Thoracic radiation leads to radiation-associated cardiac disease (RACD), associated with substantial cardiac morbidity and mortality, often requiring complex cardiothoracic surgery. In patients with ...RACD, along with valvular lesions, the aorto-mitral curtain (AMC, junction between base of anterior mitral leaflet and aortic root) thickness is increased on transthoracic echocardiography. We sought to identify clinical and transthoracic echocardiography predictors of long-term mortality in patients with RACD.
We studied 173 patients with RACD (75% women, 63±14 years, 53% with breast cancer, 27% with Hodgkin lymphoma; mean time from radiation, 18±12 years), who underwent cardiothoracic surgery (26% redo) between 2000 and 2003. Clinical, transthoracic echocardiography (along with AMC), and surgical variables were recorded. Preoperative EuroSCORE and all-cause mortality were recorded.
Mean left ventricular ejection fraction, right systolic ventricular pressure, and AMC thickness were 0.49±0.13, 41±15 mm Hg, and 0.54±0.2 cm, respectively. Fifty-one percent of patients had II+ mitral regurgitation or greater, 29% patients had II+ aortic regurgitation or greater, 23% patients had severe aortic stenosis, and 34% patients had II+ tricuspid regurgitation or greater. In 7.6±3 years of follow-up, there were 95 (55%) deaths, with a 30-day mortality rate of only 7 (4%). Absence of β-blockers (hazard ratio, 0.49; 95% confidence interval, 0.31 to 0.79), aspirin (hazard ratio, 0.53; 95% confidence interval, 0.33 to 0.84), higher EuroSCORE (hazard ratio, 1.11; 95% confidence interval, 1.02 to 1.21), and greater AMC thickness (hazard ratio, 5.75; 95% confidence interval, 1.57 to 21.03; all p<0.01) independently predicted mortality. Aorto-mitral curtain thickness of at least 0.6 cm was associated with significantly increased mortality.
Patients with RACD undergoing cardiothoracic surgery have high long-term mortality, which is independently predicted by AMC thickness, a higher preoperative risk score, and lack of cardioprotective medications.
Objective In the long-term, malignancy-associated thoracic radiation leads to varying degrees of pulmonary fibrosis and radiation-associated cardiac disease, often requiring cardiothoracic surgery. ...We sought to determine whether pulmonary fibrosis affects mortality in patients with radiation-associated cardiac disease undergoing cardiothoracic surgery. Methods We studied 117 patients (aged 63 ± 15 years, 71% were women) with radiation-associated cardiac disease receiving multimodality imaging who underwent cardiothoracic surgery (21% redo) between 2000 and 2003. Some 50% of patients had breast cancer, 28% of patients had Hodgkin's lymphoma, 9% of patients had lung cancer, and 13% of patients had other cancers. Time from radiation was 18 ± 12 years. Clinical, pulmonary function, angiographic, and echocardiographic parameters were recorded. On multidetector chest computed tomography, ascending aortic calcification and degree of pulmonary fibrosis (in 5 lobes for a score of 15: 0 = none, 1 = linear streaks, 2 = moderate fibrosis, and 3 = severe fibrosis with traction bronchiectasis) were recorded. Results Mean European System for Cardiac Operative Risk Evaluation was 7.9 ± 3, and forced expiratory volume at 1 minute/forced vital capacity ratio was 0.75 ± 0.2. Mean left ventricular ejection fraction was 49% ± 12%, and right systolic ventricular pressure was 42 ± 5 mm Hg. Some 27% of patients had severe aortic stenosis, and 46% of patients had II+ or greater mitral regurgitation. On multidetector chest computed tomography, mean pulmonary fibrosis score was 3.5 ± 3, and 59% of patients had ascending aortic calcification. Isolated coronary artery bypass was performed in 17% of patients; the rest were combination surgeries. At 6.3 ± 0.4 years, there were 59 deaths (50%) (3% died 1 month postoperatively). Forty-five patients (39%) had pulmonary complications in follow-up. Increasing pulmonary fibrosis score (hazard ratio, 1.11; 95% confidence interval, 1.02-1.20; P = .02), worse European System for Cardiac Operative Risk Evaluation (hazard ratio, 1.10; 95% confidence interval, 1.01-1.21; P = .04), and lack of beta-blocker (hazard ratio, 0.54; 95% confidence interval, 0.31-0.94, P = .008) and aspirin (hazard ratio, 0.54; 95% confidence interval, 0.31-0.94; P = .03) independently predicted mortality. Conclusions In patients with radiation-associated cardiac disease undergoing cardiothoracic surgery, worsening pulmonary fibrosis is associated with increased mortality.
Abstract Background Malignancy-associated thoracic radiation leads to radiation-associated cardiac disease (RACD) that often necessitates cardiac surgery. Myocardial dysfunction is common in patients ...with RACD. We sought to determine the predictive value of global left ventricular ejection fraction and long-axis function left ventricular global longitudinal strain (LV-GLS) in such patients. Methods We studied 163 patients (age, 63 ± 14 years; 74% women) who had RACD and underwent cardiac surgery (20% had reoperations) between 2000 and 2003. In addition to standard echocardiography, LV-GLS (%) was derived from the average of 18 segments in 3 apical views of the left ventricle, using velocity vector imaging. Standard clinical and demographic parameters were recorded. All-cause mortality was recorded. Results The mean duration between cardiac surgery and the last chest radiation was 18 ± 12 years. The median European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 8, and 88 patients died over 6.6 ± 4 years. A total of 52% of patients had ≥II+ mitral regurgitation; 23% of patients had severe aortic stenosis; and 39% of patients had ≥II+ tricuspid regurgitation. The mean left ventricular ejection fraction was 54% ± 13%, and the mean LV-GLS was −12.9% ± 4%. In a Cox proportional survival analysis, lower LV-GLS was predictive of mortality in univariable analysis (hazard ratio, 1.07 (95% confidence interval, 1.01-1.14); P = .006); however, after adjustment for other variables, the association became nonsignificant. In patients with a EuroSCORE <median, abnormal LV-GLS (<−14.5%) was associated with significantly higher mortality (48%), compared with those with normal LV-GLS (32%). Conclusions In patients who have RACD and undergo cardiac surgery, LV-GLS does not sufficiently discriminate and is not independently predictive of long-term outcomes. However, in patients with a low EuroSCORE, abnormal LV-GLS was associated with higher mortality, compared with those with normal LV-GLS.
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