NOVEL IMMUNOTHERAPIES (CAR-T, BiTE)

Diagnosis

JM is a 74-year-old male patient diagnosed with advanced left pleural malignant mesothelioma.

Treatment

JM received treatment with multiple lines of chemotherapy before undergoing a thoracotomy with a left parietal pleurectomy with decortication. He was also treated with pembrolizumab, followed by carboplatin and pemetrexed, but shortly after, he experienced disease progression. JM was then admitted for CAR-T cell therapy with manufactured autologous TC-210 T cells.

Cardiovascular Toxicity Mitigation and Management

During the course of his CAR T-cell therapy infusion, he developed a rapid wide complex tachycardia with a heart rate of 171 bpm. Electrocardiogram demonstrated a wide complex tachycardia, rate 171, right bundle branch block with prolonged QTcF 577 ms. Fusion beats with AV dissociation reflective of probable ventricular tachycardia (VT) were also present. JM was initiated and loaded on amiodarone, which aborted the VT. He then received a maintenance dose of amiodarone 400 mg orally daily thereafter.

JM underwent a cardiac workup, which included cardiac troponin T levels, which did not reflect acute coronary syndrome with levels of 79, 72, and 76. An elective echocardiogram showed preserved left ventricular systolic function with no evidence of structural heart disease and an ejection fraction of 61% without wall motion abnormalities. He was recommended to undergo a pharmacologic stress test, and the results were negative for ischemia. JM had a low clinical suspicion for myocarditis, which was considered in the differential diagnosis given his recent exposure to pembrolizumab, so a cardiac MRI was not pursued. His cardiac risk factor profile included hypertension, hyperlipidemia, diabetes, and obstructive sleep apnea, placing him in the high-risk patient category. Fortunately, JM responded favorably to amiodarone and did not experience any further VT.