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Kozhukhov SM, Bazyka OY, Dovganych NV, Yarynkina OA, Tkhor NV. RADIOTHERAPY-ASSOCIATED CARDIOVASCULAR COMPLICATIONS IN CANCER (review). PROBLEMY RADIAT︠S︡IĬNOÏ MEDYT︠S︡YNY TA RADIOBIOLOHIÏ 2020; 25:56-74. [PMID: 33361829 DOI: 10.33145/2304-8336-2020-25-56-74] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Indexed: 11/10/2022]
Abstract
The review is devoted to the current issues of radiation-induced cardiovascular complications, their diagnostics andincidence depending on the radiation doses and exposure regimens, potential efficiency of the screening strategiesfor cardiotoxicity monitoring after radiotherapy in cancer patients by analyzing the data from literature and clinical trials, based on recommendations of European Society of Cardiology and European Society of Medical Oncology.
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Affiliation(s)
- S M Kozhukhov
- SI «National Research Center «The Academician M. D. Strazhesko Institute of Cardiology» of the NAMS of Ukraine», 5 Narodnoho Opolchennia St., Kyiv, 03680, Ukraine
| | - O Ye Bazyka
- SI «National Research Center «The Academician M. D. Strazhesko Institute of Cardiology» of the NAMS of Ukraine», 5 Narodnoho Opolchennia St., Kyiv, 03680, Ukraine
| | - N V Dovganych
- SI «National Research Center «The Academician M. D. Strazhesko Institute of Cardiology» of the NAMS of Ukraine», 5 Narodnoho Opolchennia St., Kyiv, 03680, Ukraine
| | - O A Yarynkina
- SI «National Research Center «The Academician M. D. Strazhesko Institute of Cardiology» of the NAMS of Ukraine», 5 Narodnoho Opolchennia St., Kyiv, 03680, Ukraine
| | - N V Tkhor
- SI «National Research Center «The Academician M. D. Strazhesko Institute of Cardiology» of the NAMS of Ukraine», 5 Narodnoho Opolchennia St., Kyiv, 03680, Ukraine
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Imaev TE, Komlev AE, Akchurin RS. Cardiovascular surgery in cancer patients — a new challenge for hybrid surgery. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2019. [DOI: 10.15829/1728-8800-2019-4-99-104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- T. E. Imaev
- National Medical Research Center of Cardiology
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Agrawal N, Kattel S, Waheed S, Kapoor A, Singh V, Sharma A, Page BJ, Attwood KM, Iyer V, Pokharel S, Sharma UC. Clinical Outcomes after Transcatheter Aortic Valve Replacement in Cancer Survivors Treated with Ionizing Radiation. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2019; 5:8. [PMID: 31815000 PMCID: PMC6897372 DOI: 10.1186/s40959-019-0044-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 06/26/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Improved cancer survival in patients treated with thoracic ionizing radiation (XRT) has resulted in unanticipated surge of aortic stenosis. Transcatheter aortic valve replacement (TAVR) has revolutionized the management of severe aortic stenosis. However, long-term clinical outcomes in radiation-exposed cohorts undergoing TAVR are unknown. We compared the all-cause mortality and major adverse cardiac events (MACE) in patients with prior chest XRT (C-XRT) undergoing TAVR. METHODS This is an observational cohort study in subjects who underwent TAVR for symptomatic severe aortic stenosis from 2012 to 2017 in a tertiary care referral center. We examined the all-cause mortality and MACE using cox proportional hazard analysis to identify the clinical predictors of survival in the cohort of patients who had a history of prior C-XRT for malignancy. RESULTS Of the 610 patients who underwent TAVR for symptomatic severe aortic stenosis, 75 had prior C-XRT. The majority of C-XRT patients had prior breast cancer (44%) followed by Hodgkin's lymphoma (31%), with the median time from XRT to TAVR of 19.0 years. During a mean follow up of 17.1 months after TAVR, all-cause mortality was 17%. Those with prior C-XRT had higher all-cause mortality (XRT: 29%; non-XRT:15%, p<0.01) and MACE (XRT: 57%; non-XRT: 27%, p<0.001) after TAVR. Patients with prior XRT had a higher incidence of atrial fibrillation (XRT: 48 %; non-XRT: 2.4%, p<0.01) and high-grade heart block (XRT: 20%; non-XRT: 9.1%, p=0.007) requiring pacemaker implant after TAVR. On multivariate cox proportional hazard analysis, prior XRT (HR: 2.07, p=0.003), poor renal function (HR: 1.29, p<0.001) and post-operative anemia requiring transfusion (HR: 1.16, p:0.001) were the strongest predictors of reduced survival. CONCLUSIONS Cancer survivors with prior C- XRT have higher incidence of all-cause mortality and MACE after TAVR. Careful patient selection and follow-up strategies are needed to improve outcomes.
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Affiliation(s)
- Nikhil Agrawal
- Department of Medicine, Division of Cardiology, Clinical & Translational Research Center (Suite 7030), Jacob’s School of Medicine and Biomedical Sciences, Buffalo, NY USA
| | - Sharma Kattel
- Department of Medicine, Division of Cardiology, Clinical & Translational Research Center (Suite 7030), Jacob’s School of Medicine and Biomedical Sciences, Buffalo, NY USA
| | - Sameer Waheed
- Department of Medicine, Division of Cardiology, Clinical & Translational Research Center (Suite 7030), Jacob’s School of Medicine and Biomedical Sciences, Buffalo, NY USA
| | - Ankita Kapoor
- Department of Medicine, Division of Cardiology, Clinical & Translational Research Center (Suite 7030), Jacob’s School of Medicine and Biomedical Sciences, Buffalo, NY USA
| | - Vasvi Singh
- Department of Medicine, Division of Cardiology, Clinical & Translational Research Center (Suite 7030), Jacob’s School of Medicine and Biomedical Sciences, Buffalo, NY USA
- Department of Radiology, Brigham and Women’s Hospital, Boston, MA USA
| | - Ashutosh Sharma
- Department of Medicine, Division of Cardiology, Clinical & Translational Research Center (Suite 7030), Jacob’s School of Medicine and Biomedical Sciences, Buffalo, NY USA
| | - Brian J. Page
- Department of Medicine, Division of Cardiology, Clinical & Translational Research Center (Suite 7030), Jacob’s School of Medicine and Biomedical Sciences, Buffalo, NY USA
| | - Kristopher M. Attwood
- Department of Biostatistics and Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, NY USA
| | - Vijay Iyer
- Department of Medicine, Division of Cardiology, Clinical & Translational Research Center (Suite 7030), Jacob’s School of Medicine and Biomedical Sciences, Buffalo, NY USA
| | - Saraswati Pokharel
- Department of Pathology, Division of Thoracic Pathology and Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY USA
| | - Umesh C. Sharma
- Department of Medicine, Division of Cardiology, Clinical & Translational Research Center (Suite 7030), Jacob’s School of Medicine and Biomedical Sciences, Buffalo, NY USA
- Clinical & Translational Research Center (Suite 7030), 875 Ellicott Street, Buffalo, NY 14203 USA
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Staab J, Cotter E, Kidd B, Wallisch WJ, Flynn BC. Review and Update: Hematologic Malignancies and Adult Cardiac Surgery. J Cardiothorac Vasc Anesth 2019; 34:759-771. [PMID: 31447276 DOI: 10.1053/j.jvca.2019.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 06/30/2019] [Accepted: 07/02/2019] [Indexed: 01/02/2023]
Abstract
As treatments for hematologic malignancies continue to advance, many patients with active disease and many more in remission will present for cardiac surgical procedures. Radiation and chemotherapeutic therapies for hematologic malignancies often result in cardiopulmonary injury. Evidence demonstrates that patients with hematologic malignancies undergoing cardiac surgery are at risk for perioperative adverse events, including bleeding, clotting, infection, and immunomodulation. However, short- and long-term mortality has been found to be acceptable. This review will distinguish the important points of characterizing, understanding, and managing hematologic malignancies in the cardiac surgical patient.
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Affiliation(s)
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- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | - Jared Staab
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | - Elizabeth Cotter
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | - Brent Kidd
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | - William J Wallisch
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | - Brigid C Flynn
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS.
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Muratov RM, Babenko SI, Sachkov AS, Soboleva NN, Andrianova EA. [Post Radiotherapy Lesions of the Heart Valves. Principles of Diagnosis and Results of Treatment]. ACTA ACUST UNITED AC 2019; 59:36-42. [PMID: 30990139 DOI: 10.18087/cardio.2019.3.10239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 04/12/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND The use of radiation therapy for the treatment of tumors of the chest сan lead to the development of cardiac pathology, including that of the valves and coronary arteries. STUDY AIM to analyze the specifics of post-radiation lesions of the valvular apparatus and coronary arteries, and to assess the immediate results and risks of surgical correction of detected defects. Materials and methods. In the Emergency department of surgery of acquired heart disease of A. N. Bakulev National Medical Research Center of Cardiovascular Surgery in the period from 2004 to 2017 were examined and operated 46 patients aged 35-81 years (mean age 56±12.4 years, 80 % women). The period from primary irradiation of the chest to surgical treatment of valvular pathology ranged from 4 to 40 years. Indications for thoracic radiotherapy were Hodgkin's lymphoma in 23 patients (50 %), breast cancer - in 20 (43 %). RESULTS Stenosis of the aortic valve was the leading defect in 42 patients (91 %). According to coronary angiography, coronary artery disease was diagnosed in 31 patients (67 %). Isolated aortic valve prosthesis was performed in 14 (30 %) patients, other operations were combined. Hospital mortality was 11 % (5 patients). There were no deaths among patients who underwent radiation therapy after mastectomy. Main nonlethal complications were: pericardial effusion in 6 patients (13 %), hydrothorax requiring repeated pleural punctures in 5 patients (11 %). CONCLUSION The variety of clinical manifestations of radiation heart disease and its progressive nature emphasize the need for long-term dynamic observation of patients after thoracic irradiation in order to timely identify the pathology and eliminate the risk of sudden cardiac complications and the development of severe heart failure decompensation.
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Affiliation(s)
- R M Muratov
- A. N. Bakoulev Scientific Center for Cardiovascular Surgery
| | - S I Babenko
- A. N. Bakoulev Scientific Center for Cardiovascular Surgery
| | - A S Sachkov
- A. N. Bakoulev Scientific Center for Cardiovascular Surgery
| | - N N Soboleva
- A. N. Bakoulev Scientific Center for Cardiovascular Surgery
| | - E A Andrianova
- A. N. Bakoulev Scientific Center for Cardiovascular Surgery
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Ejiofor JI, Ramirez-Del Val F, Nohria A, Norman A, McGurk S, Aranki SF, Shekar P, Cohn LH, Kaneko T. The risk of reoperative cardiac surgery in radiation-induced valvular disease. J Thorac Cardiovasc Surg 2017; 154:1883-1895. [PMID: 28870399 DOI: 10.1016/j.jtcvs.2017.07.033] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 06/14/2017] [Accepted: 07/03/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Mediastinal radiation therapy (MRT) increases the risk for adverse outcomes after cardiac surgery and is not incorporated in the Society of Thoracic Surgeons (STS) risk algorithm. We aimed to quantify the surgical risk conferred by MRT in patients undergoing primary and reoperative valvular operations. METHODS A retrospective analysis of 261 consecutive patients with prior MRT who underwent valvular operations between January 2002 and May 2015. Short- and long-term outcomes were compared for STS predicted risk of mortality, surgery type, gender, year of surgery, and age-matched patients stratified by reoperative status. RESULTS Mean age was 62.6 ± 12.1 years and 174 (67%) were women. The majority had received MRT for Hodgkin lymphoma (48.2%) and breast cancer (36%). Overall, 214 (82%) were primary and 47 (18%) were reoperative procedures. Reoperation carried a higher operative mortality than primary cases (17% vs 3.7%; P = .003). Compared with the 836 nonradiated matches, operative mortality and observed-to-expected STS mortality ratios were higher in primary (3.8% [1.4] vs 0.8% [0.32]; P = .004) and reoperative (17% [3.35] vs 2.3% [0.45]; P = .001) patients with prior MRT. Cox proportional hazard modeling revealed that in patients with previous MRT, primary (hazard ratio, 2.24; 95% confidence interval, 1.73-2.91) and reoperative status (hazard ratio, 3.19; 95% confidence interval, 1.95-5.21) adversely affected long-term survival compared with nonradiated matches. CONCLUSIONS Surgery for radiation-induced valvular heart disease has a higher operative mortality than predicted by STS predicted risk of mortality. Reoperations are associated with increased morbidity and mortality compared with primary cases. Careful patient selection is paramount and expanded indications for transcatheter therapies should be considered, especially in reoperative patients.
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Affiliation(s)
- Julius I Ejiofor
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | | | - Anju Nohria
- Division of Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Anthony Norman
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Siobhan McGurk
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Sary F Aranki
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Prem Shekar
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Lawrence H Cohn
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
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Gupta D, Pun SC, Verma S, Steingart RM. Radiation-induced coronary artery disease: a second survivorship challenge? Future Oncol 2016. [PMID: 26198829 DOI: 10.2217/fon.15.121] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Dipti Gupta
- Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA.,Weill Cornell Medical College, New York, NY, USA
| | - Shawn C Pun
- Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
| | - Shivani Verma
- Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
| | - Richard M Steingart
- Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA.,Weill Cornell Medical College, New York, NY, USA
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Yusuf SW, Howell RM, Gomez D, Pinnix CC, Iliescu CA, Banchs J. Radiation-related heart and vascular disease. Future Oncol 2015. [DOI: 10.2217/fon.15.129] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Improvement in cancer therapy has led to increasing number of cancer survivors, some of whom have previously been treated with mediastinal radiation. Cardiac complication may manifest years after completion of radiation therapy. Hence long-term follow-up is essential in these patients. In this paper, we have discussed the short- and long-term cardiovascular side effects of radiation therapy.
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Affiliation(s)
- Syed Wamique Yusuf
- Department of Cardiology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Rebecca M Howell
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Daniel Gomez
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Chelsea C Pinnix
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Cezar A Iliescu
- Department of Cardiology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Jose Banchs
- Department of Cardiology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
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Gutiérrez-Barrios A, Camacho-Freire S, Agarrado-Luna A, Alba-Sánchez M, Gamaza-Chulián S, León-Jiménez J, Oneto-Otero J, Benezet-Mazuecos J. Estenosis de tronco coronario posradioterapia. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2014; 84:320-2. [DOI: 10.1016/j.acmx.2014.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 04/26/2014] [Accepted: 05/01/2014] [Indexed: 11/29/2022] Open
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Davis M, Witteles RM. Radiation-induced heart disease: an under-recognized entity? CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:317. [PMID: 24756471 DOI: 10.1007/s11936-014-0317-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OPINION STATEMENT Radiation-induced heart disease (RIHD) represents a spectrum of cardiovascular disease in patients who have undergone mediastinal, thoracic, or breast radiotherapy (RT). RIHD may involve any cardiac structure and is a major cause of morbidity and mortality in cancer survivors. While large cohort studies have demonstrated that symptomatic RIHD is a common late finding in this population, the incidence of asymptomatic disease is likely to be even higher. Long-term follow-up with regular screening for RIHD plays an important role in the management of cancer survivors who have undergone RT. Aggressive modification of traditional cardiovascular risk factors such as hypertension, dyslipidemia, and cigarette smoking is essential in patients at risk for RIHD, as these have been shown to potentiate the risks of radiation. In patients with symptomatic RIHD, medical and/or percutaneous therapies are often preferable to surgical interventions in view of the increased surgical risk associated with radiation damage to surrounding tissues. Percutaneous revascularization should generally be favored over surgical revascularization. Transcatheter valve replacements have not been widely used in this population but may offer an alternative to high-risk surgical valve procedures. Pericardiectomy is usually associated with extremely poor short-term and long-term outcomes in patients with RIHD and should be avoided in most cases. Heart transplantation is also higher risk in patients with RIHD than in patients with other etiologies of heart failure, but may be considered in young patients without other comorbidities.
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Affiliation(s)
- Margot Davis
- Division of Cardiovascular Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Falk Cardiovascular Research Center #273, Stanford, CA, 94305-5406, USA
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Jaworski C, Mariani JA, Wheeler G, Kaye DM. Cardiac complications of thoracic irradiation. J Am Coll Cardiol 2013; 61:2319-28. [PMID: 23583253 DOI: 10.1016/j.jacc.2013.01.090] [Citation(s) in RCA: 246] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Revised: 12/27/2012] [Accepted: 01/08/2013] [Indexed: 12/21/2022]
Abstract
Adjuvant radiation therapy in the management of early stage breast cancer, Hodgkin's disease, and to a lesser extent other thoracic malignancies has led to a significant improvement in disease-specific survival. Cardiovascular disease is now the most common nonmalignancy cause of death in radiation-treated cancer survivors, most often occurring decades after treatment. The spectrum of radiation-induced cardiac disease is broad, potentially involving any component of the heart. The relative risk of coronary artery disease, congestive heart failure, valvular heart disease, pericardial disease, conduction abnormalities, and sudden cardiac death is particularly increased. Over the years contemporary techniques have been introduced to reduce cardiac morbidity and mortality in radiation-treated cancer survivors; however, the long-term effects on the heart still remain unclear, mandating longer follow-up. Awareness and early identification of potential cardiac complications is crucial in cancer survivors, with the management often being quite complex. This review examines the epidemiology of radiation-induced cardiac disease together with its pathophysiology and explores the available treatment strategies and the potential utility of various screening strategies for affected cancer survivors.
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Siregar S, de Heer F, van Herwerden LA. Cardiac surgery in patients irradiated for Hodgkin's lymphoma. Neth Heart J 2010; 18:61-5. [PMID: 20200610 PMCID: PMC2828564 DOI: 10.1007/bf03091739] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background/Objectives. Therapy for Hodgkin's lymphoma is disease specific and cannot be compared with treatment for other diseases. It often includes more extensive radiotherapy on the mediastinum than for other malignancies. Cardiac morbidity is known to occur in patients previously irradiated. This study describes the postoperative course after cardiac surgery of patients previously irradiated for Hodgkin's lymphoma.Methods. From January 1990 until June 2008, 12 patients underwent cardiac surgery in the University Medical Center Utrecht after previous irradiation for Hodgkin's lymphoma. Data on radiotherapy, surgery and follow-up were collected retrospectively. The postoperative functional status was assessed by a telephone questionnaire.Results. Atrial fibrillation (33%) and pleural effusion (25%) were the most common postoperative complications. After a mean followup of 2.6+/-2.9 years four patients had died. The remaining patients were all in a favourable New York Heart Association and Canadian Cardiothoracic Society class. The estimated one-, two- and four-year survival rates were 83, 69 and 46% respectively.Conclusion. The early postoperative outcome of cardiac surgery in this population is reasonably good. The long-term results may prove to be disappointing, but the cohort is small. (Neth Heart J 2010;18:61-5.).
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Affiliation(s)
- S Siregar
- Department of Cardiothoracic Surgery, Heart and Lung Division, University Medical Center Utrecht, Utrecht, the Netherlands
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