participating; 3rd group patients without inotropic support participating in PPT. Results. Oxygen extraction ratio (O2ER) at rest was increased, while central venous oxygen saturation (ScvO2) was decreased in all groups at baseline, after 3 and 6 months. Initially, at rest, central venous blood lactate (lactate) was normal in all groups. By the 6th month, lactate in group 2 became higher than in group 1 (p=0.005) and group 3 (p=0.008). Initially, after 3 and 6 months, at peak of exercise in groups 1 and 3, lactate and O2ER increased, and ScvO2 decreased without development of life-threatening adverse events. By the 6th month, in groups 1 and 3, the distance of 6-minute walk test increased: p=0.004 and p0.00001 and the strength of hand muscles increased: p=0.01 and p=0.005. Conclusion. In patients with CHF IIIIV FC at rest, regardless of participation in PPT and inotropic therapy, there were comparable disturbances of oxygen status, characterized by decreased level of ScvO2 and increased level of O2ER, in the absence of decrease in arterial blood saturation. At peak of aerobic exercise of mild and moderate intensity in patients with advanced CHF, regardless of inotropic support, there was a comparable increase in the level of lactate and O2ER, as well as a decrease in ScvO2, which was not accompanied by life-threatening adverse events. The participation of inotrope-dependent patients in PPT is associated with decrease in blood lactate at rest, which, along with increase in hand muscle strength and exercise tolerance, may indicate an improvement in condition of muscle tissue.

scholarly journals Impact of Right Atrial Physiology on Heart Failure and Adverse Events after Myocardial Infarction

2020 ◽  
Vol 9 (1) ◽  
pp. 210 ◽  
Author(s):  
Andreas Schuster ◽  
Sören J. Backhaus ◽  
Thomas Stiermaier ◽  
Jenny-Lou Navarra ◽  
Johannes Uhlig ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Heart Failure ◽  
Adverse Events ◽  
Systolic Function ◽  
Multivariable Analysis ◽  
Right Atrial ◽  
Volume Index ◽  
Cardiac Events ◽  
St Elevation ◽  
Booster Pump

Background: Right ventricular (RV) function is a known predictor of adverse events in heart failure and following acute myocardial infarction (AMI). While right atrial (RA) involvement is well characterized in pulmonary arterial hypertension, its relative contributions to adverse events following AMI especially in patients with heart failure and congestion need further evaluation. Methods: In this cardiovascular magnetic resonance (CMR)-substudy of AIDA STEMI and TATORT NSTEMI, 1235 AMI patients underwent CMR after primary percutaneous coronary intervention (PCI) in 15 centers across Germany (n = 795 with ST-elevation myocardial infarction and 440 with non-ST-elevation MI). Right atrial (RA) performance was evaluated using CMR myocardial feature tracking (CMR-FT) for the assessment of RA reservoir (total strain εs), conduit (passive strain εe), booster pump function (active strain εa), and associated strain rates (SR) in a blinded core-laboratory. The primary endpoint was the occurrence of major adverse cardiac events (MACE) 12 months post AMI. Results: RA reservoir (εs p = 0.061, SRs p = 0.049) and conduit functions (εe p = 0.006, SRe p = 0.030) were impaired in patients with MACE as opposed to RA booster pump (εa p = 0.579, SRa p = 0.118) and RA volume index (p = 0.866). RA conduit function was associated with the clinical onset of heart failure and MACE independently of RV systolic function and atrial fibrillation (AF) (multivariable analysis hazard ratio 0.95, 95% confidence interval 0.92 to 0.99, p = 0.009), while RV systolic function and AF were not independent prognosticators. Furthermore, RA conduit strain identified low- and high-risk groups within patients with reduced RV systolic function (p = 0.019 on log rank testing). Conclusions: RA impairment is a distinct feature and independent risk factor in patients following AMI and can be easily assessed using CMR-FT-derived quantification of RA strain.

scholarly journals A Case of Acute Generalized Pustular Psoriasis of von Zumbusch Triggered by Hypocalcemia

2015 ◽  
Vol 7 (3) ◽  
pp. 345-351 ◽  
Author(s):  
Carlos Antônio Gusmão Guerreiro de Moura ◽  
Luiz Henrique de Assis ◽  
Paulo Góes ◽  
Fabiana Rosa ◽  
Victor Nunes ◽  
...  
Keyword(s):  
Heart Failure ◽  
Autoimmune Disease ◽  
Pustular Psoriasis ◽  
Cutaneous Manifestations ◽  
Clinical Forms ◽  
Generalized Pustular Psoriasis ◽  
Life Threatening

Psoriasis is an autoimmune disease triggered by different conditions in genetically susceptible people. It is characterized by variable cutaneous manifestations including localized or disseminated pustules. Generalized pustular psoriasis (GPP) has two main clinical forms: von Zumbusch psoriasis, characterized by severe erythrodermia and scaling skin after the resolution of pustules, and the annular form. GPP may also present severe extracutaneous manifestations including pneumonitis, heart failure and hepatitis. Old reports showed a relationship between hypoparathyroidism and hypocalcemia as triggers for GPP highlighting the importance of adequate workup of the patient and possible therapeutic changes in acute situations. Here, we present a case of severe von Zumbusch psoriasis with life-threatening complications triggered by severe hypocalcemia secondary to hypoparathyroidism successfully treated with aggressive calcium reposition.

Possible immune adverse events as predictors of durable response to BRAF inhibitors in patients with BRAF V600–mutant metastatic melanoma

2018 ◽  
Vol 101 ◽  
pp. 229-235 ◽  
Author(s):  
Guy Ben-Betzalel ◽  
Erez N. Baruch ◽  
Ben Boursi ◽  
Yael Steinberg-Silman ◽  
Nethanel Asher ◽  
...  
Keyword(s):  
Adverse Events ◽  
Metastatic Melanoma ◽  
Braf Inhibitors ◽  
Durable Response

Correlation between immune-related adverse events and outcomes in nivolumab/ipilimumab combination therapy for metastatic melanoma.

2020 ◽  
Vol 38 (5_suppl) ◽  
pp. 58-58
Author(s):  
Daan Rauwerdink ◽  
Dennie T. Frederick ◽  
Tatyana Sharova ◽  
Genevieve Marie Boland
Keyword(s):  
Overall Survival ◽  
Combination Therapy ◽  
Adverse Events ◽  
Metastatic Melanoma ◽  
Tumor Response ◽  
Massachusetts General Hospital ◽  
Stage Iv ◽  
Immune Checkpoint Blockade ◽  
Response To Therapy ◽  
P Value

58 Background: Systemic immune checkpoint blockade therapy anti-PD1 nivolumab combined with anti-CTLA-4 ipilimumab is an effective therapy for metastatic melanoma. The treatment, however, has a high frequency of immune related adverse events. Interestingly, immune-related adverse events in anti-PD1 and anti-CTLA4 monotherapy have been associated with an improved overall survival in melanoma. Whether immune-related events correlate with enhanced outcomes in ipilimumab/nivolumab combination therapy is unknown. Methods: Clinical data from patients diagnosed with untreated cutaneous stage IV melanoma receiving ipilimumab/nivolumab combination therapy between 2015-2018 at the Massachusetts General Hospital (MGH) and have been analyzed retrospectively. Tumor response was measured using RECIST criteria. Primary endpoints were frequencies and characteristics of immune-related adverse events, overall survival, and response to therapy. Results: A total of 57 patients received ipilimumab/nivolumab combination therapy. During a mean follow-up period of 26 months, 28 (49%) patients completed the therapy. Immune-related adverse events were observed in 45 (79%) patients, with rash (28%), colitis (23), hepatitis (21%) and fever (21%) being the most frequent. Overall survival was 29 months in patients with immune-adverse related events and 14 months in the group without any adverse events (p-value < 0.01). The onset of hypophysitis correlated with tumor response (p = 0.02) and hepatitis showed a trend in a correlation to response of therapy (p = 0.06). Conclusions: Our study demonstrates the association between improved overall survival and the onset of immune-related adverse events in ipilimumab/nivolumab combination therapy. A trend correlated with improved outcomes and onset of immune-related adverse events was seen in hepatitis and was significantly associated with hypophysitis, however these results must be interpretated carefully as larger studies must confirm our findings. Despite small study size, we are the first to describe an association between immune-related adverse events in ipilimumab/nivolumab combination therapy.

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