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A Tale of Two Valves

Transthoracic echocardiogram demonstrating mild mitral valve and aortomitral curtain thickening (arrow; Panel A), with satisfactory mitral valve opening during diastole (Panel C) in 2004; by 2016, there has been dramatic progression in mitral valve disease with severe aortomitral curtain calcification (arrow; Panel B) and severe mitral stenosis (Panels D, F), associated with significant pulmonary hypertension (Panel E).

Transthoracic echocardiogram demonstrating mild mitral valve and aortomitral curtain thickening (arrow; Panel A), with satisfactory mitral valve opening during diastole (Panel C) in 2004; by 2016, there has been dramatic progression in mitral valve disease with severe aortomitral curtain calcification (arrow; Panel B) and severe mitral stenosis (Panels D, F), associated with significant pulmonary hypertension (Panel E).

To the Editor:

Radiation heart disease is associated with a high level of morbidity and mortality. Its natural history is not well understood. Its management is difficult. We report a case of radiation heart disease with dramatic disease progression over 11 years, captured on echocardiography.

Case Report

A 66-year-old woman presented with increasing dyspnea on exertion over 1 month. Her medical history includes mediastinal radiation treatment for Hodgkin lymphoma in 1977 and 1986, and breast cancer treated with left mastectomy and chemotherapy. The patient underwent aortic valve replacement with a mechanical prosthesis (21 mm, Carbomedics; Sorin Group USA, Inc, Arvada, Colorado) in 2005 for symptomatic aortic stenosis in the setting of a bicuspid aortic valve.

To investigate her dyspnea, a transthoracic echocardiogram was performed. The most striking finding was severely thickened and calcified aortomitral curtain, consistent with radiation heart disease. Mitral valve opening was severely reduced with transmitral gradients (peak/mean) of 25/10 mm Hg at 85 beats per minute, consistent with severe mitral stenosis (Figure, Panels B, D, F). There was mild mitral regurgitation. Mechanical aortic prosthesis was well seated, with satisfactory function (peak/mean gradients: 9/5 mm Hg; dimensionless index: 0.68; trivial regurgitation). There was moderately severe pulmonary hypertension with an estimated right ventricular systolic pressure of 68 mm Hg (Figure, Panel E).

Echocardiographic imaging was not only instrumental in the diagnosis of the patient’s aortic valve disease in 2004, prior to surgery, but also important in documenting the natural history of mitral valve disease progression as a result of radiation heart disease. A transthoracic echocardiogram performed in October 2004 demonstrated a bicuspid aortic valve, with moderately severe stenosis (peak/mean gradients: 46/28 mm Hg) and mild regurgitation. The mitral valve was only mildly thickened, with mild regurgitation (Figure, Panels A, CSupplementary Videos 1 and 2, available online). At the time, there was much discussion about whether the mitral valve warranted intervention at the time of aortic valve surgery, given the patient’s previous radiation treatment.

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-Bo Xu, MB BS (Hons), Wael Jaber, MD, Serge Harb, MD, Brian Griffin, MD

This article originally appeared in the July 2017 issue of The American Journal of Medicine.

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