Radiotherapy-Induced Mitral Stenosis: A Three-Dimensional Perspective

Mediastinal irradiation for cancers, mainly breast cancer and Hodgkin’s disease, has numerous potential adverse effects, including coronary artery disease, pericarditis, cardiomyopathy, valvular disease, and conduction abnormalities. The prevalence of valvular dysfunction is relatively low, and regurgitation is more common. We report the case of a 58-year-old woman with severe radiation-induced mitral stenosis and discuss the potential additional value of three-dimensional transesophageal echocardiography.

A 58-year-old female patient was referred to the cardiology department for functional impairment and evaluation of mitral valve disease. In 1973, she underwent chemotherapy and mediastinal radiotherapy for Hodgkin’s disease. In 2002, she underwent a mechanical aortic valve replacement for severe aortic regurgitation. One year ago, she started to feel short of breath (New York Heart Association functional class III). On physical examination, her blood pressure was 110/60 mm Hg and heart rate was 80 beats/min. There was no sign of congestive heart failure, and prosthetic aortic valve sounds were normal. Electrocardiography showed a normal sinus rhythm and a complete right bundle branch block. Chest x-ray revealed a normal cardiac silhouette with a right superior pleural thickening and an upper lobe venous redistribution compatible with pulmonary edema. Blood test results were unremarkable.

Transthoracic and transesophageal echocardiography showed severe mitral stenosis with a valve area of 0.9 cm 2 and a mean transmitral pressure gradient of 12 mm Hg ( Figure 1 , Video 1 ). There was mild mitral regurgitation. The mitral aortic membrane was thickened, suggesting radiotherapy-induced valvular disease ( Figure 1 , Video 2 ). The posterior mitral leaflet was mobile, a very unusual feature in rheumatic mitral stenosis ( Figure 1 , Video 3 ). Three-dimensional transesophageal echocardiography clearly showed a complete opening of both commissures ( Figure 2 , Videos 4 and 5 ). Left ventricular function and size were normal. Aortic valve prosthesis function was normal with a mean gradient of 10 mm Hg. Systolic pulmonary artery pressure was 50 mm Hg. The left atrium was moderately enlarged. The absence of commissural fusion in this radiation-induced mitral stenosis precluded the use of percutaneous balloon commissurotomy, and a mitral valve replacement was scheduled.

Figure 1

Transthoracic (A-C) and (D) transesophageal echocardiography. (A) Parasternal long-axis view showing fibrosis and calcification extending from the aortic root to the anterior mitral leaflet. (B) Parasternal short-axis view showing severe mitral stenosis. The degree of commissural opening was difficult to assess. (C) Mean transmitral pressure gradient was 12 mm Hg. (D) Transesophageal view of the mitral valve. The posterior mitral leaflet was mobile, a very unusual feature in rheumatic mitral stenosis.

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Jun 16, 2018 | Posted by in CARDIOLOGY | Comments Off on Radiotherapy-Induced Mitral Stenosis: A Three-Dimensional Perspective

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