Complete Heart Block and Severe Tricuspid Regurgitation After Radiotherapy: Case Report and Review of the Literature

doi:10.1378/chest.108.6.1748

Chest

Volume 108, Issue 6, December 1995, Pages 1748-1751

https://doi.org/10.1378/chest.108.6.1748 Get rights and content

Cardiac complications can occur long after chest radiotherapy. We describe a patient who developed both valve disease and complete heart block at different intervals following radiotherapy for Hodgkin's disease. The combined presentation of these two very rare cardiac complications and surgery for radiation-induced tricuspid valve disease have not been described before.

Section snippets

CASE REPORT

The patient developed a carcinoma of the right breast in 1974 at the age of 24 years. She was treated with a right mastectomy and postoperative radiotherapy to the chest wall, right axilla, and supraclavicular fossa with an incident dose of 5,500 rad. On regular yearly review, there had been no evidence of recurrence. In 1983, a diagnosis of hypothyroidism was made, and she was treated with thyroxine, 100 µg/d. An ECG performed in 1984 was normal.

In October 1986, 12 years after radiotherapy,

Discussion

Radiation in significant doses can affect any part of the heart, probably as a result of microcirculatory injury causing ischemia and progressive fibrosis.¹ Pericardial effusion, acute pericarditis, and constrictive pericarditis are the most common manifestations of radiation-induced heart disease, although cardiomyopathy and coronary artery stenoses are well recognized. Radiation-associated valve disease and conducting-tissue disease are both much rarer.

There seems to be a spectrum of valve

Acknowledgments

We would like to thank Dr. D. Gibson for his help with the diagnostic studies and management of this patient and Professor Sir M. Yacoub who carried out the surgery.

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We present a 64-year-old man diagnosed with Hodgkin's lymphoma at 3 years, who received chemotherapy and several sessions of Mediastinal Radiotherapy (MRT), which caused torrential tricuspid regurgitation (TR), complete heart block (CHB) and porcelain aorta. The patient successfully underwent complex tricuspid repair without cardiac arrest and implantation of an epicardial pacemaker.
Presentamos el caso de un paciente de 64 años que recibió radioterapia mediastinal y quimioterapia por diagnóstico de linfoma a los tres años. Como secuela de la radiación desarrolló insuficiencia tricúspide torrencial, bloqueo cardiaco completo y aorta en porcelana. Tratamos exitosamente al paciente sometiéndolo a una reparación compleja de la válvula tricúspide a corazón latiendo e implantando un marcapasos epicárdico.
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Citation Excerpt :
On occasion, the valve orifice is narrowed simultaneously by fibrosis, thus impeding blood flow and producing a murmur of stenosis. The mitral and aortic valves on the left side of the heart are injured more commonly than are the tricuspid and pulmonic valves on the right side of the heart.13,14 This probably results from the irradiation technique and the fact that the left-sided mitral and aortic valves are subjected to greater trauma from the high pressure associated with the left ventricle and aorta, respectively.
People with Hodgkin’s disease and breast cancer often receive therapeutic irradiation to the chest (mediastinum) as an element of treatment. While the therapy often cures the malignancy, it has been implicated in causing late-onset heart disease that may influence the provision of dental treatment.
The authors conducted a MEDLINE search of the years 1995 through 2002 using the key terms “Hodgkin’s disease,” “breast cancer,” “radiation therapy,” “cardiac valves” and “coronary artery” to define the pathophysiology of the disorder, its epidemiology and dental implications. The articles they selected for further review included those published in English in peer-reviewed journals.
Therapeutic irradiation of the chest results in the inadvertent inclusion of the heart within the irradiation field. Over the next 10 to 20 years, some of these people may experience pathological changes of the heart valves that could predispose them to endocarditis, accelerated atherosclerosis of the coronary artery that heightens their risk of experiencing a fatal myocardial infarction or both.
Dentists need to identify patients who have received therapeutic irradiation to the chest and consult with the patients’ physicians to determine whether the therapy has damaged the heart valves or coronary arteries. Patients with radiation-induced valvular disease may require prophylactic antibiotics when undergoing specific dental procedures that are known to cause a bacteremia and a heightened risk of developing endocarditis. Patients with radiation-induced coronary artery disease should be administered only limited amounts of local anesthetic agents containing a vasoconstrictor, and they may require the administration of sedative agents and cardiac medications to preclude ischemic episodes.
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Chest

Selected ReportsComplete Heart Block and Severe Tricuspid Regurgitation After Radiotherapy: Case Report and Review of the Literature

Section snippets

CASE REPORT

Discussion

Acknowledgments

Am J Med

Am J Cardiol

Am Heart J

Am J Med

Chest

Am J Cardiol

J Thorac Cardiovasc Surg

Radiation-induced heart disease: an update

Prog Cardiovasc Dis

Radiation associated valvular disease

Chest

Late cardiac effects after mantle radiotherapy in patients with Hodgkin's disease

Ann Oncol

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

Br Heart J

Radiotherapy as a cause of complete atrioventricular block in Hodgkin's disease: an electrophysiological-pathological correlation

Arch Intern Med

Bloc aurieulo-ventriculaire succedant a la radiotherapie thoracique: a propos de deux cas

Sem Hop Paris

Selected Reports
Complete Heart Block and Severe Tricuspid Regurgitation After Radiotherapy: Case Report and Review of the Literature