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Efficacy and follow-up of transcatheter aortic valve implantation in a patient with radiation-induced aortic stenosis accompanied by extensive calcification and restrictive pulmonary dysfunction as radiotherapy complications

Gultekin NN

Istanbul University Cerrahpasa, Cardiology Institute, Department of Cardiology, Istanbul, Turkey

Yildi A

Istanbul University Cerrahpasa, Cardiology Institute, Department of Cardiology, Istanbul, Turkey

Kocas C

Istanbul University Cerrahpasa, Cardiology Institute, Department of Cardiology, Istanbul, Turkey

Burcu Topcu

Istanbul University Cerrahpasa, Cardiology Institute, Department of Cardiology, Istanbul, Turkey

Ökcun EB

Istanbul University Cerrahpasa, Cardiology Institute, Department of Cardiology, Istanbul, Turkey

DOI: 10.15761/BHC.1000154

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Abstract

We present a case of Hodgkin's lymphoma with a radiation-induced severe calcific aortic stenosis accompanied by diffuse calcifications as a complication of radiotherapy with severe exertional dyspnea was in last 6 months and 2 syncope attack in last month, also a severe restrictive pulmonary disease secondary to mediastinal radiotherapy. The Society of Thoracic Surgery (STS) risk score was 5.2% with a severe restrictive pulmonary disease.The heart  valve team in our unit decided to perform Transcatheter Aortic Valve Implantation (TAVI) due to patient-specific risk factors for surgical aortic valve replacement.Core Valve Evolut™R 26 mm valve selected according to diameters. EvolutR ™26 mm valve positioned and the procedure was finished without aortic regurgitation. Patient follow-up was uneventful for 16 months.

Key words

transcatheter aortic valve implantation, radiotherapy, aortic calcifications, multislice computed tomography angiography

Introduction

Patients  with  prior  mediastinal  radiotherapy  (XRT)  for  thoracic  malignancies  frequently  develop  radiation-associated  cardiac  disease. Valvular  heart  disease  occurs  in  ≈81%  of  patients  with  radiation-associated  cardiac  disease,  and a significant proportion present with severe symptomatic aortic stenosis (AS) requiring an intervention.  While aortic or mitral valvular regurgitation is the more commonly seen dysfunction, aortic stenosis is typically the main reason motivating surgical options .Transcatheter Aortic Valve Implantation (TAVI) appears to be a highly promising procedure with high feasibility, specific early complications, positive postprocedural haemodynamic outcomes assessed by echocardiography, and lower mid-term mortality when compared to SAVR [1-4].

Case report

We present   a case of Hodgkin's lymphoma with a radiation-induced severe calcific aortic stenosis accompanied by diffuse calcifications as a complication of radiotherapy. Hodgkin's lymphoma developed in this patient and chemotherapy and radiotherapy were applied  when he was three year old and also, performed splenectomy when he was eight years. Thyroidectomy was performed at 18 years old and developed hypoparathyroidism. Now, he was 49-year old and  admitted to our unit with severe exertional dyspnea for six months of ongoing and two syncope attack in last month. Also, there was severe restrictive pulmonary disease (secondary to mediastinal radiotherapy) in this patient. He was started on treatment; furosemide 40 mg every-other-day, ramipril 5 mg 1x1, metoprolol 50 mg 1x1, 1,25- dihydroxycholecalciferol (calcitriol) 0.5 1x1,calcimax-D3 2x1 daily.
Physical examination: Consciousness was open and cooperated. Blood pressure: 120/75 mmHg. Pulse 66/min. There was an ejection murmur spreading to all foci from the mesocardiac area.
Laboratory findings: Biochemical tests were normal. The heart cavities were of normal width. There was global ventricular hypertrophy. Global hypokinesia was present (Ejection Fraction: 50%). Aortic valve thick, the opening was restricted. Aortic root width was 3.1, Inter Ventricular Septum Thickness: 1.3, Left Ventricular Posterior  Wall Thickness: 1.2cm, Left Ventricular Diastolic Diameter: 4.5cm. Aortic valve area 1 cm2, mean 40, peak 70 mmHg gradient and medium aortic insufficiency flow were obtained with the Doppler examination. The structure and movement of the other valves were normal. Mild tricuspid insufficiency flow was obtained with the doppler examination. E/A ratio was increased in favour of A, IVRT, DT prolonged (Figures 1A and 1B). In electrocardiography (ECG) was rhythm sinus  (80/minute), LVH findings were present. In pulmonary function tests FEV: 30% showed an advanced restrictive pattern.
Multislice CT coronary angiography revealed normal coronary arteries, pericardial and aortic calcifications. It was noteworthy around two cm diameter craniocaudal calcifications on aortic valve and ascending aorta, and was extending from anterior to posterior of the pericardium, which is believed to be compatible with radiotherapy collimation windows. Multislice CT performed to determine aortic diameters (Figures 1C-1E).
Transcatheter Aortic Valve Implantation-Surgical Aortic Valve Replacement (TAVI-SAVR): The Society of Thoracic Surgery (STS) score was 5.2%, severe restrictive pulmonary disease, severe calcific aortic stenosis accompanied by diffuse calcifications as a complication of radiotherapy. The heart valve team in our unit decided to perform TAVI due to patient-specific risk factors for SAVR.

Figure 1 A, B. Baseline echocardiogram: Preserved LV function with significant LV hypertrophy Severe aortic stenosis. C. Multıslice CT: It was noteworthy around 2 cm diameter craniocaudal calcifications on aortic valve and ascending aorta, and is anteriorly and posteriorly of the pericardium, which is believed to be compatible with radiotherapy collimation windows. D,E. CT-Angiography: Multislice CT coronary angiography revealed normal coronary arteries

TAVI procedure: Core Valve Evolut™R 26 mm valve selected according to diameters. Evolut™R 26 mm valve positioned and the procedure was finished without aortic regurgitation (Figures 2A-2F) (Video 1).
Follow-up 11 months: Patient follow-up was un-eventful for 16 months (Figures 2G and 2H).

Figure 2.A-D. Multislice CT:Multislice CT performed to determine aortic diameter. E. TAVI procedure: Evolut –R 26 mm valve positioned…F. TAVI procedure:Procedure was finished without aortic regurgitation.G,H. Follow-up 11 month

Discussion

This is the first report to focus on patients with TAVI, which is referred to our institution with radiation-induced aortic stenosis. We evaluated the patient during 11 months follow-up. As the main finding, we reduced the mortality rate in patients with radiation-induced aortic stenosis at 9 months. TAVI is a good choice for patients with mediastinal radiotherapy and porcelain aortic valve and patients with a restrictive pattern of advanced respiratory function. In patients with radiation-induced aortic valve stenosis and contraindications to conventional surgery conditions, TAVI appears to be a highly promising procedure with high feasibility, specific early complications, positive postprocedural haemodynamic outcomes assessed by echocardiography, and lower mid-term mortality when compared to SAVR. In the  studies, TAVI had high clinical efficacy, more than 85% of patients were classified as NYHA class 1 or 2 at 6 months, and no readmission to the valve was required [1-4].The effect of this intervention is better selection of subgroup cardio-oncology patients for TAVI even at younger ages despite the durability problem.

Conclusion

TAVI may be a good option for cardio-oncology patients with a radiation-induced severe calcific aortic stenosis accompanied by diffuse calcifications as a complication of previous mediastinal radiotherapy.

Video 1. Evolute R ™26 mm valve positioned

References

  1. Donnellan E, Krishnaswamy A, Hutt-Centeno E, Johnston DR, Aguilera J, et al. (2018) Outcomes of Patients with Mediastinal Radiation-Associated Severe Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement. Circulation 138: 1752-54. [Crossref]
  2. Hull MC, Morris CG, Pepine CJ, Mendenhall NP (2003) Valvular dysfunction and carotid, subclavian, and coronary artery disease in survivors of Hodgkin lymphoma treated with radiation therapy. JAMA 290: 2831-7. [Crossref]
  3. Carlson RG, Mayfield WR, Normann S, Alexander JA (1991) Radiation-associated valvular disease. Chest 99: 538-545. [Crossref] 
  4. Dijos M, Reynaud A, Leroux L, Réant P, Cornolle C, et al. (2015) Efficacy and follow-up of transcatheter aortic valve implantation in patients with radiation-induced aortic stenosis. Open Heart 2: e000252. [Crossref]

Editorial Information

Editor-in-Chief

Osmar A. Centurión
Asuncion National University

Article Type

Case Report

Publication history

Received date: March 19, 2019
Accepted date: March 26, 2019
Published date: March 29, 2019

Copyright

©2019 Gultekin NN. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Citation

Gultekin NN, Yildi A, Kocas C, Topcu B, Ökcun EB (2019) Efficacy and follow-up of transcatheter aortic valve implantation in a patient with radiation-induced aortic stenosis accompanied by extensive calcification and restrictive pulmonary dysfunction as radiotherapy complications. Blood Heart Circ 3: DOI: 10.15761/BHC.1000154

Corresponding Author

Gultekin NN

Istanbul University Cerrahpasa, Cardiology Institute, Department of Cardiology, Istanbul, Turkey

E-mail : bhuvaneswari.bibleraaj@uhsm.nhs.uk

Figure 1 A, B. Baseline echocardiogram: Preserved LV function with significant LV hypertrophy Severe aortic stenosis. C. Multıslice CT: It was noteworthy around 2 cm diameter craniocaudal calcifications on aortic valve and ascending aorta, and is anteriorly and posteriorly of the pericardium, which is believed to be compatible with radiotherapy collimation windows. D,E. CT-Angiography: Multislice CT coronary angiography revealed normal coronary arteries

Figure 2.A-D. Multislice CT:Multislice CT performed to determine aortic diameter. E. TAVI procedure: Evolut –R 26 mm valve positioned…F. TAVI procedure:Procedure was finished without aortic regurgitation.G,H. Follow-up 11 month

Video 1. Evolute R ™26 mm valve positioned