Abstract

Patients with preexisting coronary artery disease (CAD) have traditionally not undergone stem cell transplantation because of the perceived cardiac risk of the procedure. With the advent of reduced intensity stem cell transplantation and increased numbers of elderly patients, the question of whether or not it is safe to transplant patients with CAD is increasingly pertinent. We reviewed the outcomes of eight transplants performed in patients with clinically significant CAD. We also assessed the contribution of anthracycline/cyclophosphamide use and mediastinal radiation to cardiac toxicity. Clinically significant CAD was defined as that associated with myocardial infarction or that requiring percutaneous intervention/coronary artery bypass grafting (see chart for individual details). All patients were clinically stable at the time of transplant although two had experienced transient angina within three months. For all patients, baseline echocardiogram demonstrated ejection fractions greater than 50%, and baseline EKG demonstrated sinus rhythm although Q waves, T wave inversions, diffuse T wave abnormalities, and first-degree AV block were present. One fully ablative allogeneic, three subablative allogeneic, and four autologous transplants were performed. Conditioning regimens are presented below. All transplants used peripheral blood stem cells. Transplants were performed for multiple myeloma, ALL, AML, and CML. None of the patients were exposed to mediastinal radiation or cardiac toxic doses of anthracyclines or cyclophosphamide. Median survival after transplant was 496.9 days (range 58 – 1367 days). Two patients have died; one from disease progression and the other from pneumonia related complications. One patient was retransplanted on day 721. No ischemic events have been reported on follow up which has included myocardial perfusion scanning in three transplants. We conclude that cardiac risk is minimal and acceptable in patients with stable CAD who undergo transplant.

Baseline Cardiac History and Transplantation Characteristics

Cardiac HistoryTransplantConditioningFollow up
1v stent Autologous Melphalan 200 mg/m2 Retransplanted day 721, no ischemic events, normal myocardial perfusion scan 
7v CABG Autologous Melphalan 200 mg/m2 Alive day 579, no ischemic events 
3v CABG Autologous Melphalan 200 mg/m2 Alive day 1367, no ischemic events 
1v stent Autologous Melphalan 200 mg/m2 Alive day 877, no ischemic events 
1v stent Haploidentical 4/6 TBI 450 cGy (single dose), campath 40 mg, fludarabine 120 mg/m2 Alive day 58, no ischemic events, normal myocardial perfusion scan 
1v stent Matched related Busulfan 6.4 mg/kg, fludarabine 120 mg/m2 Alive day 86, no ischemic events, normal myocardial perfusion scan 
3v CABG, 1v angioplasty Matched related TBI 450 cGy (single dose), campath 30 mg, anti-CD45 antibody 1.6 mg/kg, fludarabine 120 mg/m2 Dead day 68 from disease progression 
Small vessel disease with myocardial infarction Mismatched related 5/6 TBI 800 cGy, cyclophosphamide 120 mg/kg Dead day 219 from pulmonary complications 
Cardiac HistoryTransplantConditioningFollow up
1v stent Autologous Melphalan 200 mg/m2 Retransplanted day 721, no ischemic events, normal myocardial perfusion scan 
7v CABG Autologous Melphalan 200 mg/m2 Alive day 579, no ischemic events 
3v CABG Autologous Melphalan 200 mg/m2 Alive day 1367, no ischemic events 
1v stent Autologous Melphalan 200 mg/m2 Alive day 877, no ischemic events 
1v stent Haploidentical 4/6 TBI 450 cGy (single dose), campath 40 mg, fludarabine 120 mg/m2 Alive day 58, no ischemic events, normal myocardial perfusion scan 
1v stent Matched related Busulfan 6.4 mg/kg, fludarabine 120 mg/m2 Alive day 86, no ischemic events, normal myocardial perfusion scan 
3v CABG, 1v angioplasty Matched related TBI 450 cGy (single dose), campath 30 mg, anti-CD45 antibody 1.6 mg/kg, fludarabine 120 mg/m2 Dead day 68 from disease progression 
Small vessel disease with myocardial infarction Mismatched related 5/6 TBI 800 cGy, cyclophosphamide 120 mg/kg Dead day 219 from pulmonary complications 

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