Pulmonary fibrosis on multidetector computed tomography and mortality in patients with radiation-associated cardiac disease undergoing cardiac surgery.
OBJECTIVE
In the long-term, malignancy-associated thoracic radiation leads to varying degrees of pulmonary fibrosis and radiation-associated cardiac disease, often requiring cardiothoracic surgery. We sought to determine whether pulmonary fibrosis affects mortality in patients with radiation-associated cardiac disease undergoing cardiothoracic surgery.


METHODS
We studied 117 patients (aged 63 ± 15 years, 71% were women) with radiation-associated cardiac disease receiving multimodality imaging who underwent cardiothoracic surgery (21% redo) between 2000 and 2003. Some 50% of patients had breast cancer, 28% of patients had Hodgkin's lymphoma, 9% of patients had lung cancer, and 13% of patients had other cancers. Time from radiation was 18 ± 12 years. Clinical, pulmonary function, angiographic, and echocardiographic parameters were recorded. On multidetector chest computed tomography, ascending aortic calcification and degree of pulmonary fibrosis (in 5 lobes for a score of 15: 0 = none, 1 = linear streaks, 2 = moderate fibrosis, and 3 = severe fibrosis with traction bronchiectasis) were recorded.


RESULTS
Mean European System for Cardiac Operative Risk Evaluation was 7.9 ± 3, and forced expiratory volume at 1 minute/forced vital capacity ratio was 0.75 ± 0.2. Mean left ventricular ejection fraction was 49% ± 12%, and right systolic ventricular pressure was 42 ± 5 mm Hg. Some 27% of patients had severe aortic stenosis, and 46% of patients had II+ or greater mitral regurgitation. On multidetector chest computed tomography, mean pulmonary fibrosis score was 3.5 ± 3, and 59% of patients had ascending aortic calcification. Isolated coronary artery bypass was performed in 17% of patients; the rest were combination surgeries. At 6.3 ± 0.4 years, there were 59 deaths (50%) (3% died 1 month postoperatively). Forty-five patients (39%) had pulmonary complications in follow-up. Increasing pulmonary fibrosis score (hazard ratio, 1.11; 95% confidence interval, 1.02-1.20; P = .02), worse European System for Cardiac Operative Risk Evaluation (hazard ratio, 1.10; 95% confidence interval, 1.01-1.21; P = .04), and lack of beta-blocker (hazard ratio, 0.54; 95% confidence interval, 0.31-0.94, P = .008) and aspirin (hazard ratio, 0.54; 95% confidence interval, 0.31-0.94; P = .03) independently predicted mortality.


CONCLUSIONS
In patients with radiation-associated cardiac disease undergoing cardiothoracic surgery, worsening pulmonary fibrosis is associated with increased mortality.
Heart and Vascular Institute and Imaging Institute, Cleveland Clinic, Cleveland, Ohio; Imaging Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address: desaim2@ccf.org.
Milind Y
MY
Desai
Imaging Institute, Cleveland Clinic, Cleveland, Ohio.
Karuppasamy
K
Karunakaravel
Heart and Vascular Institute and Imaging Institute, Cleveland Clinic, Cleveland, Ohio.
Willis
W
Wu
Heart and Vascular Institute and Imaging Institute, Cleveland Clinic, Cleveland, Ohio.
Shikhar
S
Agarwal
Heart and Vascular Institute and Imaging Institute, Cleveland Clinic, Cleveland, Ohio.
Nicholas G
NG
Smedira
Heart and Vascular Institute and Imaging Institute, Cleveland Clinic, Cleveland, Ohio.
Bruce W
BW
Lytle
Heart and Vascular Institute and Imaging Institute, Cleveland Clinic, Cleveland, Ohio.
Brian P
BP
Griffin
D000328:Adult; D000368:Aged; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000401:mortality; D005541:Forced Expiratory Volume; D006331:Heart Diseases / Q000000981:diagnostic imaging / Q000209:etiology / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D008168:Lung / Q000000981:diagnostic imaging* / Q000503:physiopathology / Q000528:radiation effects; D008297:Male; D008875:Middle Aged; D061330:Multidetector Computed Tomography; D011237:Predictive Value of Tests; D011658:Pulmonary Fibrosis / Q000000981:diagnostic imaging* / Q000209:etiology / Q000401:mortality / Q000503:physiopathology; D011832:Radiation Injuries / Q000000981:diagnostic imaging* / Q000209:etiology / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D011878:Radiotherapy / Q000009:adverse effects; D012307:Risk Factors; D012720:Severity of Illness Index; D013318:Stroke Volume; D013997:Time Factors; D016896:Treatment Outcome; D014463:Ultrasonography; D016277:Ventricular Function, Left; D016278:Ventricular Function, Right; D017725:Ventricular Pressure; D014797:Vital Capacity