Beyond the means of natural selection: A case of end stage heart failure and advanced esophageal cancer successfully treated with an implantable left ventricular assist device (LVAD) and aggressive chemoradiation therapy

Title: Beyond the means of natural selection: A case of end stage heart failure and advanced esophageal cancer successfully treated with an implantable left ventricular assist device (LVAD) and aggressive chemoradiation therapy. Background: End-stage heart failure and advanced cancer individually share poor prognoses. The combination of the two conditions in the same patient is grave. Advances in management for both maladies continue to evolve. As such, the field of cardio-oncology has emerged as an important subspecialty. A case of Stage D heart failure treated with an implantable LVAD in a patient with subsequently found to have metastatic esophageal cancer illustrates the multi-specialty and multimodality approach to this complex problem. Case: A 72-year-old man with end-stage heart failure underwent placement of an LVAD as Destination Therapy. Seven months postoperatively he was found to have advanced gastroesophageal carcinoma. He underwent combination chemo-radiation therapy and remains on a chemotherapy regimen more than three year since the cancer diagnosis and almost four years since the LVAD implant. Conclusion: The combination of cardiovascular disease and cancer continues to be a problem as the population. As such, treatments of these maladies have evolved accordingly. Patients with implantable LVADs and cancer are beginning to appear more regularly as the number of LVADs implanted increase. It will be important for the clinician to understand the complex issues related to this unique patient population. Correspondence to: Louis Samuels, Department of Surgery, Division of Cardiothoracic Surgery, Thomas Jefferson University, Philadelphia PA, USA, E-mail: samuelsle@aol.com. Received: August 22, 2017; Accepted: September 13, 2017; Published: September 16, 2017 Introduction Heart Failure continues to plague millions of citizens throughout the world, accounting for billions of dollars in health care expenditure in the United States annually [1]. Esophageal cancer, ranked sixth among all cancers in mortality, affects 450,000 people worldwide with an alarming rise in its incidence [2]. Individually, these two diseases portend a grave prognosis in their most advanced stages, with threeyear survival being more the exception than the rule. No one knows the survival rates for NYHA IV heart failure combined with Stage IV esophageal adenocarcinoma. However, it is safe to predict that survival beyond one year would be remarkable. The purpose of this case report is to describe a 72-year-old man who underwent placement of an implantable left ventricular assist device (LVAD) as destination therapy (DT) for Stage D heart failure. Postoperatively, he was found to have adenocarcinoma at the gastroesophageal (GE) junction with loco-regional metastases to lymph nodes as well as a malignant lytic lesion in the lumbar spine. He underwent chemoradiation therapy with longer survival (> 3 yrs) than what would have been predicted. The issues related to this case raise important questions related to this unique patient population. Case A 72-year-old man was admitted with acute decompensated heart failure, complaining of dyspnea, fatigue, and generalized weakness. His past medical history was significant for cardiac disease, including cardiomyopathy and atrial fibrillation, eventually requiring mitral valve replacement and concomitant coronary artery bypass grafting seven years prior to admission. Two years following the surgery, he required admission for cardiovascular symptoms at which time echocardiography demonstrated an ejection fraction of 15 to 20%. He was medically managed and subsequently underwent insertion of an implantable cardiac defibrillator (ICD). He was discharged and remained stable until this admission five years later. Samuels L (2017) Beyond the means of natural selection: A case of end stage heart failure and advanced esophageal cancer successfully treated with an implantable left ventricular assist device (LVAD) and aggressive chemoradiation therapy Cardiovasc Disord Med, 2017 doi: 10.15761/CDM.1000151 Volume 2(6): 2-3 serial PET scans showing diminution and eventual disappearance of abnormal FDG uptake. Furthermore, follow-up UGI endoscopy showed normal benign gastric mucosa. During the treatment period, three complications occurred: 1) Portacath infection with Staphylococcus aureus requiring antibiotics, removal and replacement. 2) Bleeding following ICD removal and replacement requiring red blood cell transfusion and wound hematoma evacuation. 3) LVAD driveline site fracture requiring repair. At present (> 3 yrs), the patient remains on maintenance Oxaliplatin, leucovorin, fluorouracil (FOLFOX) therapy.