Abstract 4146263: Radiation Induced Valvular Heart Disease complicated by Concomitant Radiation Induced Coronary Artery Disease

The cardiac adverse effects of radiation therapy include both radiation-induced valvular disease and radiation-induced coronary artery disease (RICAD). However, the management of each when present concurrently is minimally described by current research and guidelines. A 60 year-old infectious disease physician with history of Stage IIA Hodgkin Disease s/p radiation therapy in 1976 (age 13) presented to cardiology for new dyspnea on exertion. She had known valvular heart disease followed with serial echocardiograms. Repeat TTE completed showing now moderate to severe aortic stenosis, moderate aortic regurgitation, moderate tricuspid regurgitation, and mild to moderate mitral regurgitation. After exercise stress testing aborted due to decrease in systolic blood pressure with exertion, patient underwent cardiac catheterization and found to have moderate-severe aortic stenosis as well as hemodynamically significant ostial disease of the right coronary artery and distal left main coronary artery; classic bi-ostial coronary stenosis characteristic of RICAD. After multidisciplinary discussion with interventional cardiology, cardiothoracic surgery, and second opinion with tertiary valve center, she was referred for surgical revascularization and aortic valve replacement (AVR). Patient underwent AVR with a 23mm bioprosthetic aortic tissue valve replacement, aortic root enlargement, tricuspid valve repair with 28mm ring, and three vessel coronary artery bypass grafting. Notably, several retrospective studies have found increased mortality with surgical aortic valve replacement in patients with prior history of radiation with many centers preferring transcatheter aortic valve replacement as a safe and effective alternative in this demographic. Despite acknowledging this predilection, SAVR chosen in this patient specifically given her concurrent RICAD requiring revascularization. This case intimately highlights the need for further studies regarding management of radiation-induced valvular disease when complicated by RICAD.