Echocardiographic Assessment of Mantle Radiation Mitral Stenosis

The long-term sequelae of mantle radiotherapy include lung disease and cardiac disorders. Dyspnea on exertion is a common complaint and can be due to one or more pathologies. We describe a case of mantle radiotherapy-induced mitral stenosis, characterized by aorto-mitral continuity calcification and absent commissural fusion which precludes balloon valvotomy. The latency period is long, and this patient presented 42 years after radiotherapy. Importantly, as previously described with radiation-induced valve disease, significant mitral stenosis developed 10 years after surgery for significant aortic stenosis. Two-dimensional and three-dimensional transthoracic and transesophageal echocardiography should be considered during assessment of symptomatic survivors of Hodgkin's disease where the index of suspicion for valvular stenosis increases over time. Given the natural history of mantle radiation valvular disease, a lower threshold for surgical intervention in radiation-induced mitral stenosis may need to be considered if cardiac surgery is planned for other reasons in order to avoid repeated sternotomy in patients with prior irradiation. Mini-Abstract We describe a case of mantle radiation-induced mitral stenosis. This 61-year-old woman presented with breathlessness 42 years after radiotherapy. Two-dimensional and three-dimensional echocardiography demonstrated critical mitral stenosis with characteristic aorto-mitral continuity calcification and absent commissural fusion which precludes balloon valvotomy. The latency period is long and in survivors of Hodgkin's disease the index of suspicion for valvular stenosis increases over time. Aortic valve lesions tend to occur earlier than mitral valve lesions. Given the natural history of mantle radiation valvular disease, a lower threshold for surgical intervention in radiation-induced mitral stenosis may need to be considered if cardiac surgery is planned for other reasons in order to avoid repeated sternotomy in patients with prior irradiation.