Background
Radiotherapy has been associated with the accelerated development of valvular heart disease (VHD) and coronary artery disease (CAD). In response to this risk, current cardio-oncology guidelines recommend coronary computed tomography screening every five years and serial echocardiography evaluations following radiotherapy to enable early detection and management. We present the case of a patient with cardiovascular toxicity following radiotherapy for breast cancer, highlighting the diagnostic workup, multidisciplinary decision-making, and individualized management approach.
Case presentation
A 64-year-old female with NYHA class III–IV dyspnea was evaluated preoperatively in the cardio-oncology department following the simultaneous diagnosis of two tumors: a left-sided thoracic sarcoma and a right-sided breast cancer. Thoracic magnetic resonance imaging revealed a large mass in the left axilla (13.3 × 12.1 × 7.1 cm), suspected to involve the thoracic wall but without evidence of pulmonary infiltration. The patient had not received any prior medical or surgical treatment for the current malignancies. Her medical history was notable for a left-sided breast cancer 29 years earlier, treated with anthracyclines, radiotherapy, and breast-conserving surgery. Staging and histopathological data from the initial diagnosis were unavailable. Based on the tumor board's recommendations, surgical resection of the sarcoma was planned, along with initiation of aromatase inhibitor therapy for the newly diagnosed breast cancer.
During the cardio-oncology consultation, the patient’s overall cardiovascular risk—assessed using the HFA-ICOS score—was classified as very high. Echocardiography revealed preserved left ventricular ejection fraction (LVEF 58%), grade III diastolic dysfunction, severe mitral regurgitation, and moderate aortic stenosis. Despite clinical recompensation, symptoms persisted and mitral regurgitation remained severe. Coronary angiography showed two-vessel CAD with a chronically occluded left circumflex artery, unsuitable for revascularization. A diagnosis of heart failure with preserved ejection fraction (HFpEF) of mixed cardiotoxic and ischemic etiology was made. Given the high surgical risk, an interdisciplinary heart team recommended transcatheter edge-to-edge mitral valve repair (TEER), which was successfully performed. Subsequently, the sarcoma was completely resected, and hormone therapy for breast cancer was initiated
At the two-year follow-up, a new-onset dyspnea was reported despite no evidence of cancer progression. Follow-up echocardiography showed a preserved LVEF of 55% but revealed newly developed severe aortic stenosis. Repeat coronary angiography revealed progression of CAD with significant stenosis of the left anterior descending artery, requiring stent implantation. A renewed interdisciplinary evaluation recommended transcatheter aortic valve implantation (TAVI), which was successfully performed, leading to improvement of symptoms and resolution of dyspnea.
Conclusion
This case highlights the profound long-term impact of prior radiotherapy on cardiovascular toxicity in cardio-oncology patients. It underscores the role of previous radiotherapy not only in accelerating VHD and CAD, but also in predisposing to secondary malignancies. Importantly, it demonstrates that advanced transcatheter interventions such as mitral TEER and TAVI are feasible and effective treatment options in high-risk oncologic patients.
