Acute Non-Ischemic Cardiomyopathy Requiring VA ECMO in the Setting of 5-Fluorouracil Chemotherapy

Introduction: 5-fluorouracil (5-FU) is a widely used chemotherapeutic agent, producing cytotoxic metabolites, leading to defective DNA/RNA replication. 5-FU has the second highest prevalence of cardiotoxicity among chemotherapeutic agents. Adverse effects range from mild to life threatening, and have previously been managed with supportive care. This practice is changing as uridine triacetate (UT) is being utilized in severe 5-FU toxicities. UT's metabolite acts as an antidote to 5-FU by competing for RNA incorporation. In addition, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a useful support modality in acute cardiogenic shock to bridge patients to recovery, transplant, or durable cardiac assist device. We report a patient with cardiogenic shock requiring VA-ECMO who recovered following initiation of UT.


Description: A 46-year-old male with a history of tongue squamous cell carcinoma, initiated on carboplatin and 5-FU infusion for palliative measures two days prior, presented to the emergency department in cardiogenic shock with evidence of end organ dysfunction. His initial troponin was 800, but EKG showed sinus tachycardia without acute ischemia. Echocardiogram revealed an ejection fraction (EF) of 5% with global hypokinesis, decreased from his previously normal baseline cardiac function (EF 60%). Coronary angiography performed on the day of admission was negative for coronary artery disease and no stents were placed. Given his refractory cardiogenic shock, he was placed on VA-ECMO. The team had suspicion for 5-FU induced cardiomyopathy or vasospasm, and initiated treatment with UT. The patient had recovery of his EF less than one week after completion of this antidote and was subsequently decannulated. He survived and was discharged to LTACH.


Discussion: There are no prior case reports of VA-ECMO use in conjunction with UT administration for 5-FU toxicity. This patient’s acute cardiomyopathy was determined to be non-ischemic, and likely secondary to checkpoint inhibitor-induced myocarditis or vasospasm, given his improvement after initiation of UT. VA-ECMO served as a pertinent bridge for acute cardiac-respiratory support while the underlying cause of his shock was being addressed.