Outcome of Allogeneic Stem Cell Transplantation in Patients with Low Ventricular Ejection Fraction

BACKGROUND: High-dose therapy and Allogeneic stem cell transplantation (allo SCT) is a potentially curative treatment for patients with hematologic malignancies. A high risk of regimen-related toxicity limits this treatment only for patients with excellent organ-system function. A low left ventricular ejection fraction (LVEF) of ≤ 45% is considered to be a major risk factor for post-transplant cardiac toxicity and nonrelapse mortality (NRM). However, several patients with advanced hematologic malignancies and low LVEF can potentially benefit from this therapy. To address this issue, we evaluated the frequency of cardiac toxicity and NRM in 56 patients with low LVEF undergoing allo SCT.

METHODS: We performed a retrospective analysis on 56 patients with baseline low LVEF who received allo SCT between January 2000 and February 2006 at our institution. Pre-transplant evaluation included an electrocardiogram and bidimensional echocardiogram or gated cardiac scan. Cardiac toxicity was defined as congestive heart failure (CHF), atrial/ventricular arrhythmia or an acute coronary syndrome. Of the 56 patients, 22 received a myeloablative regimen (16 busulfan-based, 6 total body irradiation-based) while 34 patients received a fludarabine-based reduced intensity conditioning regimen.

RESULTS: Twenty-three patients (41%) received allo SCT from an unrelated donor. Acute leukemia was the reason for allo SCT in 32 (57%) patients. Baseline LVEF within 30 days pre-transplant ranged 20 to 45%. At their 6 month follow-up, cardiac toxicity was seen in 7 (12%) patients. Toxicity included congestive heart failure (CHF) in 4 (7%) and atrial fibrillation (AF) in 4 (7%). One patient had both CHF and AF. There were no documented episodes of acute coronary syndrome. Cumulative incidence of NRM at 100 days was 12%; none of the deaths were attributable to cardiac causes. These results were comparable to allo SCT performed in patients with normal LVEF. Variables such as age, LVEF, type of transplant, or the underlying disease did not emerge as significant predictors of post-transplant cardiac toxicity or NRM.

CONCLUSION: Patients with low LVEF (<45%) are acceptable candidates for allo SCT. A prospective study with stratification of cardiac risk factors is warranted in patients with low LVEF.