CARBOPLATIN-PACLITAXEL INDUCED ACUTE MULTI-VESSEL CORONARY THROMBOSIS

ABSTRACT

Background: Delayed cancer screenings during COVID-19 pandemic are expected to increase use of chemotherapy agents like paclitaxel. Paclitaxel has been implicated in rare cases of acute myocardial infarction from chemotoxicity. We present a rare case and literature review of Paclitaxel-induced acute multiple vessel coronary thrombosis in absence of native coronary artery atherosclerosis. Case A 68-year-old man with a history of metastatic stage IV non-small cell lung cancer, hypertension, hyperlipidemia, normal baseline left ventricular systolic function and without coronary disease on recent heart catheterization, was found unresponsive with telemetry showing monomorphic ventricular tachycardia six hours post Carboplatin-Paclitaxel infusion. Decision-making The patient was emergently cardioverted at bedside, intubated, and started on amiodarone, lidocaine, and norepinephrine infusions. The patient was thrombocytopenic at 61K, leukopenic at 1.2K, and anemic at 7.1 with INR of 1.8. ECG showed new ST-elevation in inferior leads. Bedside echocardiogram revealed global hypokinesis with apical akinesis and a newly reduced LVEF 25%. Troponin measured 0.5 ng/mL (normal <0.04 ng/mL), creatinine 1.4, K+ 3.4, and Mg2+ 1.8. After cardio-oncology led multidisciplinary discussion, a decision was made to pursue invasive angiogram. Found to have de novo triple-vessel coronary thrombosis in mid-LAD, proximal OM1 and mid RCA (Figure 2), percutaneous intervention was performed with drug-eluting stents placed in mid-LAD and mid-RCA, with staged PCI planned on proximal OM1 if needed. Patient responded well to the intervention and was extubated the same day. Patient remained medically stable at 3-month follow-up despite continued chemotherapy. Staged PCI to OM1 was not needed. Conclusion: Paclitaxel based therapy can cause ventricular arrhythmias and sudden cardiac death secondary to acute multi-vessel coronary thrombosis in patients without underlying coronary artery disease in the setting of pronounced thrombocytopenia. Prompt recognition of this severe adverse effect and timely utilization of multidisciplinary care models led by a cardio-oncologist achieves optimal outcomes.