Associated cardiac lesions in patients with radiation-induced complete heart block.

We investigated the clinical, electrophysiological, haemodynamic and angiographic aspects of four patients (two men and two women, aged 31-46 years) who developed complete heart block 13-20 years after therapeutic irradiation of the chest for Hodgkin's disease. The initial cardiac symptom was syncope in three, effort intolerance in one. The electrocardiogram recorded third-degree atrioventricular block in three patients, right bundle branch block and posterior fascicular block in one. The electrophysiological study, performed in three cases, showed that the block was infranodal in two. Three patients had significant coronary arterial stenoses, that involved the ostia in two. All patients had mild-to-moderate aortic and mitral regurgitation. One patient had haemodynamic signs of constriction. Another patient had recurrent pericardial effusions. All had echocardiographic evidence of a thickened pericardium. Cardiac involvement can be extensive in patient with radiation-induced heart block. Because coronary artery disease can be particularly severe, coronary angiography appears to be warranted in such patients.

[Cardiopathy due to therapeutic irradiation of the thorax. The diagnostic criteria]. / La cardiopatia da irradiazione terapeutica del torace. Criteri diagnostici.

Between January 1, 1985 and June 30, 1992, 37 patients (25 women and 12 men, aged 13-65 years) who had undergone a radiation treatment to the anterior chest and mediastinum, were admitted to our Institution for cardiac evaluation, which included left and right heart catheterisation in all, but 3 patients. Seventeen had signs or symptoms of ischaemic heart disease, in 8 a pericardial disease was suspected, 5 had a complete heart block, 4 were in congestive heart failure caused by valvular dysfunction, and 3 had a dilated, hypokinetic left ventricle. Diagnostic criteria in these patients were as follows. Stenoses of the coronary ostia were always considered to be caused by radiation damage, in the absence of coronary risk factors. Obstructions of other coronary segments were taken to be of X-ray origin only when accompanied by damage to other cardiac structures. Pericardial lesions were always reckoned to be of X-ray origin in the absence of other recognisable causes. The same held true for aortic stenosis or insufficiency of any degree and for mitral insufficiency > or = 3+. Cases of complete heart block were diagnosed according to Slama's criteria. A restrictive cardiomyopathy was recognised only in patients operated on for pericardiectomy, in whom clinical or haemodynamic signs of "constriction" persisted after the operation, or extensive subendocardial fibrosis was found at biopsy. According to the above-mentioned criteria, it was established that radiation therapy was the cause of the cardiac problems in 19 cases: 4 with ischaemic symptoms, 8 with pericardial disease, 4 with complete atrioventricular block, and 3 with valvular disease and congestive heart failure. Coronary ostial lesions were found in all patients with angina, and in 8 of the 14 patients without angina (in 1 the coronary arteries were not investigated), and were critical in 4. Eleven patients were operated on. A myocardial revascularisation was performed in 7 cases, a pericardiectomy in 6, a valve replacement or repair was done in 4. A combined procedure was performed in 4 instances. A pacemaker was implanted in 3 cases, 2 patients had a pericardial drainage, and 3 patients continued their medical treatment. Of the 11 operated patients, 1 died at surgery, in refractory cardiac failure, from what was suspected to be a restrictive disease (normal preoperative left ventricular volume and ejection fraction, extensive myocardial fibrosis at autopsy).(ABSTRACT TRUNCATED AT 400 WORDS)

[ Bacterial endocarditis of the pulmonary valve damaged by thoracic radiotherapy (in Hodgkin's disease)]. / Endocardite batterica su valvola polmonare danneggiata da radioterapia toracica (per morbo di Hodgkin).

It is well known that radiation therapy to the anterior mediastinum may induce lesions of all cardiac structures. The pericardium is most frequently involved, but atrioventricular conduction disorders, cardiomyopathy, coronary stenosis may also be produced. Aortic, mitral and tricuspid lesions have been described. However, clinical evidence of pulmonic valve involvement has not been reported. Only at necropsy has fibrotic thickening of the pulmonic cusps occasionally been found. We report a case of infective endocarditis of the pulmonic valve in a 53-year-old patient who had undergone thoracic radiation therapy for Hodgkin's disease 31 years previously. Four years prior to the endocarditis he had also been submitted to myocardial revascularisation for critical lesions of the left main and right coronary ostia, and to aortic valve replacement because of stenosis and insufficiency. At that time, the pulmonic valve was fibrotic on echo examination. It is noteworthy that, of all the cardiac valves, the infective process involved only the pulmonic one, which is seldom the target of an infection. To our knowledge this is the first case of bacterial endocarditis of a heart valve that had been previously damaged by radiation therapy.

Severe coronary artery disease after radiation therapy of the chest and mediastinum: clinical presentation and treatment.

OBJECTIVE: To define the clinical and angiographic features and the therapeutic problems in patients with coronary artery disease after therapeutic irradiation of the chest. DESIGN: An observational retrospective study. SETTING: The cardiac catheterisation laboratory, university medical school. PATIENTS: 15 subjects (8 men and 7 women, aged 25-56 years, mean 44) examined in the cardiac catheterisation laboratory, who had significant coronary artery disease years after having radiation treatment to the chest and anterior mediastinum. In the early stages of the study angiography was performed because of typical symptoms of ischaemic heart disease. Later on it was performed because of a high index of suspicion in people with signs of extensive radiation heart damage. MAIN OUTCOME MEASURES: Clinical and electrocardiographic evidence of ischaemic heart disease; echocardiographic signs of pericardial, myocardial or valvar involvement; angiographic evidence of coronary arterial stenosis, with special attention to the ostia; haemodynamic and angiographic signs of pericardial, myocardial, and valvar disease. Survival and symptomatic and functional status were ascertained after medical or surgical treatment. RESULTS: The patients were relatively young and had no risk factors. Seven patients had no signs or symptoms of ischaemic heart disease. Ten patients had ostial stenosis, which was associated with extensive involvement of other cardiac structures in nine of them. Seven required surgical treatment for coronary artery disease. Two died, one at surgery and the other one six months later. Five patients had complications associated with irradiation. CONCLUSIONS: Coronary arterial disease can be reasonably ascribed to the effects of chest irradiation when the patients are young and free from risk factors, especially if the obstructions are ostial and there is important damage to other cardiac structures. In patients with damage to other cardiac structures angina and infarction are often absent and coronary angiography seems to be mandatory. Patients often require surgical treatment and postoperative complications are common.

[Rapid onset aortic stenosis and clinical course in adults. Clinico-hemodynamic correlations]. / Stenosi aortica a rapida insorgenza ed evoluzione nell'adulto. Correlazioni clinico-emodinamiche.

In 8 patients aged 41-66 years, a second left heart catheterisation done 27-98 months after the first study, demonstrated a pressure gradient across the aortic valve, that had not previously existed, or had been trivial. No significant change of the cardiac output had occurred. All but 1 patient were hypertensive. The etiology was rheumatic in 4, degenerative in 4. Electrocardiographic, radiographic, and echocardiographic evolution could not separate the patients with a gradient greater than or equal to 70 mmHg from those whose gradient was less than or equal to 40 mmHg. The intensity of the aortic component of the second heart sound, however, decreased in all former patients, and in only 1 of the latter. Aortic valvular stenosis can arise and rapidly develop in adult patients. Concomitant rheumatic mitral valve disease, coronary artery disease and hypertension can mask and/or modify symptoms, signs and laboratory findings. Changes of the aortic component of the second sound may suggest its occurrence.