ID:145 FC-D02-4 A case of VA-ECMO and Impella support improved for severe heart failure due to Pembrolizumab and Lenvatinib

Background: Lenvatinib is a tyrosine kinase inhibitor (TKI) used for unresectable renal cell carcinoma. Although cardiotoxicity is less common than with other TKIs such as cabozantinib, severe heart failure can occur. We report a case of fulminant lenvatinib-induced cardiomyopathy successfully managed with veno-arterial extracorporeal membrane oxygenation (VA–ECMO) and Impella support. Clinical Course: A 49-year-old man with right renal cell carcinoma and pulmonary metastases underwent nephrectomy and subsequently received four cycles of pembrolizumab and lenvatinib beginning one month after surgery. One week before presentation, he developed anorexia, vomiting, and malaise, and presented emergently three months after initiation of pembrolizumab and lenvatinib. Chest CT revealed marked cardiomegaly. Transthoracic echocardiography showed biventricular dilation with a left ventricular ejection fraction of 6%, elevated B–type natriuretic peptide, and negative cardiac troponin. Right heart catheterization demonstrated a mean right atrial pressure of 19 mmHg, pulmonary capillary wedge pressure of 30 mmHg, and cardiac index of 1.52 L/min/m2, consistent with elevated filling pressures and low cardiac output. Lenvatinib-induced cardiomyopathy was suspected. Despite dobutamine infusion and intra-aortic balloon pump insertion, hemodynamics remained unstable. VA–ECMO and Impella were initiated, and the patient was transferred to the ICU. Fluid balance was managed with diuretics. Cardiac function gradually improved, allowing VA–ECMO removal on day 7, extubation on day 9, Impella removal on day 25, and ICU discharge on day 28. Discussion: Approximately half of reported cases of cabozantinib-associated heart failure recover after drug discontinuation and heart failure therapy, and a similar course may occur with lenvatinib. As the use of anticancer therapies continues to expand, the need for cardiovascular critical care in oncology is increasing. Early recognition and timely escalation to mechanical circulatory support can be lifesaving in severe drug–induced cardiomyopathy.