Anthracyclines in a patient with acute leukemia and severe cardiomyopathy requiring mechanical support: A case report

Introduction For young adult patients with acute leukemia, both the efficacy and cardiotoxicity of anthracycline-based regimens have been documented. We report the case of a patient with severe cardiomyopathy, mechanically supported by a left ventricular assist device (LVAD), who subsequently developed Philadelphia-chromosome positive acute lymphoblastic leukemia (Ph + ALL). To our knowledge, this is the first report of anthracycline administration in a patient with heart failure requiring mechanical support. Case report Our 27-year-old female patient was diagnosed with Ph + B-ALL as part of workup for leukocytosis. Past medical history included non-ischemic cardiomyopathy with a left ventricular ejection fraction of 30-35% and moderate-severe right ventricular dysfunction, for which LVAD had been placed 4 years previously. Management & outcome After shared decision-making and multidisciplinary discussions, we felt that hyperfractionated cyclophosphamide, doxorubicin, vincristine, and dexamethasone alternating with cytarabine and high-dose methotrexate in addition to ponatinib (HyperCVAD-ponatinib) best balanced the patient's goals for aggressive treatment with the potential for rapid and durable remissions. The patient received a single reduced dose of doxorubicin alongside dexrazoxane with her first cycle of HyperCVAD-ponatinib. She attained a complete molecular response 22 days later and remains in remission (with stable cardiac function) 30 months later on maintenance therapy. Discussion In conclusion, LVAD placement is not an absolute contra-indication to anthracyclines if such therapies offer the best opportunity for a durable response.