Imaging of the Acute and Chronic Cardiovascular Complications of Radiation Therapy

Figures

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  Figure 1.. Central illustration: manifestations of radiation-induced cardiovascular toxicity over time. Created in BioRender. https://BioRender.com/n00z870.

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  Figure 2.. Radiotherapy-induced mitral valve changes in a 60-year-old female treated with mantle field radiotherapy for lymphoma aged 24 years. Transthoracic and transesophageal echocardiographic images A through C, Marked thickening and calcification of the basal anterior mitral valve leaflet and aorto-mitral curtain (D): posterior jet of mitral regurgitation (E and F): 4-dimensional models of the mitral valve, demonstrating relative sparing of the leaflet tips and commissures. E represents surgical view and F represents view from left ventricle.

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  Figure 3.. European Society of Cardiology and International Cardio-Oncology Society image screening guidelines post–chest radiotherapy (XRT). CMR indicates cardiovascular magnetic resonance imaging; CT, computed tomography; Gy, Gray; and TTE, transthoracic echocardiogram. †If mean heart dose (MHD) is not available, prescribed radiotherapy dose (RT) ≥35 Gy to a volume exposing the heart. ‡If MHD is not available, prescribed RT 15–34 Gy to a volume exposing the heart. §If MHD is not available RT <15 Gy to a volume exposing the heart. *At dose of/equivalent to ≥100 mg/m2 of doxorubicin. **With heart in treatment field.

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  Figure 4.. Multimodality differentiation between constrictive pericarditis and restrictive cardiomyopathy. A indicates mitral A-wave inflow; CMR, cardiovascular magnetic resonance imaging; CT, computed tomography; D, diastolic forward flow; DFR, diastolic flow reversal; E, mitral E-wave inflow; e′, mitral e′ value; S, systolic forward flow; and TTE, transthoracic echocardiogram. Created in BioRender. https://BioRender.com/n00z870.

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  Figure 5.. A 54-year-old man with pericardial constriction after chest radiotherapy for lymphoma aged 18 years. A, Transthoracic echocardiography images demonstrating pericardial thickening, increased echogenicity as well as septal flattening with inspiration (i), annulus reversus with e′ sept 0.16 m/s and e′ lateral 0.11 m/s (ii and iii) >25% respiratory variation of transmitral E-wave velocity (iv) and decreased hepatic vein forward flow with expiration (v). B, Three-dimensional computed tomography reconstruction showing extensive pericardial calcification. C, Cardiovascular magnetic resonance imaging showing pericardial thickening on T1 black-blood imaging (i) and deformation of left ventricular with inspiration (ii) with resolution with expiration (iii).

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  Figure 6.. Multimodality imaging demonstrating radiation-induced cardiovascular toxicity in a 72-year-old man who had mantle radiotherapy aged 38 years for Hodgkin lymphoma. Patient had presented with exertional breathlessness and chest pain with transthoracic echocardiogram demonstrating aortic stenosis. Transesophageal echocardiography (A) demonstrated typical radiotherapy-induced changes of the aortic valve, while computed tomography coronary angiogram (B) showed diffuse coronary disease with severe disease in proximal left anterior decending, left circumflex and right coronary arteries. Patient went on to have cardiovascular magnetic resonance imaging which showed severe aortic stenosis through planimetry of the valve on cine imaging (C), late gadolinium enhancement in the basal-mid inferior walls (arrows) suggesting subendocardial infarction (E and D), and adenosine-induced reductions in stress myocardial blood flow in the basal inferior, inferolateral, and inferoseptal segments using quantitative perfusion mapping (F).

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  Figure 7.. A 29-year-old man who had undergone mantle field radiotherapy for lymphoma aged 4 years. A, Transthoracic echocardiography image showing visually dilated left ventricle (i), heavy calcification of the aortic valve (ii), and severe aortic stenosis (Velocity-max of 4.57 m/s; iii). B, Cardiac computed tomography coronary angiography showing noncalcified ostial disease (left) as well as calcification of posterior aorta (right). C, Cardiovascular magnetic resonance imaging on 3T scanner showing marked aortic thickening and stenosis on 3-chamber cine (i) and flow mapping (ii), with tissue characterization showing areas of basal subendocardial and intramyocardial septal late gadolinium enhancement (iii, arrow), as well as raised septal T1 MOLLI at 1387 (normal values, 1220–1360) (iv) and raised septal extracellular volume (ECV) at 34% (v).

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  Figure 8.. Echocardiogram demonstrating restrictive physiology in a 53-year-old female patient who had undergone radiotherapy 16 years previously for lung cancer. A, Transthoracic echocardiogram tissue Doppler of medial (i) and lateral (ii) mitral annuluses showing decreased e′ velocities. Pulsed wave Doppler of the mitral valve (MV) inflow showing E-wave>A-wave velocity (E Vel, A Vel) with a ratio of 2.57 with short deceleration time (DECT) of 106 ms (iii). Average E-wave/e′ of 40.54 and septal (SEPT) e′<lateral (LAT) E′ in keeping with restriction. B, Cardiovascular magnetic resonance imaging (CMR) (i) scout (ii) late gadolinium enhancement (LGE) imaging (iii) T1 MOLLI mapping and (iv) extracellular (ECV) mapping on 1.5T Scanner. Raised T1 at 1376 ms (normal values 970–1050 ms) and ECV at 32%.