{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,29]],"date-time":"2026-06-29T11:29:50Z","timestamp":1782732590067,"version":"3.54.5"},"reference-count":55,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2021,3,17]],"date-time":"2021-03-17T00:00:00Z","timestamp":1615939200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Diseases"],"abstract":"<jats:p>Chimeric antigen receptor T-cells (CAR-T) are improving outcomes in pediatric and adult patients with relapsed or refractory B-cell acute lymphoblastic leukemias and subtypes of non-Hodgkin Lymphoma. As this treatment is being increasingly utilized, a better understanding of the unique toxicities associated with this therapy is warranted. While there is growing knowledge on the diagnosis and treatment of cytokine release syndrome (CRS), relatively little is known about the associated cardiac events that occur with CRS that may result in prolonged length of hospital stay, admission to the intensive care unit for pressor support, or cardiac death. This review focuses on the various manifestations of cardiotoxicity, potential risk factors, real world and clinical trial data on prevalence of reported cardiotoxicity events, and treatment recommendations.<\/jats:p>","DOI":"10.3390\/diseases9010020","type":"journal-article","created":{"date-parts":[[2021,3,17]],"date-time":"2021-03-17T21:43:31Z","timestamp":1616017411000},"page":"20","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":36,"title":["Cardiotoxicity Associated with Anti-CD19 Chimeric Antigen Receptor T-Cell (CAR-T) Therapy: Recognition, Risk Factors, and Management"],"prefix":"10.3390","volume":"9","author":[{"given":"Ethan A.","family":"Burns","sequence":"first","affiliation":[{"name":"Houston Methodist Cancer Center, Houston Methodist Hospital, 6445 Main Street, Outpatient Center, 24th Floor, Houston, TX 77030, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7643-8154","authenticated-orcid":false,"given":"Cesar","family":"Gentille","sequence":"additional","affiliation":[{"name":"Houston Methodist Cancer Center, Houston Methodist Hospital, 6445 Main Street, Outpatient Center, 24th Floor, Houston, TX 77030, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Barry","family":"Trachtenberg","sequence":"additional","affiliation":[{"name":"Houston Methodist DeBakey Heart and Vascular Center, 6565 Fannin St, Houston, TX 77030, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sai Ravi","family":"Pingali","sequence":"additional","affiliation":[{"name":"Houston Methodist Cancer Center, Houston Methodist Hospital, 6445 Main Street, Outpatient Center, 24th Floor, Houston, TX 77030, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4480-1443","authenticated-orcid":false,"given":"Kartik","family":"Anand","sequence":"additional","affiliation":[{"name":"Callahan Cancer Center, Great Plains Health, 601 W Leota St, North Platte, NE 69101, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2021,3,17]]},"reference":[{"key":"ref_1","first-page":"375","article-title":"The use of chimeric antigen receptor T cells in patients with non-Hodgkin lym-phoma","volume":"16","author":"Lulla","year":"2018","journal-title":"Clin. Adv. Hematol. Oncol."},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Zmievskaya, E., Valiullina, A., Ganeeva, I., Petukhov, A., Rizvanov, A., and Bulatov, E. (2021). Application of CAR-T Cell Therapy beyond Oncology: Autoimmune Diseases and Viral Infections. Biomedcines, 9.","DOI":"10.3390\/biomedicines9010059"},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Filin, I.Y., Solovyeva, V.V., Kitaeva, K.V., Rutland, C.S., and Rizvanov, A.A. (2020). Current Trends in Cancer Immunotherapy. Biomedcines, 8.","DOI":"10.3390\/biomedicines8120621"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1785","DOI":"10.1080\/10428194.2017.1387905","article-title":"Axicabtagene ciloleucel, a first-in-class CAR T cell therapy for aggressive NHL","volume":"59","author":"Roberts","year":"2017","journal-title":"Leuk. Lymphoma"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"97","DOI":"10.1016\/j.jaccao.2020.02.011","article-title":"CAR T Cell Therapy\u2013Related Cardiovascular Outcomes and Management","volume":"2","author":"Ghosh","year":"2020","journal-title":"JACC Cardio Oncol."},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"McHayleh, W., Bedi, P., Sehgal, R., and Solh, M. (2019). Chimeric Antigen Receptor T-Cells: The Future is Now. J. Clin. Med., 8.","DOI":"10.3390\/jcm8020207"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"45","DOI":"10.1056\/NEJMoa1804980","article-title":"Tisagenlecleucel in Adult Relapsed or Refractory Diffuse Large B-Cell Lymphoma","volume":"380","author":"Schuster","year":"2019","journal-title":"N. Engl. J. Med."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"439","DOI":"10.1056\/NEJMoa1709866","article-title":"Tisagenlecleucel in Children and Young Adults with B-Cell Lymphoblastic Leukemia","volume":"378","author":"Maude","year":"2018","journal-title":"N. Engl. J. Med."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"2531","DOI":"10.1056\/NEJMoa1707447","article-title":"Axicabtagene Ciloleucel CAR T-Cell Therapy in Refractory Large B-Cell Lymphoma","volume":"377","author":"Neelapu","year":"2017","journal-title":"N. Engl. J. Med."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1331","DOI":"10.1056\/NEJMoa1914347","article-title":"KTE-X19 CAR T-Cell Therapy in Relapsed or Refractory Mantle-Cell Lymphoma","volume":"382","author":"Wang","year":"2020","journal-title":"N. Engl. J. Med."},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Penack, O., and Koenecke, C. (2020). Complications after CD19+ CAR T-Cell Therapy. Cancers, 12.","DOI":"10.3390\/cancers12113445"},{"key":"ref_12","first-page":"1","article-title":"Grading of cytokine release syndrome associated with the CAR T cell therapy tisagenlecleucel","volume":"11","author":"Porter","year":"2018","journal-title":"J. Hematol. Oncol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"188","DOI":"10.1182\/blood-2014-05-552729","article-title":"Current concepts in the diagnosis and management of cytokine release syndrome","volume":"124","author":"Lee","year":"2014","journal-title":"Blood"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"625","DOI":"10.1016\/j.bbmt.2018.12.758","article-title":"ASTCT Consensus Grading for Cytokine Release Syndrome and Neurologic Toxicity Associated with Immune Effector Cells","volume":"25","author":"Lee","year":"2019","journal-title":"Biol. Blood Marrow Transpl."},{"key":"ref_15","first-page":"1","article-title":"Immunotherapy-Associated Cardiotoxicity of Immune Checkpoint Inhibitors and Chimeric Antigen Receptor T Cell Therapy: Diagnostic and Management Challenges and Strategies","volume":"23","author":"Rothberg","year":"2021","journal-title":"Curr. Cardiol. Rep."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"114","DOI":"10.1111\/imr.12768","article-title":"Cellular therapy: Immune-related complications","volume":"290","author":"Oved","year":"2019","journal-title":"Immunol. Rev."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"878","DOI":"10.1016\/j.bbamcr.2011.01.034","article-title":"The pro- and anti-inflammatory properties of the cytokine interleukin-6","volume":"1813","author":"Scheller","year":"2011","journal-title":"Biochim. Biophys. Acta Mol. Cell Res."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1687","DOI":"10.1161\/CIRCULATIONAHA.120.048100","article-title":"Chimeric Antigen Receptor T-Cell Therapy\u2013Associated Cardiomyopathy in Patients with Refractory or Relapsed Non-Hodgkin Lymphoma","volume":"142","author":"Ganatra","year":"2020","journal-title":"Circulation"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"203","DOI":"10.1016\/S0140-6736(03)15326-3","article-title":"Role of interleukin 6 in myocardial dysfunction of meningococcal septic shock","volume":"363","author":"Pathan","year":"2004","journal-title":"Lancet"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"863","DOI":"10.1182\/blood-2013-03-490565","article-title":"Cardiovascular toxicity and titin cross-reactivity of affinity-enhanced T cells in myeloma and melanoma","volume":"122","author":"Linette","year":"2013","journal-title":"Blood"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"e186","DOI":"10.1097\/HS9.0000000000000186","article-title":"CAR T Cell Toxicity: Current Management and Future Directions","volume":"3","author":"Perales","year":"2019","journal-title":"HemaSphere"},{"key":"ref_22","unstructured":"(2021, March 01). Kymriah-Epar-Product-Information. Available online: https:\/\/www.ema.europa.eu\/documents\/product-information\/kymriah-epar-product-information_en.pdf."},{"key":"ref_23","unstructured":"(2021, March 01). Yescarta-Epar-Product-Information. Available online: https:\/\/www.ema.europa.eu\/documents\/product-information\/yescarta-epar-product-information_en.pdf."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1803","DOI":"10.1200\/JCO.2016.71.3024","article-title":"Lymphoma Remissions Caused by Anti-CD19 Chimeric Antigen Receptor T Cells Are Associated with High Serum Interleukin-15 Levels","volume":"35","author":"Kochenderfer","year":"2017","journal-title":"J. Clin. Oncol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1507","DOI":"10.1056\/NEJMoa1407222","article-title":"Chimeric antigen receptor T cells for sustained remissions in leukemia","volume":"371","author":"Maude","year":"2014","journal-title":"N. Engl. J. Med."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"517","DOI":"10.1016\/S0140-6736(14)61403-3","article-title":"T cells expressing CD19 chimeric antigen receptors for acute lymphoblastic leukaemia in children and young adults: A phase 1 dose-escalation trial","volume":"385","author":"Lee","year":"2015","journal-title":"Lancet"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"224ra25","DOI":"10.1126\/scitranslmed.3008226","article-title":"Efficacy and Toxicity Management of 19-28z CAR T Cell Therapy in B Cell Acute Lymphoblastic Leukemia","volume":"6","author":"Davila","year":"2014","journal-title":"Sci. Transl. Med."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"e001159","DOI":"10.1136\/jitc-2020-001159","article-title":"Impact of cytokine release syndrome on cardiac function following CD19 CAR-T cell therapy in children and young adults with hematological malignancies","volume":"8","author":"Shalabi","year":"2020","journal-title":"J. Immunother. Cancer"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1590","DOI":"10.1016\/j.bbmt.2018.05.014","article-title":"Cardiac Profile of Chimeric Antigen Receptor T Cell Therapy in Children: A Single-Institution Experience","volume":"24","author":"Burstein","year":"2018","journal-title":"Biol. Blood Marrow Transpl."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"e124","DOI":"10.1097\/CCM.0000000000002053","article-title":"Cytokine Release Syndrome After Chimeric Antigen Receptor T Cell Therapy for Acute Lymphoblastic Leukemia","volume":"45","author":"Fitzgerald","year":"2017","journal-title":"Crit. Care Med."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"3099","DOI":"10.1016\/j.jacc.2019.10.038","article-title":"Cardiovascular Events Among Adults Treated With Chimeric Antigen Receptor T-Cells (CAR-T)","volume":"74","author":"Alvi","year":"2019","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"193","DOI":"10.1016\/j.jaccao.2020.04.012","article-title":"Cardiovascular Effects of CAR T Cell Therapy","volume":"2","author":"Lefebvre","year":"2020","journal-title":"JACC Cardio Oncol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"385","DOI":"10.1016\/j.ccl.2019.07.008","article-title":"Cardiotoxicity of Immune Therapy","volume":"37","author":"Ganatra","year":"2019","journal-title":"Cardiol. Clin."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"4","DOI":"10.1007\/s11912-019-0753-y","article-title":"Cytokine Release Syndrome with the Novel Treatments of Acute Lymphoblastic Leukemia: Pathophysiology, Prevention, and Treatment","volume":"21","author":"Aldoss","year":"2019","journal-title":"Curr. Oncol. Rep."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"3153","DOI":"10.1016\/j.jacc.2019.10.049","article-title":"Chimeric Antigen Receptor T-Cell Therapy for Cancer and Heart","volume":"74","author":"Ganatra","year":"2019","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"130","DOI":"10.1007\/s11899-020-00567-4","article-title":"The Cardiovascular Complications of Chimeric Antigen Receptor T Cell Therapy","volume":"15","author":"Jamal","year":"2020","journal-title":"Curr. Hematol. Malign-Rep."},{"key":"ref_37","first-page":"1","article-title":"Cardiotoxicity of Contemporary Anticancer Immunotherapy","volume":"22","author":"Patel","year":"2020","journal-title":"Curr. Treat. Options Cardiovasc. Med."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1007\/s11912-018-0690-1","article-title":"Cardiotoxicity of Immunotherapy: Incidence, Diagnosis, and Management","volume":"20","author":"Asnani","year":"2018","journal-title":"Curr. Oncol. Rep."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"47","DOI":"10.1038\/nrclinonc.2017.148","article-title":"Chimeric antigen receptor T-cell therapy\u2014Assessment and management of toxicities","volume":"15","author":"Neelapu","year":"2018","journal-title":"Nat. Rev. Clin. Oncol."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"43","DOI":"10.2147\/ITT.S202015","article-title":"Cytokine Release Syndrome: Current Perspectives","volume":"8","author":"Murthy","year":"2019","journal-title":"ImmunoTargets Ther."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"323","DOI":"10.2147\/TCRM.S150524","article-title":"Current approaches in the grading and management of cytokine release syndrome after chimeric antigen receptor T-cell therapy","volume":"15","author":"Riegler","year":"2019","journal-title":"Ther. Clin. Risk Manag."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"943","DOI":"10.1634\/theoncologist.2018-0028","article-title":"FDA Approval Summary: Tocilizumab for Treatment of Chimeric Antigen Receptor T Cell-Induced Severe or Life-Threatening Cytokine Release Syndrome","volume":"23","author":"Le","year":"2018","journal-title":"Oncologist"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"26","DOI":"10.1016\/j.bbmt.2018.09.024","article-title":"American Society for Blood and Marrow Transplantation Pharmacy Special Interest Group Survey on Chimeric Antigen Receptor T Cell Therapy Administrative, Logistic, and Toxicity Management Practices in the United States","volume":"25","author":"Mahmoudjafari","year":"2019","journal-title":"Biol. Blood Marrow Transpl."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"179","DOI":"10.1016\/j.ijcard.2020.08.033","article-title":"Cardiotoxic mechanisms of cancer immunotherapy\u2014A systematic review","volume":"323","author":"Lobenwein","year":"2021","journal-title":"Int. J. Cardiol."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"1319","DOI":"10.1164\/rccm.200509-1369OC","article-title":"Diagnosis of Adrenal Insufficiency in Severe Sepsis and Septic Shock","volume":"174","author":"Annane","year":"2006","journal-title":"Am. J. Respir. Crit. Care Med."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"296","DOI":"10.1097\/01.CCM.0000298158.12101.41","article-title":"Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008","volume":"36","author":"Dellinger","year":"2008","journal-title":"Crit. Care Med."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"9317","DOI":"10.1073\/pnas.97.16.9317","article-title":"Interleukin-6 is an essential, corticotropin-releasing hormone-independent stimulator of the adrenal axis during immune system activation","volume":"97","author":"Bethin","year":"2000","journal-title":"Proc. Natl. Acad. Sci. USA"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"2063","DOI":"10.1093\/eurheartj\/ehy128","article-title":"Interleukin-1 blockade in cardiovascular diseases: A clinical update","volume":"39","author":"Buckley","year":"2018","journal-title":"Eur. Hear. J."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"739","DOI":"10.1038\/s41591-018-0036-4","article-title":"Monocyte-derived IL-1 and IL-6 are differentially required for cytokine-release syndrome and neurotoxicity due to CAR T cells","volume":"24","author":"Norelli","year":"2018","journal-title":"Nat. Med."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"731","DOI":"10.1038\/s41591-018-0041-7","article-title":"CAR T cell\u2013induced cytokine release syndrome is mediated by macrophages and abated by IL-1 blockade","volume":"24","author":"Giavridis","year":"2018","journal-title":"Nat. Med."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"632","DOI":"10.1016\/j.clml.2020.04.020","article-title":"Myeloma CAR-T CRS Management With IL-1R Antagonist Anakinra","volume":"20","author":"Jatiani","year":"2020","journal-title":"Clin. Lymphoma Myeloma Leuk."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"212","DOI":"10.1111\/bjh.16623","article-title":"Efficacy and safety of humanized anti-CD19CAR-T therapy following intensive lymphodepleting chemotherapy for refractory\/relapsed B acute lymphoblastic leukaemia","volume":"191","author":"Wang","year":"2020","journal-title":"Br. J. Haematol."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s40164-021-00209-2","article-title":"Etanercept as a new therapeutic option for cytokine release syndrome following chimeric antigen receptor T cell therapy","volume":"10","author":"Zhang","year":"2021","journal-title":"Exp. Hematol. Oncol."},{"key":"ref_54","doi-asserted-by":"crossref","unstructured":"Rodr\u00edguez-Otero, P., Pr\u00f3sper, F., Alfonso, A., Paiva, B., and Miguel, J.F.S.S. (2020). CAR T-Cells in Multiple Myeloma Are Ready for Prime Time. J. Clin. Med., 9.","DOI":"10.3390\/jcm9113577"},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"1509","DOI":"10.1056\/NEJMoa1215134","article-title":"Chimeric Antigen Receptor\u2013Modified T Cells for Acute Lymphoid Leukemia","volume":"368","author":"Grupp","year":"2013","journal-title":"N. Engl. J. 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