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Table of Contents
CASE REPORT
Year : 2016  |  Volume : 17  |  Issue : 3  |  Page : 114-116  

Transesophageal echocardiography and radiation-induced damages


Department of Heart and Vessels, Cardiac Surgery Unit and Heart Transplantation Center, S. Camillo-Forlanini Hospital, Rome, Italy

Date of Web Publication19-Oct-2016

Correspondence Address:
Marzia Cottini
Department of Heart and Vessels, Cardiac Surgery Unit and Heart Transplantation Center, S. Camillo-Forlanini Hospital, Circonvallazione Gianicolense 87, 00152 Rome
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1995-705X.192561

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   Abstract 

The long-term sequelae of mantle therapy include, especially lung and cardiac disease but also involve the vessels and the organs in the neck and thorax (such as thyroid, aorta, and esophagus). We presented the case of 66-year-old female admitted for congestive heart failure in radiation-induced heart disease. The patient had undergone to massive radiotherapy 42 years ago for Hodgkin's disease (type 1A). Transesophageal echocardiography was performed unsuccessfully with difficulty because of the rigidity and impedance of esophageal walls. Our case is an extraordinary report of radiotherapy's latency effect as a result of dramatic changes in the structure of mediastinum, in particular in the esophagus, causing unavailability of a transesophageal echocardiogram.

Keywords: Constrictive pericarditis, esophageal fibrosis, radiation-induced damage, transesophageal echocardiogram


How to cite this article:
Cottini M, Polizzi V, Pino PG, Buffa V, Musumeci F. Transesophageal echocardiography and radiation-induced damages. Heart Views 2016;17:114-6

How to cite this URL:
Cottini M, Polizzi V, Pino PG, Buffa V, Musumeci F. Transesophageal echocardiography and radiation-induced damages. Heart Views [serial online] 2016 [cited 2017 Feb 24];17:114-6. Available from: http://www.heartviews.org/text.asp?2016/17/3/114/192561


   Introduction Top


Radiation therapy for Hodgkin's lymphoma treatment has evolved dramatically in the last century.

It was realized that radiation works very well for Hodgkin's disease. Medical researchers also realized that treating only small areas originally involved by lymphoma with radiation was not good enough,[1],[2] if radiation had to be used as the only treatment.

A large area covering all lymph node areas in the upper or lower half of the body had to be treated. This became known as extended field radiation therapy (EFRT). When the upper half of the body was being treated, the EFRT field was called the “mantle field.”[3]

A high-dose radiation exposure on the thorax is mainly used in the context of adjuvant radiotherapy after conservative or radical breast surgery, adjuvant or exclusive radiotherapy of lung and esophageal cancer, and as a complement to systemic treatment in lymphoma. Irradiation of the heart increases the risk of the so-called “radiation-induced” heart disease (RIHD).[4]

The incidence of RIHD is 10–30% by 5–10 years posttreatment;[5] the prevalence of RIHD, in the setting of the modern protocols of delivering adjuvant radiotherapy, reduction in doses, and field radiation size, is still poorly defined.[6]


   Case Report Top


We describe the case of a 66-year-old female with a history of Hodgkin's lymphoma (type 1A) treated with mantle radiotherapy in 1973.

She was admitted for congestive heart failure in radiation-induced heart disease. A cardiac computed tomography angiography (64 Dual-Source, CareDose, and electrocardiogram pulsing MinDose) showed calcified ascending aorta and pericardium calcification narrowing the right ventricle, bronchiectasis and fibrosis of the lungs, and esophagus [Figure 1]a and [Figure 1]b.
Figure 1: (a) Multidetector computed tomography short-axis view of the calcification in the ascending aorta and the nearest thickened pericardium, (b) multidetector computed tomography long.axis view of the thickened wall of the esophagus

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A cardiac magnetic resonance imaging (1.5 T) revealed normal left ventricle size (VTS 17 ml, VTSI 10 ml/m 2), with ejection fraction of 0.87, stroke volume (SV) of 70 ml, SV index 39 ml/m 2, aortic regurgitation and stenosis with aortic valve peak velocity of 163 cm/s and a mild thickness of pericardium (3 mm) and esophagus [Figure 2].
Figure 2: Magnetic cardiac imaging (magnetic resonance imaging), axial image demonstrating circumferential thickening of the pericardium (>3 mm), normal volume of the heart, and calcification of the ascending aorta

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A transthoracic echocardiography was performed and documented normal EF, aortic regurgitation and aortic stenosis with effective orifice area of 0.78 cmq [Figure 3]a and [Figure 3]b, calcified mitral annulus, signs of constrictive pericarditis (pericardial calcifications, augmented thickness, and Doppler signs of constriction – high filling pressure in the left and right ventricle, annulus paradoxes, and diastolic flow reversal in expiration in the suprahepatic veins), and of myocardial damage (low-tissue Doppler velocities at the mitral annulus level [Figure 3]c, significant pulmonary hypertension [Figure 3]d). Therefore, we wanted to observe better heart and the signs of constrictive pericarditis, so we performed a transesophageal echocardiogram (TEE). Surprisingly, we were unable to visualize the cardiac structures because of high and completely acoustic impedance and interfaces [Figure 4]. The acoustic shadowing due to the interface of two different structures with a high level of impedance showed the suboptimal image and no resolution of cardiac structures. The resultant images were echodense with the lack of signal in the sector beyond the structure [Video 1].
Figure 3: (a) Transthoracic echocardiography view of aortic regurgitation, (b) transthoracic echocardiography showing aortic valve stenosis, (c) transthoracic echocardiography demonstrating the myocardial damage by low.tissue Doppler velocities at the mitral annulus level, (d) transthoracic echocardiography showing pulmonary hypertension

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Figure 4: Transesophageal echocardiography failure: The completely impedance to visualize the cardiac structure

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   Discussion Top


Radiation therapy uses high-energy rays (or particles) to destroy cancer cells. To treat Hodgkin's disease, a carefully focused beam of radiation is delivered from a machine outside of the body.[6],[7] If the Hodgkin's disease was in the upper body, radiation was given to the mantle field, which included lymph node areas in the neck, chest, and under the arms.[8] The side effects of radiation depend on where the radiation is aimed. They could be short- or long-term effects. The long-term sequelae of mantle therapy include, especially the lung and cardiac disease but also involve the vessels and the organs in the neck and thorax (such as thyroid, aorta, and esophagus).[9],[10]

In our case report, the significant thickness of esophagus [Figure 1]b caused the acoustic impedance due to the inability of TEE to view correctly and complete cardiac structure. Any degree of vision or level of depth of the probe did not capture defined images.


   Conclusion Top


The short- and long-term sequelae of mantle field radiation were not predictable and quantifiable and included, especially heart and thoracic structure labeling radiation-induced heart disease. In the literature, the descriptions of unavailable TEE in a patient with a history of radiation therapy have been few, all of them have pointed out to the RIHD or other radiation-induced effects. Our case report emphasized the failure of the TEE, in particular, the impedance of radiation-induced thickness of the esophagus hence the unavailability to collect good quality images during the examination.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflflicts of interest.

 
   References Top

1.
Baker JE, Moulder JE, Hopewell JW. Radiation as a risk factor for cardiovascular disease. Antioxid Redox Signal 2011;15:1945-56.  Back to cited text no. 1
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2.
Yeh ET, Veijpongsa P. Subclinical Cardiotoxicity Associated With Cancer Therapy: Early Detection and Future Directions. J Am Coll Cardiol 2015;65:2523-5.  Back to cited text no. 2
    
3.
Mell LK, Mehrotra AK, Mundt AJ. Intensity-modulated radiation therapy use in the U.S 2004. Cancer 2005;104:1296-303.  Back to cited text no. 3
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4.
Aleman BM, van den Belt-Dusebout AW, Klokman WJ, Van't Veer MB, Bartelink H, van Leeuwen FE. Long-term cause-specific mortality of patients treated for Hodgkin's disease. J Clin Oncol 2003;21:3431-9.  Back to cited text no. 4
    
5.
Carver JR, Shapiro CL, Ng A, Jacobs L, Schwartz C, Virgo KS, et al. American Society of Clinical Oncology clinical evidence review on the ongoing care of adult cancer survivors: Cardiac and pulmonary late effects. J Clin Oncol 2007;25:3991-4008.  Back to cited text no. 5
[PUBMED]    
6.
Lancellotti P, Nkomo VT, Badano LP, Bergler-Klein J, Bogaert J, Davin L, et al. Expert consensus for multi-modality imaging evaluation of cardiovascular complications of radiotherapy in adults: A report from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. J Am Soc Echocardiogr 2013;26:1013-32.  Back to cited text no. 6
[PUBMED]    
7.
Maraldo MV, Specht L. A decade of comparative dose planning studies for early-stage Hodgkin lymphoma: What can we learn? Int J Radiat Oncol Biol Phys 2014;90:1126-35.  Back to cited text no. 7
[PUBMED]    
8.
Yahalom J. Transformation in the use of radiation therapy of Hodgkin lymphoma: New concepts and indications lead to modern field design and are assisted by PET imaging and intensity modulated radiation therapy (IMRT). Eur J Haematol Suppl 2005;66:90-7.  Back to cited text no. 8
[PUBMED]    
9.
Jørgensen AY, Maraldo MV, Brodin NP, Aznar MC, Vogelius IR, Rosenschöld PM, et al. The effect on esophagus after different radiotherapy techniques for early stage Hodgkin's lymphoma. Acta Oncol 2013;52:1559-65.  Back to cited text no. 9
    
10.
Yeh ET, Vejpongsa P. Subclinical cardiotoxicity associated with cancer therapy: Early detection and future directions. J Am Coll Cardiol 2015;65:2523-5.  Back to cited text no. 10
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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