Original Articles
Surgical Management of Radiation-Induced Heart Disease

https://doi.org/10.1016/S0003-4975(98)00082-4Get rights and content

Abstract

Background. With the increasing population of patients with prior mediastinal irradiation, cardiac surgeons will encounter patients with radiation-induced damage to the heart and the great vessels. Awareness of the pathology and the surgical management is essential to provide optimal care for these patients.

Methods. Eight patients with radiation-induced heart disease were encountered in the last 10 years. After a brief clinical presentation, the surgical management of radiation-induced heart disease is reviewed.

Results. Radiation can affect all the structures in the heart, including the coronary arteries, the valves, and the conduction system. The pericardium is the most commonly involved, and the conduction system is the least involved. Pericardiectomy is quite effective in patients with symptomatic pericardial effusion or constriction. The coronary lesions are located predominantly in the ostial or proximal regions of the epicardial vessels. Percutaneous transluminal coronary angioplasty alone appears to have a high rate of restenosis. Surgical revascularization has good long-term results, and the internal mammary artery should be used if it is satisfactory. The aortic and mitral valves are more commonly involved than the tricuspid and pulmonary valves. Myocardial dysfunction predominantly affects the right ventricle and requires particular attention during cardiopulmonary bypass and in the postoperative period. Restoration of sinus rhythm is essential in view of stiffness of the ventricles. Flexibility in the surgical approach with selective use of thoracotomy will facilitate the surgical procedure in certain patients.

Conclusions. Surgeons should be well versed in all the manifestations and the management of radiation-induced heart disease.

Section snippets

Clinical Summary

We have encountered 8 patients with radiation-induced heart disease in the last 10 years. The mode of presentation, the nature of the lesions, and the management of the lesions are summarized in Table 1. This does not include all the patients with radiation-induced heart disease seen in our institution and hence does not indicate the true incidence of the problem. There were 6 men and 2 women between the ages of 22 and 67 years at initial presentation. Lymphoma was the most common primary

Spectrum of Disease

Irradiation can affect all of the structures in the heart. The spectrum of disease, the mean dose of radiation, and the time of presentation compiled from large series are shown in Table 2. The pericardium is the most often involved and the conduction system, the least frequently involved. The overall incidence of clinically detectable radiation-induced heart disease is about 5% to 30% depending on the method of diagnosis. Three groups of patients treated with mediastinal irradiation are

Screening Techniques

As radiation-induced heart disease occurs in a substantial number of patients with prior mediastinal irradiation, screening of asymptomatic patients should be considered. The extent to which these patients benefit from systematic screening with electrocardiography, stress test, echocardiography, or cardiac catheterization is controversial. In a series [24] of 25 patients with Hodgkin’s disease evaluated 37 to 144 months after thoracic mantle irradiation, only 1 patient had normal findings. This

Conclusions

Radiation-induced heart disease must be considered in any patient who has had mediastinal irradiation of more than 3,500 cGy and is seen with cardiac symptomatology. Newer radiation techniques with cardiac shielding may decrease the incidence, but physicians will continue to encounter patients with this problem. Pericardial disease is the most common manifestation, and anterior pericardiectomy is advisable when a patient is seen with symptomatic pericardial effusion. Concomitant pericardiectomy

References (25)

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