Cardiovascular magnetic resonance vs. echocardiography for assessing baseline cardiovascular reserve in patients undergoing CAR-T therapy

Abstract Introduction Patients eligible for CAR-T cell therapy face a significant risk of impaired cardiovascular reserve due to prior exposure to multiple lines of potentially cardiotoxic treatments, the need for additional conditioning chemotherapy, and the presence of pre-existing cardiovascular disease (CVD) and comorbidities. While cardiovascular magnetic resonance (CMR) is the gold standard for assessing cardiac volumes, systolic function, and tissue characterization, its role in the baseline evaluation of these patients remains underexplored. Additionally, up to 25% of CAR-T therapy recipients may develop cardiovascular complications, highlighting the need for improved risk stratification. Purpose To evaluate the added value of CMR compared to transthoracic echocardiography (TTE) in assessing baseline cardiovascular reserve in patients eligible for CAR-T cell therapy. Methods A prospective, descriptive, and non-interventional single-centre study included 150 patients undergoing CAR-T therapy. A comprehensive cardiovascular evaluation incorporating CMR and TTE was performed. Epidemiological variables, CVD and imaging parameters from CMR and TTE were collected. Statistical analyses were conducted using SPSS version 27. Results The mean age was 58±12 years, with a predominance of male patients (61%). The main haematologic diseases that received CAR-T cell therapy were lymphoma (61%) and multiple myeloma (MM) (37%). Pre-CART disease status was in stable disease or progression in 76%; and the median of previous lines before CAR-T cell therapy was of 2 (1-7) in patients with lymphoma and 2 (0-8) in patients with MM. Pre-existing CVD was found in 23% (arrhythmias 11%, cardiotoxicity 9%, ischemic heart disease 7%). TTE could be performed in 131 patients and CMR in 124. The mean left ventricular ejection fraction (LVEF) evaluated by TTE was 62±7%, while in CMR was 60±6%; and the correlation observed in LVEF measurement between TEE and CRM was 0,533 (p<0,001). Left ventricular systolic dysfunction was identified in 4% in TTE vs. 8% in CRM (p 0,011). Furthermore, tissue characterization in CMR revealed late gadolinium enhancement in 11% of patients (25% transmural and 44% with silent ischemic heart disease), myocardial oedema in 4% and evidence suggestive of cardiotoxicity in 9% Conclusion Patients eligible for CAR-T therapy have a high cardiovascular risk. While CMR and TTE show moderate correlation in LVEF assessment, CMR provides additional value by evaluating myocardial tissue characteristics, enabling the identification of high-risk patients with silent ischemic heart disease, cardiotoxicity, and myocardial oedema. Integrating CMR into baseline cardiovascular assessment may improve risk stratification and facilitate early interventions to optimize treatment before CAR-T therapy, potentially reducing cardiovascular complications.