Abstract
The clinical, features, serial electrocardiograms, and autopsy findings of a patient with symptomatic complete AV block, who had received mediastinal radiation therapy 81/2 years previously, are presented. The cardiac histopathology disclosed immense fibrosis of the conduction system and of the atria and ventricles. The enormous amount of fibrosis was similar in location and intensity to that observed in our previously reported patient (Cohen et al., Arch Intern Med 1981;141:676-679) who had undergone mediastinal radiation. We conclude that the severe fibrosis was primarily due to radiation, rather than secondary to atherosclerotic coronary artery disease, which also has been described as a consequence of mediastinal radiotherapy. This patientÆs serial electrocardiograms disclosed evidence of complete block both in the AV nodal area and infra His system, which correlated well with the histopathology. The characteristic clinical features of patients with symptomatic complete AV block post mediastinal radiation therapy are presented, along with a review of the world literature.
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References
Cohen SI, Bharati S, Glass J, Lev M. Radiotherapy as a cause of complete atrioventricular block in Hodgkin’s disease: An electrophysiological-pathological correlation. Arch Intern Med 1981;141:676–679.
Rubin E, Camara J, Grayzel DM, Zak FG. Radiation induced cardiac fibrosis. Am J Med 1963;34:71–75.
Slama MS, Le Guludec D, Sebag C, et al. Complete atrioventricular block following mediastinal irradiation: A report of six cases. PACE 1991;14:1112–1118.
Ladero-Quesada JM, Amarillas-Sanchez L, Furio-Bacete V, Laredo-Velasco L. Peritoneal mesothelioma and complete auriculo-ventricular block as late complications in Hodgkin’s disease. Rev Clin Esp 1991;189:221–223.
Ali MK, Khalil KG, Fuller LM, et al. Radiation related myocardial injury. Cancer 1976;38:1941–1946.
Tzivoni D, Ratzkowski E, Biran S, Brook JG, Stern S. Complete heart block following therapeutic radiation of the left side of the chest. Chest 1977;71:231–234.
Mary-Rabine L, Waleffe A, Kulbertus H. Severe conduction disturbances and ventricular arrhythmias complicating mediastinal irradiation for Hodgkin’s disease-a case report. PACE 1980;3:612–617.
Gottdiener JS, Katin MJ, Borer JS, Bacharach SL, Green MV. Late cardiac effects of therapeutic mediastinal irradiation: Assessment by echocardiography and radionuclide angiography. N Engl J Med 1983;308:569–572.
Kereiakes DJ, Morady F, Ports TA. High degree atrio-ventricular block after radiation therapy. Am J Cardiol 1983; 51:1233–1234.
Lamaud M, Duranton B, Reymond S, Verneyre H. Bloc auriculo-ventriculaire complet après radiotherapie. Lyon Med 1985;253:335–337.
Velebit V, Von Segesser L, Gabathuler J, Jornod J, Faidutti B. Right ventricular outflow obstruction after radiation therapy. J Thorac Cardiovasc Surg 1986;92:153–155.
Villavicencio R, Gaspar J, Arriaga J, Reyes E. Post radiation heart disease: Report of case. Rev Invest Clin 1987;39:67–70.
Grotta JC. A cause of episodic neurologic dysfunction [letter]. Arch Neurol 1987;44:795–796.
McEniery PT, Dorosti K, Schiavone WA, Pedrick TJ, Sheldon WC. Clinical and angiographic features of coronary artery disease after chest irradiation. Am J Cardiol 1987; 60:1020–1024.
Fischbein L, Valtier B, Sachs RN, Beaudet B, Lanfranchi J. Radiation-related atrioventricular block [review]. Arch Mal Coeur 1987;80:1823–1825.
Nishizawa T, Suzuki I, Kobayashi J. A case report of complete atrioventricular block following therapeutic irradiation for breast cancer. Rinsyo-Geka 1987;42:1993–1996.
Prez M, Deghezdere C. Une observation de bloc auriculoventriculo post radique. Stimacouer 1988;15:269–270.
Grollier G, Commeau P, Mercier V, et al. Post-radiotherapeutic left main coronary ostial stenosis: Clinical and histological study. Euro Heart J 1988;9:567–570.
Ebagosti A, Guenoun M, Favre R, et al. Atrioventricular block as a complication of mediastinal radiation. Arch Mal Coeur 1989;82:935–939.
Mejia VE, Wolf FC, Duvernoy, Nair MRS. Complete heart block and chronic pericardial effusion 17 years after radiation therapy to the chest. Cardiovasc Rev Rounds 1989 (January):60–62.
Baylac-Domengetry F, Gallimard JF, Elbaz-Rostykus C, Coisne D, Allal J, Barraine R. Complications rhythmologiquest de la radiotherapie. Ann Cardiol Angeiol 1989; 38:219–223.
Ferrari E, Darmon JP, Taillan B, Raybaud F, Camous JP, Leonetti JA. Bloc auriculo-ventriculaire radique 18 ans apres traitement d’une maladie de Hodgkin. Presse Med 1990;1463–1464.
Borrel E, Wolf JE, Page E, et al. A rare complication of thoracic radiotherapy: Auriculoventricular block. Ann Cardio Angeiol 1990;39:351–355.
Nakao T, Kanaya H, Namura M, et al. Complete atrioventricular block following radiation therapy for malignant thymoma. Jpn J Med 1990;29:104–110.
Orzan F, Brusca A, Gaita A, Giustetto C, Figliomeni MC, Libero L. Associated cardiac lesions in patients with radiation-induced complete heart block. Int J Cardio 1993;39: 151–156.
Knight CT, Sutton GC. Complete heart block and severe tricuspid regurgitation after radiotherapy. Chest 1995;108: 1748–1745.
Roberts WC, Sjoerdsma A. The cardiac disease associated with the carcinoid syndrome (carcinoid heart disease). Am J Med 1964:36:5–34.
Dollinger MF, Lavine DM, Foye V Jr. Myocardial infarction due to postirradiation fibrosis of the coronary arteries: Case of successfully treated Hodgkin’s disease with lower esophageal involvement. JAMA 1966;195:316.
Roberts WC, Glancy DL, DeVita VT. Heart in malignant lymphoma (Hodgkin’s disease, lymphosarcoma, reticulum cell sarcoma and mycosis fungoides). A study of 196 autopsy cases. Am J Cardiol 1968;22:85–107.
McReynolds RA, Gold GL, Roberts WC. Coronary heart disease after mediastinal irradiation for Hodgkin’s disease. Am J Med 1976;60:39–45.
Patri B, Patri N. Bloc auriculo-ventriculaire succedant a la radiotherapie thoracique. A propos de 2 cas. Sem in Hop Paris 1977;53:38:2141–2142.
Brosius FC, Waller BF, Roberts WC. Radiation heart disease: Analysis of 16 young (aged 15 to 33 years) necropsy patients who received over 3,500 rads to the heart. Am J Med 1981;70:519–530.
Baylac-Domengetroy F, Elbaz-Rostykus C, Christiaenes L, Gallimard JF, Cosine D, Allial J, Barranine R. Cardiac complications of radiotherapy. Sem in Hop Paris 1984;64: 1407–1414.
Boivin JF, Hutchinson GB. Coronary heart disease mortality after irradiation for Hodgkin’s disease. Cancer 1982;49: 2470–2475.
Hicks G1. Radiation induced coronary artery disease-Post operative follow-up. Abstract, 56th Annual Scientific Assembly, American Heart Association 1990;88S.
Heider KM, Drobny H, Salewski D, et al. Cardiac changes following supradiaphragmatic mantle field irradiation. Radiother (Ber) 1982; 23:517–525.
Musabaeva LI, Kolycheva NI. Clinico-morphological characteristics of the radiation changes in the heart in cancer patients [review] Vopr Onkol 1982;28:88–94.
Frolich D, Adler K, Neumeister K, Uhlmann B. Electrocardiographic findings during radiotherapy in the thoracic area. Radiobiol-Radiother (Ber) 1984;25:99–106.
Wehr M. Late chronic serous-constrictive pericarditis after radiotherapy of Hodgkin’s disease. Internist (Berl) 1981; 22:749–753.
Shashaty GG. Aortic insufficiency following mediastinal radiation for Hodgkin’s disease. Am J Med Sci 1984;287: 46–47.
Applefeld MM, Slawson RG, Spicer KM, Singleton RT, Wesley MN, Wiernik PH. Long-term cardiovascular evaluation of patients with Hodgkin’s disease treated by thoracic mantle radiation therapy. Cancer Treat Rep 1982;66: 1003–1013.
Applefeld MM, Cole JF, Pollock SH, Sutton FJ, Slawson RG, Singleton RT, Wiernik PH. The late appearance of chronic pericardial disease in patients treated by radiotherapy for Hodgkin’s disease. Ann Intern Med 1981;94:338–341.
Applefeld MM, Wiernik PH. Cardiac disease after radiation therapy for Hodgkin’s disease: Analysis of 48 patients. Am J Cardiol 1983;51:1679–1681.
Kolar J, Vrabec R, Bek V, Jakoubkova J, Zidkova H, Suna Z. Radiation-induced damages of the heart and major arteries. Acta Univ Carol Med (Praha) 1976;22:455–481.
Mill WB, Baglan J, Kurichety P, Prasad S, Lee JY, Moller R. Symptomatic radiation induced pericarditis in Hodgkin’s disease. Int J Radiat Oncol Biol Phys 1984;10:2061–2065.
Coltart RS, Roberts JT, Thom CH, Petch MC. Severe constrictive pericarditis after single 16 mev anterior mantle irradiation for Hodgkin’s disease. Lancet 1985;1:488–489.
Burch GE, Sohal RS, Sun SC, Miller GC, Colcolough HL. Effects of radiation on the human heart: An electron microscopic study. Arch Intern Med 1968;121:230–234.
Tracy GP, Brown DE, Johnson LW, Gottlieb, AJ. Radiation-induced coronary artery disease. JAMA 1974;228: 1660–1662.
Myers RW. Radiation heart disease. J Tenn Med Assoc 1975;68:292–295.
Johnson NR. Radiation injury of lungs and heart [letter]. Ann Intern Med 1974;81:568–569.
Radwaner BA, Bradley A, Geringer R, Goldman AM, Schwartz MJ, Kemp HG. Left main coronary artery following mediastinal radiation. Am J Med 1987;82:1017–1020.
Ikaheimo MJ, Niemela KO, Linnaluoto MM, Jakobsson MJ, Takkunen JT, Taskinen PJ. Early cardiac changes related to radiation therapy. Am J Cardiol 1985;56:943–946.
Cooper EE. Breast cancer: Radiation effects on the myocardium. Tex Med 1967;63:52–59.
Totterman KJ, Personen E, Siltanen P. Radiation-related chronic heart disease. Chest 1983;83:875–878.
Takaoka A, Kaneda H, Urano M, Kikkawa S. An electrocardiographic study of cardiac damage secondary to radiotherapy of malignant intrathoracic tumors. Radiol Clin Biol 1968;37:1–12.
Detrano RC, Yiannikas J, Salcedo EE. Two-dimensional echocardiographic assessment of radiation-induced valvular heart disease. Am Heart J 1984;107:584–585.
Cohn KE, Stewart JR, Fajardo LF, Hancock EW. Heart disease following radiation. Medicine 1967;46:281–298.
Biran S, Hochmann A, Stern S. Therapeutic irradiation of the chest and electrocardiographic changes. Clin Radiol 1969;20:433–439.
Magyar E, Talerman A, Treurniet RE. Myocardial lesions subsequent to roentgenotherapy. Acta Med Acad Sci Hung 1976;33:345–351.
Mathur RL, Mangal D, Singhal NC. Electrocardiographic changes by thoracic irradiation. Indian J Cancer 1985; h22:182–188.
Morton DL, Kagan AR, Roberts WC, O’Brien KP, Holmes EC, Adkins PC. Pericardiectomy for radiation induced pericarditis with effusion. Ann Thorac Surg 1969;8:195–208.
Morgan GW, Freeman AP, McLean RG, Jarvis BH, Giles RW. Late cardiac, thyroid and pulmonary sequelae of mantle radiotherapy for Hodgkin’s disease. Int J Radiat Oncol Biol Phys 1985;11:1925–1931.
Fajardo LF. Radiation induced coronary artery disease. Chest 1977;71:563–564.
Carlson RG, Mayfield WR, Normann S, Alexander JA. Radiation-associated valvular disease. Chest 1991;99:538–545.
Fraumenti JS Jr, Herwig JC, Kissane JM. Panaortitis complicating Hodgkin’s disease. Am Int Med 1967;67:1242–1248.
Gharagozloo F, Clements IP, Mullany CJ. Use of the internal mammary artery for myocardial revascularization in a patient with radiation-induced coronary artery disease. Mayo Clin Proc 1992;67:1081–1084.
Chinnasami BR, Schwartz RC, Pink SB, Skotnicki RA. Isolated left main coronary stenosis and mediastinal irradiation. Clin Cardiol 1992;15:459–561.
Loire R, Saint-Pierre A. Radiation-induced pericarditis. Long-term outcome. 15 cases with thoracotomy and biopsy. Presse Med 1990;19:1931–193.
Cucchi G. Cardiotoxicity caused by radiation. Description of 2 clinical cases. Minerva Med 1992;83 385–387.
Huber K. Side effects of percutaneous radiotherapy in the area of the thorax: Cardiac toxicity of mantle field irradiation. Bildgebung 1991;58 (Suppl. 1):23–25.
Kleikamp G, Schnepper U, Seifer D, Korfer R. Coronary artery stenoses close to the ostia after mediastinal irradiation. Dtsch Med Wochenschr 1990;115:501–504.
Om A, Ellahham S, Vetrovec GW. Radiation-induced coronary artery disease [review]. Am Heart J 1992;124: 1598–1602.
Corn BW, Trock BJ, Goodman RL. Irradiation-related ischemic heart disease [review]. J Clin Oncol 1990;8:741–750.
Cocchieri M, Ramoni N, Severini D. Cardiotoxicity induced by radiotherapy. Minerva Cardioangiol 1993;41:119–122.
Hancock SL, Tucker MA, Hoppe RT. Factors affecting late mortality from heart disease after treatment of Hodgkin’s disease. JAMA 1993;270:1949–1955.
Lev M, Widran J, Erickson EE. A method for the histopathologic study of the atrioventricular node, bundle and branches. Arch Pathol 1951;52:73–83.
Lev M, Watne AL. Method for routine histopathological study of the sinus node. Arch Pathol 1954;57:168–177.
Lev M. The pathology of complete atrioventricular block. Prog Cardiovasc Dis 1964;6:317–326.
Lev M, Unger PN. The pathology of the conduction system in acquired heart disease. I. Severe atrioventricular block. AMA Arch Pathol 1955;60:502–529.
Lev M, Unger PN, Lesser ME, Pick A. Pathology of the conduction system in acquired heart disease. Complete right bundle branch block. Am Heart J 1961;61:593–614.
Lev M, Kinare SG, Pick A. The pathogenesis of atrioventricular block in coronary disease. Circulation 1970;42: 409–425.
Lev M. The pathology of the conduction system in atrioventricular block associated with coronary heart disease. Arterioscler Cor Heart Dis 1972;129–132.
Bharati S, Lev M, Dhingra RC, Chuquimia R, Towne WD, Rosen KM. Electrophysiologic and pathologic correlations in two cases of chronic second degree atrioventricular block with left bundle branch block. Circulation 1975;52:221–229.
Lev M, Bharati S. The conduction system in coronary artery disease. Curr Cardiovasc Topics 1978;1–16.
Miller AJ, Jain S, Levin B. Radiographic visualization of lymphatics of heart muscle and pericardial sac in the dog. Chest 1971;59:271–275.
Katz LN, Pick A. Clinical Electrocardiography: The Arrhythmias. Philadelphia: Lea and Febiger, 1956.
Marriott Henry JL. Arrhythmia Clinic 1989;6:7–13.
Kaplan BM, Pick A, Pirani CC. Clinical pathologic conference. Am Heart J 1967;73:245–260.
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Kaplan, B.M., Miller, A.J., Bharati, S. et al. Complete AV Block Following Mediastinal Radiation Therapy: Electrocardiographic and Pathologic Correlation and Review of the World Literature. J Interv Card Electrophysiol 1, 175–188 (1997). https://doi.org/10.1023/A:1009756504168
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DOI: https://doi.org/10.1023/A:1009756504168