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Is radiation-induced arteriopathy in long-term breast cancer survivors an underdiagnosed situation?: Critical and pragmatic review of available literature. Radiother Oncol 2021; 157:163-174. [PMID: 33515666 DOI: 10.1016/j.radonc.2021.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 01/01/2021] [Accepted: 01/10/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE Although considered exceptional, radiation-induced arteriopathy in long-term breast cancer survivors involves three main arterial domains in the irradiated volume, namely axillary-subclavian, coronary, and carotid. Stenosis of medium-large arteries is caused by "accelerated" atherosclerosis, particularly beyond 10 years after long-forgotten radiotherapy. The present review aims at summarizing what is known about arteriopathy, as well as the state of the art in terms of diagnosis and therapeutic management. DIAGNOSIS Pauci-symptomatic over years, the usual clinical presentation of arteriopathy involves arm pain with coldness due to subacute or critical ischemia (arterial occlusion), wrongly attributed to an exclusive neurological disorder, and more rarely transient ischemic accident or angina. Evaluation of the supra-aortic trunks by computed tomography and/or magnetic resonance angiography visualizes artery lesions, while Doppler ultrasonography in expert hands assesses diagnosis and downstream functional impact. In severe cases, more invasive angiography directly visualizes long irregular arterial stenosis (full-field radiotherapy), allowing accurate prognosis and treatment. MANAGEMENT Requires early diagnosis to enable initiation of medical treatment that increases blood flow (aspirin) as soon as moderate stenosis is detected, combined with correction of vascular risk factors. In intermediate cases, these therapeutic measures are completed by revascularization strategies using transluminal angioplasty-stenting (wall thickness). Antifibrotic treatment is useful in advanced cases with combined radiation injuries. CONCLUSION In follow-up of long-term breast cancer survivors with node irradiation, myocardial infarction is treated even if radiotherapy is forgotten, while recognition and diagnosis of chronic arm ischemia due to subclavian artery stenosis needs to be improved for appropriate therapeutic management.
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Calabrese P, Oliva S, Gaglione A. Coronary Artery Stenosis following Mediastinal Radiation Therapy. Case Report and Review of the Literature. TUMORI JOURNAL 2019; 91:369-72. [PMID: 16277109 DOI: 10.1177/030089160509100419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
A case of coronary artery stenosis following mediastinal radiation therapy in a young woman and a review of the literature offer indications on the criteria to follow in the diagnosis of coronary artery disease secondary to mediastinal radiation therapy.
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Acharya MN, El-Diasty M, Schmack B, Weymann A, Mansur A, Popov AF. Severe bilateral isolated coronary ostial lesions as a rare manifestation of radiation-induced cardiac disease A case report. Medicine (Baltimore) 2018; 97:e9867. [PMID: 29595699 PMCID: PMC5895407 DOI: 10.1097/md.0000000000009867] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
RATIONALE With advances in contemporary radiotherapy techniques, and as cancer survival improves, severe isolated coronary ostial disease may develop many years following mediastinal radiotherapy, even in the absence of classical cardiovascular risk factors. PATIENT CONCERNS We describe the case of a 73-year-old woman with previous chest radiotherapy for breast cancer who underwent coronary artery bypass graft surgery for severe bilateral coronary ostial lesions. DIAGNOSES Coronary angiography demonstrated severe, isolated bilateral coronary ostial lesions. INTERVENTIONS The patient underwent urgent coronary artery bypass graft surgery to treat her critical coronary artery disease. OUTCOMES Intra-operatively, internal mammary arteries were not amenable to harvesting due to very dense mediastinal adhesions. Therefore, saphenous vein grafts were performed to the left anterior descending, distal left circumflex, obtuse marginal and distal right coronary arteries. The patient made a satisfactory in-hospital recovery, and was subsequently discharged back to her local hospital for rehabilitation. LESSONS Patients successfully treated with mediastinal radiotherapy require careful long-term follow-up for the assessment of radiation-induced coronary artery disease. Importantly, mediastinal irradiation may preclude internal mammary artery utilization, and thus alter the strategy for surgical myocardial revascularization.
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Affiliation(s)
| | | | - Bastian Schmack
- Department of Cardiothoracic Surgery, Harefield Hospital, Harefield, UK
| | - Alexander Weymann
- Department of Cardiac Surgery, University Hospital Oldenburg, Oldenburg
| | - Ashham Mansur
- Department of Anesthesiology, University Medical Centre, Georg August University, Goettingen
| | - Aron-Frederik Popov
- Department of Cardiac Surgery, University Hospital Frankfurt, Frankfurt, Germany
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Mahajan N, Hollander G, Malik B, Temple B, Thekkoott D, Abrol S, Schulhoff N, Ghosh J, Shani J, Lichstein E. Isolated and Significant Left Main Coronary Artery Disease: Demographics, Hemodynamics and Angiographic Features. Angiology 2016; 57:464-77. [PMID: 17022383 DOI: 10.1177/0003319706290740] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Left main coronary artery disease carries a poor prognosis. The etiology of isolated and significant left main coronary artery (ILMCA) disease is not well understood. Studies so far were limited by small numbers. The authors identified 46 patients with ILMCA disease from their database over 10 years (group I) and compared them with 83 consecutive patients undergoing catheterization (group II). They also compared patients with ostial vs distal ILMCA disease. Group I represented 0.1% of catheterization patients. The demographic profile and atherosclerotic risk factor profile of the 2 groups as well as ostial and distal ILMCA disease were compared. This is the largest study of ILMCA disease. Risk factors for atherosclerosis were commonly seen. Nonatherosclerotic causes of ILMCA disease were not seen. This study suggests coronary atherosclerosis as the predominant cause of ILMCA disease. ILMCA disease is more common in women. Diabetes is more commonly associated with distal ILMCA lesion. There is a trend suggesting that ostial ILMCA lesion is more common in smokers and women.
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Affiliation(s)
- Nitin Mahajan
- Department of Medicine, Maimonides Medical Center, Brooklyn, NY, USA.
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5
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Isolated left main coronary artery stenosis after thoracic radiation therapy: to operate or not to operate. Case Rep Med 2014; 2013:834164. [PMID: 24416042 PMCID: PMC3876687 DOI: 10.1155/2013/834164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Accepted: 11/06/2013] [Indexed: 11/18/2022] Open
Abstract
Radiation therapy of neoplasms involving the chest or mediastinum results in a wide spectrum of cardiac complications including coronary artery disease, which can present in patients with few or no traditional cardiac risk factors. We report a case of radiation induced coronary artery disease in a 60-year-old female with a history of stage IIIA nonsmall cell lung carcinoma which was diagnosed eight years earlier and treated with chemotherapy and radiotherapy. She presented to the hospital with atypical chest pain that had occurred intermittently over the preceding week. Her initial electrocardiogram and cardiac enzymes were within normal limits. However, following an indeterminate exercise nuclear stress test, she developed chest pain and elevated cardiac enzymes. Coronary angiography demonstrated 90% stenosis of the left main coronary artery ostium, without any evidence of atherosclerotic disease or stenosis in other coronary arteries. She underwent surgical revascularization, which revealed dense adhesions surrounding the heart. During surgery, she developed severe bleeding and died. Coronary artery disease can present within years of radiation exposure, and ostial lesions are typical. Treatment is often challenging because of the effects of radiation on other tissues and the risks of revascularization procedures. Therefore, a multidisciplinary team approach should be considered.
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Darabian S, Reza Amirzadegan A, Sadeghian H, Sadeghian S, Abbasi A, Raeesi M. Ostial Lesions of Left Main and Right Coronary Arteries: Demographic and Angiographic Features. Angiology 2008; 59:682-7. [DOI: 10.1177/0003319707310275] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In 258 patients with left main tract disease, the atherosclerotic risk factors were compared between patients with ostial and nonostial lesions of the left main coronary artery. Also, it was done for patients with ostial right coronary artery. Women were more likely to have ostial left main coronary artery and/or ostial right coronary artery. A multivariate logistic regression analysis revealed that the female sex (odds ratio: 2.336) and hypertriglyceridemia (odds ratio: 1.004) were independent risk factors of ostial left main coronary artery lesion. For ostial right coronary artery lesion, the female sex and family history of coronary artery disease were independent predictors. Ostial left main coronary artery and right coronary artery lesions were strongly correlated. The demographic and clinical profiles of ostial stenosis suggest that this group may represent a distinct entity, different from the more common atherosclerotic left main trunk stenosis (LMTD). The female sex and serum triglyceride level can be considered as independent predictors of ostial left main tract disease.
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Affiliation(s)
- Sirous Darabian
- Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran,
| | - Ali Reza Amirzadegan
- Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Hakimeh Sadeghian
- Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Saeed Sadeghian
- Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Abbasi
- Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Maria Raeesi
- Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
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Abstract
Patients with stenosis of the left main coronary artery present difficult challenges. The risks associated with this lesion have been known since the early days of angiography when patients were found to have increased mortality during follow-up. This information led to the general guidelines that surgical revascularization should be considered the treatment of choice in patients with significant left main coronary artery stenosis. Current advances in invasive cardiology have brought important information to the field. Intravascular ultrasound is now used routinely to evaluate angiographically indeterminate lesions with criteria now set forward as to what constitutes an indication for revascularization. Stents have even further dramatically changed the landscape. There are substantial issues, however, that need to addressed. These include the following: (1) the effect of specific lesion location on outcome - it is known that patients with distal bifurcation left main disease have worse outcome; (2) the potential for subacute thrombosis of the left main coronary artery; (3) the impact of left ventricular function and patient comorbidities irrespective of the degree and location of left main coronary artery stenosis; and (4) the risk-benefit ratio of stenting versus coronary artery bypass graft surgery. These issues are currently being addressed in two seminally important trials including the SYNTAX trial, which randomizes patients with left main and/or three-vessel disease to either coronary artery bypass graft surgery or a TAXUS drug-eluting stent. This trial is in the final stages of patient recruitment and will have important implications for the field. The other trial is the COMBAT trial, which is focused exclusively on left main coronary artery stenosis and randomizes patients with left main coronary artery disease either to a Sirolimus-eluting stent (Cypher, Johnson and Johnson Cordis, USA) or to coronary artery bypass graft surgery. The field of left main coronary artery disease continues to expand in terms of the evidence available for optimal patient evaluation and selection of treatment modalities.
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Heidenreich PA, Schnittger I, Strauss HW, Vagelos RH, Lee BK, Mariscal CS, Tate DJ, Horning SJ, Hoppe RT, Hancock SL. Screening for coronary artery disease after mediastinal irradiation for Hodgkin's disease. J Clin Oncol 2007; 25:43-9. [PMID: 17194904 DOI: 10.1200/jco.2006.07.0805] [Citation(s) in RCA: 178] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Incidental cardiac irradiation during treatment of thoracic neoplasms has increased risks for subsequent acute myocardial infarction or sudden cardiac death. Identifying patients who have a high risk for a coronary event may decrease morbidity and mortality. The objective of this study was to evaluate whether stress imaging can identify severe, unsuspected coronary stenoses in patients who had prior mediastinal irradiation for Hodgkin's disease. PATIENTS AND METHODS We enrolled 294 outpatients observed at a tertiary care cancer treatment center after mediastinal irradiation doses 35 Gy for Hodgkin's disease who had no known ischemic cardiac disease. Patients underwent stress echocardiography and radionuclide perfusion imaging at one stress session. Coronary angiography was performed at the discretion of the physician. RESULTS Among the 294 participants, 63 (21.4%) had abnormal ventricular images at rest, suggesting prior myocardial injury. During stress testing, 42 patients (14%) developed perfusion defects (n = 26), impaired wall motion (n = 8), or both abnormalities (n = 8). Coronary angiography showed stenosis 50% in 22 patients (55%), less than 50% in nine patients (22.5%), and no stenosis in nine patients (22.5%). Screening led to bypass graft surgery in seven patients. Twenty-three patients developed coronary events during a median of 6.5 years of follow-up, with 10 acute myocardial infarctions (two fatal). CONCLUSION Stress-induced signs of ischemia and significant coronary artery disease are highly prevalent after mediastinal irradiation in young patients. Stress testing identifies asymptomatic individuals at high risk for acute myocardial infarction or sudden cardiac death.
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Affiliation(s)
- Paul A Heidenreich
- Department of Medicine, Division of Cardiology, Stanford University Medical Center, Stanford, CA, USA.
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Waksman R, Bhargava B, Mintz GS, Mehran R, Lansky AJ, Satler LF, Pichard AD, Kent KM, Leon MB. Late total occlusion after intracoronary brachytherapy for patients with in-stent restenosis. J Am Coll Cardiol 2000; 36:65-8. [PMID: 10898414 DOI: 10.1016/s0735-1097(00)00681-1] [Citation(s) in RCA: 175] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The study sought to determine the incidence and predictors of late total occlusion (LTO, >30 days) in-patients with in-stent restenosis who were treated with intracoronary radiation. BACKGROUND Intracoronary radiation both with beta and gamma emitters has been shown to reduce recurrent in-stent restenosis. METHODS We reviewed the records of 473 patients who presented with in-stent restenosis and who were enrolled in various radiation protocols, whether randomized to placebo versus radiation or entered into registries. There were 165 placebo and 308 radiated patients, including both gamma and beta emitters. Maximum dose to the vessel wall was 30 to 55 Gy. Following radiation, all patients received antiplatelet therapy with aspirin and either ticlopidine or clopidogrel for one month. All patients completed at least six months of angiographic follow-up. RESULTS The LTO was documented in 28 patients (9.1%) from the irradiated group versus 2 placebo patients (1.2%), p < 0.0001. The LTO rates were similar across studies and emitters. In the irradiated group, LTO presented as acute myocardial infarction in 12 patients (43%), unstable angina in 14 (50%), and asymptotic in 2 (7%). Mean time to LTO was 5.4 +/- 3.2 months in the irradiated group versus 4.5 +/- 2.1 in placebo patients (p = NS). The overall rate of restenting for the entire study group at the time of radiation was 48.6%. Importantly, new stents were placed in 82% of the irradiated and in 100% of the placebo patients who presented with LTO. Multivariate analysis determined that new stenting was the main predictor of LTO. CONCLUSIONS Intracoronary radiation for patients with in-stent restenosis is associated with a high rate of LTO. Restenting may contribute late thrombosis. Prolonged antiplatelet therapy (up to six months) should be considered for these patients.
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Affiliation(s)
- R Waksman
- Cardiac Catheterization Laboratories, Washington Hospital Center, DC, USA.
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10
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Left Main Coronary Artery Disease. Am J Med Sci 1999. [DOI: 10.1016/s0002-9629(15)40665-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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11
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Cardiology Grand Rounds from The University of Texas Medical Branch. Am J Med Sci 1999. [DOI: 10.1097/00000441-199912000-00007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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12
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Spektor M, Tsiodras S, Kelly JJ. Acute myocardial infarction after irradiation for Hodgkin's disease: a not so unusual case. Ann Emerg Med 1999; 33:124-5. [PMID: 9867908 DOI: 10.1016/s0196-0644(99)70433-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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13
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Kaplan BM, Miller AJ, Bharati S, Lev M, Martin Grais I. Complete AV block following mediastinal radiation therapy: electrocardiographic and pathologic correlation and review of the world literature. J Interv Card Electrophysiol 1997; 1:175-88. [PMID: 9869969 DOI: 10.1023/a:1009756504168] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The clinical, features, serial electrocardiograms, and autopsy findings of a patient with symptomatic complete AV block, who had received mediastinal radiation therapy 8 1/2 years previously, are presented. The cardiac histopathology disclosed immense fibrosis of the conduction system and of the atria and ventricles. The enormous amount of fibrosis was similar in location and intensity to that observed in our previously reported patient (Cohen et al., Arch Intern Med 1981; 141:676-679) who had undergone mediastinal radiation. We conclude that the severe fibrosis was primarily due to radiation, rather than secondary to atherosclerotic coronary artery disease, which also has been described as a consequence of mediastinal radiotherapy. This patient's serial electrocardiograms disclosed evidence of complete block both in the AV nodal area and infra His system, which correlated well with the histopathology. The characteristic clinical features of patients with symptomatic complete AV block post mediastinal radiation therapy are presented, along with a review of the world literature.
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Affiliation(s)
- B M Kaplan
- Department of Medicine, Northwestern University Medical School, Chicago, Illnois, USA
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14
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Aronow H, Kim M, Rubenfire M. Silent ischemic cardiomyopathy and left coronary ostial stenosis secondary to radiation therapy. Clin Cardiol 1996; 19:260-2. [PMID: 8674269 DOI: 10.1002/clc.4960190325] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
A 55-year-old woman presented with profound congestive heart failure 23 years following mediastinal radiation. Ejection fraction (EF) was 35%. Symptoms markedly improved and EF increased to > 55% following saphenous vein bypass for > or = 80% ostial left main stenosis. Radiation therapy, a known risk factor for coronary atherosclerosis, may present with reversible severe silent ischemia.
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Affiliation(s)
- H Aronow
- Department of Internal Medicine, University of Michigan, Ann Arbor, USA
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Abstract
This article reviews and updates the current literature concerning the assessment, diagnosis, and therapy of coronary disease involving the LMCA. Included is recent information regarding the natural history, congenital abnormalities, noninvasive diagnostic studies, and role of coronary bypass surgery and percutaneous coronary interventions in treating disease of the LMCA. At present, it remains that the LMCA is a difficult segment to assess angiographically. The use of noninvasive imaging does not specifically distinguish LMCA from other types of coronary disease. Coronary bypass surgery has a proven benefit in the treatment of disease of the LMCA. Currently, interventional procedures are limited by significant risks, and surgical treatment with coronary bypass surgery remains the therapy of choice.
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Affiliation(s)
- B A Bergelson
- Department of Medicine, Northwestern Memorial Hospital, Chicago, IL 60611
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16
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Orzan F, Bellis D, Mollo F, Brusca A. Ostial stenosis of the left main coronary artery in a young woman 10 years after radiation therapy. Cardiovasc Pathol 1995; 4:69-71. [PMID: 25850782 DOI: 10.1016/1054-8807(94)00014-i] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/1993] [Accepted: 04/14/1994] [Indexed: 11/28/2022] Open
Affiliation(s)
- F Orzan
- Istituto di Medicina e Chirurgia Cardiovascolare, Sezione di Anatomia Patologica, Università degli Studi di Torino, Torino, Italy
| | - D Bellis
- Dipartimento di Scienze Biomediche e Oncologia Umana, Sezione di Anatomia Patologica, Università degli Studi di Torino, Torino, Italy
| | - F Mollo
- Dipartimento di Scienze Biomediche e Oncologia Umana, Sezione di Anatomia Patologica, Università degli Studi di Torino, Torino, Italy
| | - A Brusca
- Istituto di Medicina e Chirurgia Cardiovascolare, Sezione di Anatomia Patologica, Università degli Studi di Torino, Torino, Italy
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Orzan F, Brusca A, Conte MR, Presbitero P, Figliomeni MC. Severe coronary artery disease after radiation therapy of the chest and mediastinum: clinical presentation and treatment. BRITISH HEART JOURNAL 1993; 69:496-500. [PMID: 8343315 PMCID: PMC1025159 DOI: 10.1136/hrt.69.6.496] [Citation(s) in RCA: 98] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
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.
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Affiliation(s)
- F Orzan
- Istituto di Medicina e Chirurgia Cardiovascolare, Università degli Studi di Torino, Italy
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Orzan F, Brusca A, Gaita F, Giustetto C, Figliomeni MC, Libero L. Associated cardiac lesions in patients with radiation-induced complete heart block. Int J Cardiol 1993; 39:151-6. [PMID: 8314649 DOI: 10.1016/0167-5273(93)90027-e] [Citation(s) in RCA: 71] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
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.
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Affiliation(s)
- F Orzan
- Istituto di Medicina e Chirurgia Cardiovascolare, University of Torino Medical School, Italy
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Affiliation(s)
- A Om
- Department of Internal Medicine, Medical College of Virginia, Virginia Commonwealth University, Richmond 23298
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20
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Wan SK, Babb JD. Radiation-induced stenosis of the left main coronary artery. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1993; 28:225-7. [PMID: 8439999 DOI: 10.1002/ccd.1810280307] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Isolated left main coronary artery stenosis induced by mediastinal radiation is a well-documented but rare entity. Its clinical manifestations can be latent for many years, but its ominous sequela cannot be ignored. We report here such a patient presenting 16 yr postmediastinal radiation, the longest documented latency to date.
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Affiliation(s)
- S K Wan
- Bridgeport Hospital, CT 06610
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21
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Abstract
Excessive unprotected radiation to the heart appears to lead to the development of CAD, even in the absence of significant cardiovascular risk factors. The coexistence of such factors may enhance the probability of CAD. The presence of hypercholesterolemia and concomitant or sequential use of chemotherapeutic agents (especially doxorubicin) could further increase this risk. Therapeutic decisions, as with any other manifestation of CAD, relate to the extent of myocardium at jeopardy and to the overall diffuseness of CAD. Management options possible are PTCA or coronary artery bypass surgery. The latter may be required in left main artery stenosis and complicated ostial lesions. Use of shielding should decrease the associated risk of radiation-induced CAD in future years. However, clinicians should continue to have a high degree of suspicion of CAD in patients treated with thoracic radiation without cardiac shielding.
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Affiliation(s)
- A Om
- Department of Internal Medicine, Medical College of Virginia, Richmond 23298
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22
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Abstract
Mediastinal radiation damages endothelial cells, with resulting loss of capillaries and ischemia at the level of the microcirculation. These changes lead to increases in collagen and proliferation of fibrous tissue throughout the heart. Cardiac dysfunction following radiotherapy is surprisingly common and may be due to pericardial, myocardial, valvular, conduction system, or coronary artery disease. Greater awareness of cardiotoxicity has prompted changes in radiation techniques that appear to reduce clinical cardiovascular complications.
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Affiliation(s)
- M A Arsenian
- Department of Internal Medicine, University of Tennessee, Knoxville
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Handler CE, Livesey S, Lawton PA. Coronary ostial stenosis after radiotherapy: angioplasty or coronary artery surgery? Heart 1989; 61:208-11. [PMID: 2522311 PMCID: PMC1216643 DOI: 10.1136/hrt.61.2.208] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
A thirty year old man underwent coronary angioplasty for an isolated ostial stenosis of the ostium of the right coronary artery after mediastinal radiotherapy given ten years previously. Despite an angiographically acceptable angioplasty result, he had a myocardial infarction two months later and coronary artery surgery was performed. The most effective form of myocardial revascularisation for radiotherapy related coronary artery lesions remains to be established.
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Affiliation(s)
- C E Handler
- Department of Cardiology, Middlesex Hospital, London
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