Heart and blood vessel late effects are more likely to occur after treatment for certain childhood cancers.

Treatment for these and other childhood cancers may cause heart and blood vessel late effects:

• Acute lymphoblastic leukemia (ALL).
• Acute myelogenous leukemia (AML).
• Brain and spinal cord tumors.
• Head and neck cancer.
• Hodgkin lymphoma.
• Non-Hodgkin lymphoma.
• Osteosarcoma.
• Wilms tumor.
• Cancers treated with a stem cell transplant.

The heart is an organ, about the size of a fist. It is made of muscle and pumps blood through the body. Blood is carried through the body in blood vessels, or tubes, called arteries and veins. The process of moving blood through the body is called circulation. Together, the heart and vessels make up the cardiovascular system.

Structure of the Heart

The heart has four chambers (two atria and two ventricles). There is a wall (septum) between the two atria and another wall between the two ventricles. Arteries and veins go into and out of the heart. Arteries carry blood away from the heart and veins carry blood to the heart. The flow of blood through the vessels and chambers of the heart is controlled by valves.

Blood Flow Through the Heart

(Abbreviations refer to labels in the illustration)

The heart pumps blood to all parts of the body. Blood provides oxygen and nutrients to the body and removes carbon dioxide and wastes. As blood travels through the body, oxygen is used up, and the blood becomes oxygen poor.

1. Oxygen-poor blood returns from the body to the heart through the superior vena cava (SVC) and inferior vena cava (IVC), the two main veins that bring blood back to the heart.
2. The oxygen-poor blood enters the right atrium (RA), or the right upper chamber of the heart.
3. From there, the blood flows through the tricuspid valve (TV) into the right ventricle (RV), or the right lower chamber of the heart.
4. The right ventricle (RV) pumps oxygen-poor blood through the pulmonary valve (PV) into the main pulmonary artery (MPA).
5. From there, the blood flows through the right and left pulmonary arteries into the lungs.
6. In the lungs, oxygen is put into the blood and carbon dioxide is taken out of the blood during the process of breathing. After the blood gets oxygen in the lungs, it is called oxygen-rich blood.
7. Oxygen-rich blood flows from the lungs back into the left atrium (LA), or the left upper chamber of the heart, through four pulmonary veins.
8. Oxygen-rich blood then flows through the mitral valve (MV) into the left ventricle (LV), or the left lower chamber.
9. The left ventricle (LV) pumps the oxygen-rich blood through the aortic valve (AoV) into the aorta (Ao), the main artery that takes oxygen-rich blood out to the rest of the body.

Radiation to the chest and certain types of chemotherapy increase the risk of heart and blood vessel late effects.

The risk of health problems involving the heart and blood vessels increases after treatment with the following:

• Radiation to the chest, spine, brain, neck, kidneys, or total-body irradiation (TBI) as part of a stem cell transplant. The risk of problems depends on the area of the body that was exposed to radiation, the amount of radiation given, and whether the radiation was given in small or large doses.
• Certain types of chemotherapy and the total dose of anthracycline given. Chemotherapy with anthracyclines such as doxorubicin, daunorubicin, idarubicin, and epirubicin, and with anthraquinones such as mitoxantrone increase the risk of heart and blood vessel problems. The risk of problems depends on the total dose of chemotherapy given and the type of drug used. It also depends on whether treatment with anthracyclines was given to a child younger than 13 years and whether a drug called dexrazoxane was given during treatment with anthracyclines. Dexrazoxane may lessen heart and blood vessel damage up to 5 years after treatment. Ifosfamide, cyclophosphamide, methotrexate, asparaginase, and chemotherapy with platinum, such as carboplatin and cisplatin, may also cause heart and blood vessel late effects.
• Stem cell transplant.
• Nephrectomy (surgery to remove all or part of a kidney).

Childhood cancer survivors who were treated with radiation therapy to the heart or blood vessels and certain types of chemotherapy are at greatest risk.

New treatments that decrease the amount of radiation given and use lower doses of chemotherapy or less harmful chemotherapy drugs may lessen the risk of heart and blood vessel late effects compared with older treatments.

The following may also increase the risk of heart and blood vessel late effects:

• Longer time since treatment.
• Having high blood pressure or other risk factors for heart disease, such as a family history of heart disease, being overweight, smoking, high cholesterol, or diabetes. When these risk factors are combined, the risk of late effects is even higher.
• Having lower than normal amounts of thyroid, growth, or sex hormones.

Late effects that affect the heart and blood vessels may cause certain health problems.

Childhood cancer survivors who received radiation or certain types of chemotherapy have an increased risk of late effects to the heart and blood vessels and related health problems. These include the following:

• Abnormal heartbeat.
• Weakened heart muscle.
• Inflamed heart or sac around the heart.
• Damage to the heart valves.
• Coronary artery disease (hardening of the heart arteries).
• Congestive heart failure.
• Chest pain or heart attack.
• Blood clots or one or more strokes.
• Carotid artery disease.

Possible signs and symptoms of heart and blood vessel late effects include trouble breathing and chest pain.

These and other signs and symptoms may be caused by heart and blood vessel late effects or by other conditions:

• Trouble breathing, especially when lying down.
• Heartbeat that is too slow, too fast, or different from the heart's normal rhythm.
• Chest pain or pain in the arm or leg.
• Swelling of the feet, ankles, legs, or abdomen.
• When exposed to cold or having strong emotions, the fingers, toes, ears, or nose become white and then turn blue. When this happens to the fingers, there may also be pain and tingling.
• Sudden numbness or weakness of the face, arm, or leg (especially on one side of the body).
• Sudden confusion or trouble speaking or understanding speech.
• Sudden trouble seeing with one or both eyes.
• Sudden trouble walking or feeling dizzy.
• Sudden loss of balance or coordination.
• Sudden severe headache for no known reason.
• Pain, warmth, or redness in one area of the arm or leg, especially the back of the lower leg.

Talk to your child's doctor if your child has any of these problems.

Certain tests and procedures are used to diagnose health problems in the heart and blood vessels.

These and other tests and procedures may be used to diagnose heart and blood vessel late effects:

• Physical exam and health history: An exam of the body to check general signs of health, including checking the heart for signs of disease, such as abnormal heart beat, high blood pressure, or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
• Electrocardiogram (EKG): A recording of the heart's electrical activity to check its rate and rhythm. A number of small pads (electrodes) are placed on the patient’s chest, arms, and legs, and are connected by wires to the EKG machine. Heart activity is then recorded as a line graph on paper. Electrical activity that is faster or slower than normal may be a sign of heart disease or damage.
• Echocardiogram: A procedure in which high-energy sound waves (ultrasound) are bounced off the heart and nearby tissues or organs and make echoes. A moving picture is made of the heart and heart valves as blood is pumped through the heart.
• Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs such as the heart and make echoes. The echoes form a picture of body tissues called a sonogram. The picture can be printed to be looked at later.
• MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI). This procedure is done to check for blood clots.
• CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography. This procedure is done to check for blood clots.
• MRA (magnetic resonance angiography): A procedure that uses radio waves and a powerful magnet linked to a computer to create detailed pictures of the blood vessels and blood flow inside the body. A dye may be injected into a vein to make the blood vessels and blood flow easier to see. This may be used to check for blood clots or other blood vessel problems.
• Lipid profile studies: A procedure in which a blood sample is checked to measure the amounts of triglycerides, cholesterol, and low- and high-density lipoprotein cholesterolin the blood.

Talk to your child's doctor about whether your child needs to have tests and procedures to check for signs of heart and blood vessel late effects. If tests are needed, find out how often they should be done.

Childhood cancer survivors may have late effects that affect the heart during pregnancy.

Long-term survivors of childhood, adolescent, and young adult cancers who have received radiation therapy or certain types of chemotherapy are at risk of a rare type of heart failure during pregnancy called peripartum cardiomyopathy (PPCM). It may occur during late pregnancy and up to 5 months after giving birth. Patients at risk of this condition should be closely followed for weakness of the heart muscle during pregnancy.

Health habits that promote a healthy heart and blood vessels are important for survivors of childhood cancer.

Childhood cancer survivors may lower their risk of heart and blood vessel late effects by having a healthy lifestyle, which includes:

• A healthy weight.
• A heart-healthy diet.
• Regular exercise.
• Not smoking.