Orly Leiva Jr, MD
Advanced Heart Failure and Transplantation Fellow
University of Chicago
Chicago, Illinois
Incoming Interventional Cardiology Fellow
University of Kentucky
Lexington, Kentucky
oleiva@bu.edu
Disclosures: None.

Cardio-oncology is a booming field that is rapidly becoming less “niche” and more recognized as an important discipline that aims to improve the care of a growing patient population. Interventional cardio-oncology is a more nascent field, but one that holds great potential. Historically, if you look at practice patterns in the real world and published literature, patients with cancer tend to undergo indicated invasive procedures less often than their noncancer contemporaries. For example, percutaneous coronary intervention (PCI) in acute coronary syndrome (ACS), mechanical circulatory support for cardiogenic shock, and catheter-directed therapies for pulmonary embolism (PE) are used less often in the cancer population despite the prevalence of these disorders in this cohort.1-4 The apprehension may lie in a perceived poor prognosis of patients with cancer or real/perceived increased risk of bleeding and other complications. However, cancer therapies have progressed to the point where a lot of cancers can be thought of as chronic diseases.

With more interventional cardiologists focusing specifically on cardio-oncology patients, I believe the care of these patients will be improved through a more nuanced understanding of prognosis and disease trajectory (in a multidisciplinary manner, with oncology and other stakeholders), the education of fellow cardiologists, and an increase in research that will shed light on the real risks and benefits of interventional procedures.

In 10 years, I can see the increased influence of cardio-oncology on other aspects of cardiology, including interventional cardiology. More trainees, like myself, are becoming interested in cardio-oncology, and with that, momentum will build and the field will continue to grow.

1. Rohrmann S, Witassek F, Erne P, et al. Treatment of patients with myocardial infarction depends on history of cancer. Eur Heart J Acute Cardiovasc Care. 2018;7:639-645. doi: 10.1177/2048872617729636

2. Leiva O, Cheng RK, Pauwaa S, et al. Outcomes of patients with cancer with myocardial infarction-associated cardiogenic shock managed with mechanical circulatory support. J Soc Cardiovasc Angiogr Interv. 2023;3:101208. doi: 10.1016/j.jscai.2023.101208

3. Leiva O, Yang EH, Rosovsky RP, et al. In-hospital and readmission outcomes of patients with cancer admitted for pulmonary embolism treated with or without catheter-based therapy. Int J Cardiol. 2024;408:132165. doi: 10.1016/j.ijcard.2024.132165

4. Leiva O, Yuriditsky E, Postelnicu R, et al. Catheter-based therapy for intermediate or high-risk pulmonary embolism is associated with lower in-hospital mortality in patients with cancer: Insights from the National Inpatient Sample. Catheter Cardiovasc Interv. 2024;103:348-358. doi: 10.1002/ccd.30917

Sara C. Martinez, MD, PhD, FACC, FSCAI
Providence Cardiology Associates
Olympia, Washington
sara.martinez@providence.org
Disclosures: None.

Interventional cardiology is evolving at a rapid pace, with the development of newer technology, techniques, and treatments in coronary artery disease (CAD), valvular heart disease, PE, and cardiogenic shock. Similarly, worldwide research efforts in oncology have developed modern cancer care to include targeted radiation oncology practices, small molecule and antibody-specific inhibitor drugs, genetic profiling of malignancies, and targeted therapies. The World Health Organization projects new cancer cases to jump 77% in 2050 compared to 2022.1 Because heart disease and cancer are the two leading causes of death and have many shared risk factors, contemporary general and interventional cardiologists can expect to encounter more cardiovascular patients with cancer in the next 10 years.

CORONARY ARTERY DISEASE

Patients with cancer and CAD with ACS present unique challenges regarding bleeding and thrombosis. Based on data on short dual antiplatelet therapy (DAPT) in patients undergoing PCI with and without ACS, patients with cancer who undergo PCI might expect to be treated with shortened DAPT or single antiplatelet therapy to minimize risks of serious bleeding.

The increased utilization of intracoronary imaging and expertise of interventionalists contributes to improved outcomes for all PCI patients, but this may be an added advantage in the cardio-oncology patient population. We may see data on drug-coated balloons (DCBs) versus third-generation drug-eluting stents in primary PCI for cancer patients within the next 10 years. DCB therapies and bioabsorbable stents for bifurcation disease and treatment of in-stent restenosis are likely to find increased application in patients with cancer in an effort to minimize early or late stent thrombosis events. By considering individual patient characteristics, historical or current cancer diagnoses, and PCI adverse outcomes, a more personalized treatment plan and mutually informed assessment of risks can be undertaken.

VALVULAR HEART DISEASE

The field of structural interventional cardiology initially blossomed as a result of advanced improvements in quality of life and survival for patients with severe valvular heart disease who were not surgical candidates, and it has expanded to include patients with lower risk profiles for aortic stenosis, functional mitral valve regurgitation, and left atrial appendage occlusion (LAAO). Many patients who have received cancer treatments are at increased risk of valvular heart disease and bleeding but are questionable candidates for surgical intervention.

Within the next 10 years, as cancer therapies continue to improve and survival increases, transcatheter valve therapeutics may become a mainstay for oncology patients. Malignancy imposes bleeding and thrombosis risks that are higher than observed in patients without cancer. Patients with cancer and atrial fibrillation (AF) or AF and CAD who require concomitant antiplatelet therapy unfortunately have a greater chance of serious bleeding, although cancer or cancer therapies are not considered traditional risk factors for stroke or hemorrhage. LAAO may decrease the risk of hemorrhagic complications of oral anticoagulation in patients with nonvalvular AF. As more real-world data and trial data are generated, LAAO may become increasingly offered to patients with cancer and AF requiring oral anticoagulation.

CARDIOGENIC SHOCK AND PULMONARY EMBOLISM

Because of increased efforts to develop algorithmic approaches to identify the etiology of cardiogenic shock and appropriately implement therapy and support, survival from cardiogenic shock has become more optimistic. Patients with malignancy are at increased risk of bleeding with large-bore access, and the development and implementation of lower-profile mechanical circulatory support devices to support right and left ventricular function is likely to occur in the future.

PE remains a significant cause of morbidity, shock, and mortality in patients with cancer. The emergence of regional PE response teams within specialized centers, along with prospective randomized controlled trials evaluating percutaneous thrombectomy, fibrinolytics, and anticoagulation will likely lead to updates in recommendations for best practices.

CONCLUSION

Management of the cardio-oncology patient presenting with CAD, AF, valvular heart disease, or cardiogenic shock requires an informed and tailored approach to mitigate primarily increased bleeding and procedural recovery risks. Early career training in cardio-oncology has become a special subdivision within many mature cardiology practices. Within the next 10 years, cardio-oncology rotations and training will likely become standard in cardiology fellowship programs. A cardio-oncology team’s familiarity and fluency in the health status of the patient with both cancer and cardiovascular conditions allows for a shared discussion between provider and patient regarding options and risk. Coupling enhanced knowledge and communication with the practice of decreasing adverse outcomes in interventional cardiology over the next 10 years will lead to improved shared decision-making, congruency with goals of care, and improved quality of life for the cardio-oncology patient.

1. World Health Organization. Global cancer burden growing, amidst mounting need for services. February 1, 2024. Accessed March 4, 2025. https://www.who.int/news/item/01-02-2024-global-cancer-burden-growing--amidst-mounting-need-for-services