5-fluorouracil ( 5-fu ) is a widely used chemotherapeutic drug and cardiac complications are not rare .
however myocardial infarction , tako - tsubo - like syndrome and cardiogenic shock are also described .
a 50-year - old man ( weight 70 kg , height 180 cm ) was admitted to a primary care hospital following an episode of syncope . he reported acute orthopnea and an attack of sweating at night accompanied by nausea and vomiting before loss of consciousness for 1 min .
in the emergency room , patient developed asystole and was immediately and successfully resuscitated for 2 min . afterwards , he was fully oriented without any neurological dysfunction .
consequently , he was transferred to our heart center for further diagnostic work - up and therapy .
importantly , patient had no previous history of cardiovascular disease or risk factors , but was diagnosed with colorectal cancer ( ct3 n1 m0 ) and underwent recent neoadjuvant chemotherapy with 5-fu ( 9500 mg by continuous infusion over a period of 120 h ) until 1 day before his acute presentation .
his physical examination revealed hypotensive blood pressures ( 89/58 mmhg ) and heart rate at rest of 95 bpm .
the electrocardiogram documented sinus rhythm at 95 bpm with non - significant st - elevation in leads ii , iii , avf .
high - sensitive troponin t ( 60 ng / l ; upper reference value 14 ng / l ) and creatine kinase - mb fraction ( 0.74 mol / l*s ; upper reference value 0.41 mol / l*s ) were slightly elevated .
creatinine kinase showed a normal value of 0.93 mol / l*s ( upper reference value 3.17 mol / l*s ) .
initial transthoracic echocardiography ( tte ) showed a normal sized left ventricle ( left - ventricular end - diastolic diameter : 48 mm , left - ventricular end - diastolic volume : 103 ml ) with global hypokinesia and severely decreased left - ventricular systolic function [ left - ventricular ejection fraction : 16% ; [ figure 1a and b ] .
transthoracic echocardiography on day 1 ( a ) apical four - chamber view during diastole , ( b ) apical four - chamber view during systole ( there is global hypokinesia with severely impaired thickening of the left ventricular wall in systole ) one day after admission , patient had persistent hypotension with increasing lactate levels as a sign of peripheral malperfusion . on repeat echocardiographic examination , left - ventricular systolic function was found to have further decreased with a left - ventricular ejection fraction of < 10% . due to the progressive cardiogenic shock
, we decided to treat this condition by the use of an extracorporeal membrane oxygenation ( ecmo ) support by percutaneous implantation .
on ecmo support , hemodynamic stabilization was evident and medical heart failure treatment including angiotensin - converting enzyme - inhibitor , diuretics and spironolactone was commenced .
after 4 days with ecmo therapy , left - ventricular ejection fraction improved to 45% and lactate levels were in normal ranges ( < 2
therefore , ecmo - flow was reduced slowly up to 1.5 l / min . due to the stable lactate levels ( < 2
the following course was uncomplicated with normalization of blood pressures and no signs of heart failure .
eight days after admission , he was transferred to the normal ward . left - ventricular ejection fraction was now recovered to a normal value of 60% [ figure 2a and b ] . for confirmation and further differential diagnosis cardiac , magnetic resonance imaging ( mri )
the mri showed a normal sized left ventricle ( left ventricular end - diastolic volume : 149 ml ; normal value 102 - 235 ml ) with normal ejection fraction of 57% and without any specific wall motion abnormality .
furthermore , t1-weighted imaging showed pronounced early contrast enhancement , indicating some degree of myocardial hyperemia .
patient was discharged from hospital in a stable cardiac condition without symptoms of heart failure 11 days after admission .
transthoracic echocardiography on day 10 ( a ) apical four - chamber view during diastole , ( b ) apical four - chamber view during systole .
this report describes a patient with no history of cardiovascular disease who experienced acute left - ventricular failure after administration of 5-fu .
cardiac complications ranging from angina pectoris to cardiogenic shock after chemotherapy with 5-fu are not rare .
coronary vasospasm , endothelial damage with consequent thrombus formation , increased myocardial oxygen demand , block of myocardial cell metabolism and tako - tsubo - like syndrome with supraphysiologic levels of plasma catecholamines are discussed as potential pathogenetic mechanisms .
our patient did not report any angina and obstructive coronary lesions were excluded by angiography .
echocardiography did not reveal an apical ballooning as common in tako - tsubo - like syndrome .
the cardiac mri of our patient strengthens the concept of an additional temporary myocardial inflammation .
increased global myocardial edema and evidence of myocardial hyperemia are compatible with a regressive inflammation .
unfortunately , the mri could not be performed in the acute setting with severely decreased left - ventricular function due to ecmo - therapy and therefore , the extent of myocardial edema and hyperemia might be underestimated .
treatment of cardiogenic shock is still a therapeutic challenge , especially if coronary artery disease was excluded .
usually , sympathomimetics are used as first line therapeutics , but several disadvantages in their use have to be taken into account .
sympathomimetics induced vasoconstriction can lead to perfusion mismatch or even deficit within the microcirculation and metabolic acidosis due to an increased oxygen demand can be observed regularly .
in addition , some studies give evidence that use of sympathomimetics is directly linked to enhanced systemic inflammatory response due to an increased interleukin-6 expression . in our case with unclear pathogenesis of cardiogenic shock
, we decided to use a mechanical hemodynamic support ( intraaortic balloon counterpulsation or ecmo ) to avoid above mentioned disadvantages with the use of sympathomimetics , especially with the knowledge about inflammation as a possible cause of 5-fu induced left - ventricular dysfunction .
recently , intraaortic balloon counterpulsation was shown not to reduce 30-day mortality in patients with cardiogenic shock complicating myocardial infarction . in our case with progressive cardiogenic shock ,
therefore , we decided to use ecmo - the most potent form of acute cardiorespiratory support , which enables complete relief of cardiac workload and prevents high - dose usage of sympathomimetics .
cardiogenic shock should be taken into consideration as a possible complication secondary to chemotherapy with 5-fu , even in patients without a history of cardiovascular disease . to the best of our knowledge ,
this is the first report of an ecmo support in this kind of chemotherapeutic induced cardiogenic shock .
ecmo support enabled complete relief of cardiac workload and together with medical therapy for heart failure , complete recovery of cardiac function was possible .
 a 50-year - old man with no previous history of cardiovascular disease or risk factors was admitted for syncope and orthopnea . 
 importantly , he underwent recent chemotherapy with 5-fluorouracil ( 5-fu ) until 1 day before his acute presentation . in the emergency room , 
 patient developed asystole and was successfully resuscitated for 2 min . at coronary angiography , no signs of coronary artery disease were detectable , but transthoracic echocardiography showed a severely decreased left - ventricular systolic function . due to the progressive cardiogenic shock , an extracorporeal membrane oxygenation ( ecmo ) support was used as bridge - to - recovery and to avoid the use of sympathomimetics with their known disadvantages . on ecmo support , hemodynamic stabilization was evident and medical heart failure treatment was commenced . 
 left - ventricular function recovered to normal values within a short period of time . 
 cardiac complications after chemotherapy with 5-fu are not rare and should be taken into consideration even in acute heart failure with cardiogenic shock . 
 ecmo as the most potent form of acute cardiorespiratory support enables complete relief of cardiac workload and therefore recovery of cardiac function . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION