Iron overload-related heart failure in a patient with transfusion-dependent myelodysplastic syndrome reversed by intensive combined chelation therapy.

Patients with transfusion-dependent myelodysplastic syndromes (MDS) have an increased risk of cardiac events, due to both chronic anemia and iron overload. Here, we report the recovery of cardiac function after an intensive iron chelation therapy in a MDS patient who had developed heart failure due to iron overload.

The finding that intensive iron chelation therapy (ICT) can aid recovery of cardiac function in heart failure resulting from myocardial iron deposition in β-thalassemia major (TM), has dramatically decreased the number of deaths due this life-treating complication 1–3. Patients with transfusion-dependent myelodysplastic syndromes (MDS) also have an increased risk of cardiac events, due to both chronic anemia and iron overload 4. Here, we report the use of intensive ICT in a low-risk transfusion-dependent MDS patient with SF3B1 mutations who had developed heart failure due to iron overload.

A 78-year-old man with refractory anemia with ring sideroblasts presented in our clinic. He carried a somatic mutation of SF3B1 (K700E allelic burden 41.4%) 5,6, and was H63D heterozygous for HFE gene.

Treatment with epoetin alfa (40,000 UI twice weekly) had been unsuccessful, so he was regularly transfused. After receiving 25 units of packed red blood cells (PRBC), the patient's serum ferritin value was 1214 μg/L and the magnetic resonance imaging (MRI) showed a mild liver iron overload with T2-star (T2*) of 4.1 msec ± 0.61 (liver T2* normal value >6.3 msec).

The patient was started on subcutaneous deferoxamine (DFO; 30 mg/kg/day five times per week) 7–9, but with limited compliance. After 4 months, the patient was switched to deferasirox (DFX; 15 mg/kg/day). Deferasirox was well tolerated initially, but later the patient experienced headache and systemic skin reactions affecting his legs. Chelation therapy was discontinued and when the patient was subsequently twice rechallenged at a lower dose of DFX plus a low dose of steroid, the skin reaction reappeared. During this time, the median serum ferritin increased to 1595 μg/L and the liver iron overload worsened, T2* by MRI was 2.16 msec ± 0.37.

By contrast, cardiac MRI indicated a myocardial T2* of 29 ± 4.23 msec (heart T2* normal value >20 msec) and a normal left ventricular ejection fraction (LVEF; 61%, normal value >55%). After twelve months of chelation therapy with DFX with a limited compliance, DFO was restarted (at 40 mg/kg daily) but compliance was still low. After 15 months of chelation therapy with DFO, effort dyspnea appeared (NYHA class III) and transthoracic echocardiography showed a reduction in LVEF (to 40%). The serum ferritin value increased to 2118 μg/L, while the blood transfusion requirement was similar. Cardiac MRI indicated a myocardial T2* of 7.9 ± 1.33 msec (severe iron overload T2* < 10 msec) without alterations of delayed enhancement. Holter EkG recording was normal, and ergometric stress test and angioTC were negative. No endocrinopathies were pointed out.

Based on the reversal of cardiac disease obtained by the combined therapy with deferiprone (DFP) and DFO observed in TM patients – and after having obtained off-label consent from our Ethical Committee and written informed consent from the patient –combined ICT was prescribed. The patient received DFP at 50 mg/kg in three doses/day and then increased to 75 mg/Kg after 2 weeks, and DFO was received at 30 mg/kg daily. Hematological parameters were monitored weekly.

After 6 months of therapy, transthoracic echocardiography and MRI indicated a recovery in LVEF to 55%. During the first year of combined ICT, the patient experienced a stable improvement in both cardiac and hepatic condition, and the volume of blood products used remained stable. Median serum ferritin was 1186 μg/L and MRI evaluation showed cardiac T2* of 13.3 ± 1.37 msec and liver T2* 3.22 msec (Fig. 1). Iron overload is common in transfusion-dependent low-risk MDS patients. It was recently shown that SF3B1 mutation is significantly associated with a high degree of ineffective erythropoiesis and marked suppression of hepcidin, resulting in increased iron absorption and recirculation. However, whether these changes may result in parenchymal iron overload and organ damage is still unclear.

Figure 1

Patient trend of serum ferritin, liver T2*, LVEF, heart T2* with chelation and transfusion therapy.

After 120 PRBC units, the patient here reported developed a clinically significant liver and cardiac iron overload, suggesting that in MDS associated with SF3B1 mutation, suppression of hepcidin mediated by ineffective erythropoiesis may result in a clinically relevant parenchymal iron overload 10.

Use of DFP is not widely used because of the risk of granulocytopenia 11. The efficacy and safety of combined ICT in reducing severe IO is well-known in patients affected by TM 2, but to the best of our knowledge, this is the first report showing its use in a transfusion-dependent MDS patient. Our findings suggest that combined ICT with DFP and DFO should be used safely and effectively to restore cardiac function in patients with transfusion-dependent MDS experiencing heart failure due to iron overload.

Conflict of Interest

None declared.