ABSTRACT
Intracardiac metastases in the absence of inferior vena cava involvement is a rare occurrence in patients with metastatic renal cell carcinoma (mRCC). There is limited evidence regarding the efficacy and safety of standard treatment modalities for mRCC patients with intracardiac metastases. Presence of intracardiac metastases is known to indicate poor prognosis and may potentially increase risk of treatment-related complications. Recent advances in RCC management have integrated nivolumab, a programmed death-1 (PD-1) receptor inhibitor, as a preferred treatment option in the second-line setting after failure of prior anti-angiogenic therapy; or in combination with ipilimumab, an anti-Cytotoxic T-lymphocyte antigen-4 antibody as first-line therapy for intermediate to poor risk patients with mRCC. The efficacy and toxicity of nivolumab in patients with mRCC and intracardiac metastases has never been reported previously. We herein present the first reported case of mRCC with intracardiac metastasis and a resultant excellent response to nivolumab treatment and discuss the imaging techniques and treatment options for this rare presentation.
ABSTRACT
PURPOSE: Patients undergoing mitral valve surgery are at risk for right ventricular (RV) dysfunction resulting from increased left atrial pressure and increased pulmonary artery impedance. Measures of longitudinal measures of RV function, such as displacement, are commonly performed but have been shown to be depressed after cardiac surgery despite good patient recovery. The aim of this observational study was to assess the early perioperative time course of longitudinal transthoracic echocardiographic (TTE) markers of RV function in a patient population undergoing mitral valve surgery. METHODS: Twenty patients undergoing mitral valve surgery were enrolled in this observational study. Right ventricular longitudinal measurements (tricuspid annular plane systolic excursion [TAPSE], strain, annular velocity [S'], and isovolumic acceleration [IVA]) were performed using TTE and colour Doppler imaging preoperatively (day 1) and postoperatively (days 2 and 6). Comparisons were made between the preoperative and postoperative measurements. RESULTS: Adequate echocardiographic imaging was obtained for all 20 patients. The TAPSE, strain, and S' measures remained depressed for up to one week (i.e., day 6) after surgery compared to preoperative values. The IVA was depressed on the first postoperative day (P > 0.001), but by day 6 it was no different from the preoperative value (P = 0.37). The median [interquartile range] time to discharge from hospital was 7 [6-9] days. CONCLUSION: Persistent, significant depression of longitudinal markers of RV function despite functional improvement (discharge from hospital) make it difficult to assess recovery during the early perioperative period. Isovolumic acceleration, a load-independent measure of contractility, might be a more reliable measure of early recovery in RV function in this patient population.
