Radiation Induced Symptomatic Critical Left Main Lesion and Symptomatic Aortic Stenosis In An Inoperable Candidate. Role of percutaneous intervention.

Background
We are presenting a challenging case of radiation induced critical left main stenosis and severe aortic stenosis in an inoperable candidate. TAVR plus left main stenting resulted in successful outcome.

Methods
67 year old female who received chest radiation therapy 16 years ago for Hodgkin lymphoma, newly discovered ESRD and stage IV rectal carcinoma presented with severe dyspnea at rest and found to have severe aortic stenosis with aortic valve area of 0.44 cm2 and mean gradient of 48 mmHg, ejection fraction 45% and LAD wall motion abnormality. Cardiac catheterization showed isolated 95% ostial left main stenosis. She has resting dyspnea and could not ambulate more than 5 steps. Given prior radiation therapy related mediastinal changes, adhesions, lung fibrosis, comorbidities and short lifespan due to stage IV malignancy, she was deemed prohibitive surgical candidate. Decision was made to intervene percutaneously.

Results
She underwent combined procedure for TAVR and left main drug eluting stenting with excellent outcome. Left main was stented first immediately followed by TAVR implantation without mechanical circulatory support. She notes great improvement in her dyspnea from NYHA class IV to class I on subsequent follow up. Ejection fraction normalized.

Conclusions
The pathogenesis of radiation induced is not completely understood. Ostial coronary artery lesions with valvular stenosis are classic long term sequale of prior mediastinal radiation therapy. Post radiation changes in mediastinal anatomy increases the surgical risk and percutaneous interventions seem promising. Current literature is limited to case reports and large scale studies are needed. Our case demonstrate the long term consequences of radiation therapy and use of modern percutaneous intervention technique that has improved the symptoms and cardiac mortality of this patient.