Successful Transcatheter Aortic Valve Implantation in a Patient with Radiation-induced Aortic Stenosis for Mediastinal Hodgkin Lymphoma

Abstract

Aortic stenosis (AS), a late complication of thoracic radiation therapy for chest lesions, is often coincident with porcelain aorta or hostile thorax. We herein report a 59-year-old man with a history of mediastinal Hodgkin lymphoma treated with radiation therapy but later presenting with heart failure caused by severe AS. Severe calcification in the mediastinum and around the ascending aorta made it difficult to perform surgical aortic valve replacement. The patient therefore underwent transcatheter aortic valve implantation (TAVI). It is important to recognize radiation-induced AS early, now that TAVI is a well-established treatment required by increasing numbers of successfully treated cancer patients.

Keywords: Hodgkin lymphoma; TAVI; aortic stenosis; calcification; radiation.

Figure 1.

(A) Chest radiography on admission showing infiltrative shadows in the right lung field. The cardiothoracic ratio (55.7%) is high, and the right cardiopulmonary angle is slightly dull. (B) Chest computed tomography (lung window) showing ground-glass opacity and patchy shadows in the right upper lung field, suggesting pulmonary hemorrhaging. There is pleural effusion in the right thorax.

Figure 2.

Chest CT [mediastinal window, axial view (A), coronal view (B)] showing porcelain aorta and hostile thorax caused by radiation therapy. (C) 3D image of the aorta showing heavy calcification in the ascending aorta. (D) Short-axis view of the aortic valve. All three cusps are severely calcified, especially in the non-coronary cusp. (E) A self-expandable valve is suitable for the icicle calcification in the left ventricular outflow tract. Residual aortic regurgitation is also attributable to the calcification.

Figure 3.

An Evolut R valve (29 mm) was successfully expanded, and post-dilation was performed for residual prosthetic valve regurgitation.