Current Cardiology Reports

, 21:97 | Cite as

Radiation-Associated Pericardial Disease

  • Natalie Szpakowski
  • Milind Y. DesaiEmail author
Pericardial Disease (AL Klein and CL Jellis, Section Editors)
Part of the following topical collections:
  1. Topical Collection on Pericardial Disease


Purpose of Review

This review highlights the literature related to pericardial injury following radiation for oncologic diseases.

Recent Findings

Radiation-associated pericardial disease can have devastating consequences. Unfortunately, there is considerably less evidence regarding pericardial syndromes following thoracic radiation as compared to other cardiovascular outcomes. Pericardial complications of radiation may arise acutely or have an insidious onset several decades after treatment. Transthoracic echocardiography is the screening imaging modality of choice, while cardiac magnetic resonance imaging further characterizes the pericardium and guides treatment decision-making. Cardiac CT can be useful for assessing pericardial calcification. Ongoing efforts to lessen inadvertent cardiac injury are directed towards the revision of radiation techniques and protocols.


As survival of mediastinal and thoracic malignancies continues to improve, radiation-associated pericardial disease is increasingly relevant. Though advances in radiation oncology demonstrate promise in curtailing cardiotoxicity, the long-term effects pertaining to pericardial complications remain to be seen.


Pericardial disease Radiation Pericardial effusion Constrictive pericarditis 



Dr. Desai is supported by the Haslam Family Endowed Chair in Cardiovascular Medicine.

Compliance with Ethical Standards

Conflict of Interest

Natalie Szpakowski and Milind Y. Desai declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Mulrooney DA, Yeazel MW, Kawashima T, Mertens AC, Mitby P, Stovall M, et al. Cardiac outcomes in a cohort of adult survivors of childhood and adolescent cancer: retrospective analysis of the Childhood Cancer Survivor Study cohort. BMJ. 2009;339:b4606.PubMedPubMedCentralGoogle Scholar
  2. 2.
    Veinot JP, Edwards WD. Pathology of radiation-induced heart disease: a surgical and autopsy study of 27 cases. Hum Pathol. 1996;27(8):766–73.PubMedGoogle Scholar
  3. 3.
    Wei X, Liu HH, Tucker SL, Wang S, Mohan R, Cox JD, et al. Risk factors for pericardial effusion in inoperable esophageal cancer patients treated with definitive chemoradiation therapy. Int J Radiat Oncol Biol Phys. 2008;70(3):707–14.PubMedGoogle Scholar
  4. 4.
    Gaya AM, Ashford RF. Cardiac complications of radiation therapy. Clin Oncol (R Coll Radiol). 2005;17(3):153–9.Google Scholar
  5. 5.
    McGale P, Darby SC, Hall P, Adolfsson J, Bengtsson NO, Bennet AM, et al. Incidence of heart disease in 35,000 women treated with radiotherapy for breast cancer in Denmark and Sweden. Radiother Oncol. 2011;100(2):167–75.PubMedGoogle Scholar
  6. 6.
    Brosius FC 3rd, 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(3):519–30.PubMedGoogle Scholar
  7. 7.
    Xue J, Han C, Jackson A, Hu C, Yao H, Wang W, et al. Doses of radiation to the pericardium, instead of heart, are significant for survival in patients with non-small cell lung cancer. Radiother Oncol. 2019;133:213–9.PubMedGoogle Scholar
  8. 8.
    Hayashi K, Fujiwara Y, Nomura M, Kamata M, Kojima H, Kohzai M, et al. Predictive factors for pericardial effusion identified by heart dose-volume histogram analysis in oesophageal cancer patients treated with chemoradiotherapy. Br J Radiol. 2015;88(1046):20140168.PubMedPubMedCentralGoogle Scholar
  9. 9.
    Tamari K, Isohashi F, Akino Y, Suzuki O, Seo Y, Yoshioka Y, et al. Risk factors for pericardial effusion in patients with stage I esophageal cancer treated with chemoradiotherapy. Anticancer Res. 2014;34(12):7389–93.PubMedGoogle Scholar
  10. 10.
    Niska JR, Thorpe CS, Allen SM, Daniels TB, Rule WG, Schild SE, et al. Radiation and the heart: systematic review of dosimetry and cardiac endpoints. Expert Rev Cardiovasc Ther. 2018;16(12):931–50.PubMedGoogle Scholar
  11. 11.
    Arsenian MA. Cardiovascular sequelae of therapeutic thoracic radiation. Prog Cardiovasc Dis. 1991;33(5):299–311.PubMedGoogle Scholar
  12. 12.
    Cosset JM, Henry-Amar M, Pellae-Cosset B, Carde P, Girinski T, Tubiana M, et al. Pericarditis and myocardial infarctions after Hodgkin's disease therapy. Int J Radiat Oncol Biol Phys. 1991;21(2):447–9.PubMedGoogle Scholar
  13. 13.
    Martel MK, Sahijdak WM, Ten Haken RK, Kessler ML, Turrisi AT. Fraction size and dose parameters related to the incidence of pericardial effusions. Int J Radiat Oncol Biol Phys. 1998;40(1):155–61.PubMedGoogle Scholar
  14. 14.
    Taylor CW, McGale P, Povall JM, Thomas E, Kumar S, Dodwell D, et al. Estimating cardiac exposure from breast cancer radiotherapy in clinical practice. Int J Radiat Oncol Biol Phys. 2009;73(4):1061–8.PubMedGoogle Scholar
  15. 15.
    Carmel RJ, Kaplan HS. Mantle irradiation in Hodgkin's disease. An analysis of technique, tumor eradication, and complications. Cancer. 1976;37(6):2813–25.PubMedGoogle Scholar
  16. 16.
    Reshko LB, Kalman NS, Hugo GD, Weiss E Jr. Cardiac radiation dose distribution and cardiotoxicity in early-stage non-small cell lung cancer treated with stereotactic body radiation therapy. Int J Radiat Oncol Biol Phys. 2017;99(2):E492.Google Scholar
  17. 17.
    Marinko T, Borstnar S, Blagus R, Dolenc J, Bilban-Jakopin C. Early cardiotoxicity after adjuvant concomitant treatment with radiotherapy and trastuzumab in patients with breast cancer. Radiol Oncol. 2018;52(2):204–12.PubMedPubMedCentralGoogle Scholar
  18. 18.
    Lancellotti P, Nkomo VT, Badano LP, Bergler-Klein J, Bogaert J, Davin L, et al. Expert consensus for multi-modality imaging evaluation of cardiovascular complications of radiotherapy in adults: a report from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. J Am Soc Echocardiogr. 2013;26(9):1013–32.PubMedGoogle Scholar
  19. 19.
    Hancock SL, Donaldson SS, Hoppe RT. Cardiac disease following treatment of Hodgkin's disease in children and adolescents. J Clin Oncol Off J Am Soc Clin Oncol. 1993;11(7):1208–15.Google Scholar
  20. 20.
    Hancock SL, Tucker MA, Hoppe RT. Factors affecting late mortality from heart disease after treatment of Hodgkin's disease. JAMA. 1993;270(16):1949–55.PubMedGoogle Scholar
  21. 21.
    Ning MS, Tang L, Gomez DR, Xu T, Luo Y, Huo J, et al. Incidence and predictors of pericardial effusion after chemoradiation therapy for locally advanced non-small cell lung cancer. Int J Radiat Oncol Biol Phys. 2017;99(1):70–9.PubMedPubMedCentralGoogle Scholar
  22. 22.
    Fukada J, Shigematsu N, Ohashi T, Shiraishi Y, Takeuchi H, Kawaguchi O, et al. Pericardial and pleural effusions after definitive radiotherapy for esophageal cancer. J Radiat Res. 2012;53(3):447–53.PubMedGoogle Scholar
  23. 23.
    Stewart JR, Fajardo LF. Radiation-induced heart disease: an update. Prog Cardiovasc Dis. 1984;27(3):173–94.PubMedGoogle Scholar
  24. 24.
    Fajardo LF, Stewart JR. Experimental radiation-induced heart disease: light microscopic studies. Am J Pathol. 1970;59(2):299–316.PubMedPubMedCentralGoogle Scholar
  25. 25.
    Cohn KE, Stewart JR, Fajardo LF, Hancock EW. Heart disease following radiation. Medicine. 1967;46(3):281–98.PubMedGoogle Scholar
  26. 26.
    Rodemann HP, Bamberg M. Cellular basis of radiation-induced fibrosis. Radiother Oncol. 1995;35(2):83–90.PubMedGoogle Scholar
  27. 27.
    Martin RG, Ruckdeschel JC, Chang P, Byhardt R, Bouchard RJ, Wiernik PH. Radiation-related pericarditis. Am J Cardiol. 1975;35(2):216–20.PubMedGoogle Scholar
  28. 28.
    Greenwood RD, Rosenthal A, Cassady R, Jaffe N, Nadas AS. Constrictive pericarditis in childhood due to mediastinal irradiation. Circulation. 1974;50(5):1033–9.PubMedGoogle Scholar
  29. 29.
    Bertog SC, Thambidorai SK, Parakh K, Schoenhagen P, Ozduran V, Houghtaling PL, et al. Constrictive pericarditis: etiology and cause-specific survival after pericardiectomy. J Am Coll Cardiol. 2004;43(8):1445–52.PubMedGoogle Scholar
  30. 30.
    Adler Y, Charron P, Imazio M, Badano L, Baron-Esquivias G, Bogaert J, et al. 2015 ESC guidelines for the diagnosis and management of pericardial diseases: the task force for the diagnosis and management of pericardial diseases of the European Society of Cardiology (ESC) endorsed by: the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2015;36(42):2921–64.PubMedGoogle Scholar
  31. 31.
    Welch TD. Constrictive pericarditis: diagnosis, management and clinical outcomes. Heart. 2018;104(9):725–31.PubMedGoogle Scholar
  32. 32.
    Sagristà-Sauleda J, Angel J, Sánchez A, Permanyer-Miralda G, Soler-Soler J. Effusive–constrictive pericarditis. N Engl J Med. 2004;350(5):469–75.PubMedGoogle Scholar
  33. 33.
    Desai MY, Jellis CL, Kotecha R, Johnston DR, Griffin BP. Radiation-associated cardiac disease: a practical approach to diagnosis and management. J Am Coll Cardiol Img. 2018;11(8):1132–49.Google Scholar
  34. 34.
    Geske JB, Anavekar NS, Nishimura RA, Oh JK, Gersh BJ. Differentiation of constriction and restriction: complex cardiovascular hemodynamics. J Am Coll Cardiol. 2016;68(21):2329–47.PubMedGoogle Scholar
  35. 35.
    Reuss CS, Lusk JL, Lester SJ, Wilansky SM, Tajik AJ, Grill DE, et al. Using mitral ‘annulus reversus’ to diagnose constrictive pericarditis. Eur J Echocardiogr. 2008;10(3):372–5.PubMedGoogle Scholar
  36. 36.
    Napolitano G, Pressacco J, Paquet E. Imaging features of constrictive pericarditis: beyond pericardial thickening. Can Assoc Radiol J. 2009;60(1):40–6.PubMedGoogle Scholar
  37. 37.
    Talreja DR, Edwards WD, Danielson GK, Schaff HV, Tajik AJ, Tazelaar HD, et al. Constrictive pericarditis in 26 patients with histologically normal pericardial thickness. Circulation. 2003;108(15):1852–7.PubMedGoogle Scholar
  38. 38.
    Desai MY, Karunakaravel K, Wu W, Agarwal S, Smedira NG, Lytle BW, et al. Pulmonary fibrosis on multidetector computed tomography and mortality in patients with radiation-associated cardiac disease undergoing cardiac surgery. J Thorac Cardiovasc Surg. 2014;148(2):475–81 e3.PubMedGoogle Scholar
  39. 39.
    Cremer PC, Tariq MU, Karwa A, Alraies MC, Benatti R, Schuster A, et al. Quantitative assessment of pericardial delayed hyperenhancement predicts clinical improvement in patients with constrictive pericarditis treated with anti-inflammatory therapy. Circ Cardiovasc Imaging. 2015;8(5):e003125.PubMedGoogle Scholar
  40. 40.
    Feng D, Glockner J, Kim K, Martinez M, Syed IS, Araoz P, et al. Cardiac magnetic resonance imaging pericardial late gadolinium enhancement and elevated inflammatory markers can predict the reversibility of constrictive pericarditis after antiinflammatory medical therapy. Circulation. 2011;124(17):1830–7.PubMedGoogle Scholar
  41. 41.
    Francone M, Dymarkowski S, Kalantzi M, Rademakers FE, Bogaert J. Assessment of ventricular coupling with real-time cine MRI and its value to differentiate constrictive pericarditis from restrictive cardiomyopathy. Eur Radiol. 2006;16(4):944–51.PubMedGoogle Scholar
  42. 42.
    Bogaert J, Francone M. Cardiovascular magnetic resonance in pericardial diseases. J Cardiovasc Magn Reson. 2009;11(1):14.PubMedPubMedCentralGoogle Scholar
  43. 43.
    Morton DL, Glancy DL, Joseph WL, Adkins PC. Management of patients with radiation-induced pericarditis with effusion: a note on the development of aortic regurgitation in two of them. CHEST. 1973;64(3):291–7.PubMedGoogle Scholar
  44. 44.
    Adams MJ, Hardenbergh PH, Constine LS, Lipshultz SE. Radiation-associated cardiovascular disease. Crit Rev Oncol Hematol. 2003;45(1):55–75.PubMedGoogle Scholar
  45. 45.
    Murashita T, Schaff HV, Daly RC, Oh JK, Dearani JA, Stulak JM, et al. Experience with pericardiectomy for constrictive pericarditis over eight decades. Ann Thorac Surg. 2017;104(3):742–50.PubMedGoogle Scholar
  46. 46.
    Busch C, Penov K, Amorim PA, Garbade J, Davierwala P, Schuler GC, et al. Risk factors for mortality after pericardiectomy for chronic constrictive pericarditis in a large single-centre cohort. Eur J Cardiothorac Surg. 2015;48(6):e110–6.PubMedGoogle Scholar
  47. 47.
    Avgerinos D, Rabitnokov Y, Worku B, Neragi-Miandoab S, Girardi LN. Fifteen-year experience and outcomes of pericardiectomy for constrictive pericarditis. J Card Surg. 2014;29(4):434–8.PubMedGoogle Scholar
  48. 48.
    •• George TJ, Arnaoutakis GJ, Beaty CA, Kilic A, Baumgartner WA, Conte JV. Contemporary etiologies, risk factors, and outcomes after pericardiectomy. Ann Thorac Surg. 2012;94(2):445–51 This study showed high mortality following pericardiectomy for radiation-related pericarditis. PubMedPubMedCentralGoogle Scholar
  49. 49.
    •• Wu W, Masri A, Popovic ZB, Smedira NG, Lytle BW, Marwick TH, et al. Long-term survival of patients with radiation heart disease undergoing cardiac surgery. Circulation. 2013;127(14):1476–84 This important study illustrated the poor outcomes of patients with radiation heart disease. PubMedGoogle Scholar
  50. 50.
    Zamorano JL, Lancellotti P, Rodriguez Munoz D, Aboyans V, Asteggiano R, Galderisi M, et al. 2016 ESC position paper on cancer treatments and cardiovascular toxicity developed under the auspices of the ESC committee for practice guidelines: the task force for cancer treatments and cardiovascular toxicity of the European Society of Cardiology (ESC). Eur Heart J. 2016;37(36):2768–801.PubMedGoogle Scholar
  51. 51.
    Armenian SH, Lacchetti C, Barac A, Carver J, Constine LS, Denduluri N, et al. Prevention and monitoring of cardiac dysfunction in survivors of adult cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2017;35(8):893–911.PubMedGoogle Scholar
  52. 52.
    Specht L, Yahalom J, Illidge T, Berthelsen AK, Constine LS, Eich HT, et al. Modern radiation therapy for Hodgkin lymphoma: field and dose guidelines from the International Lymphoma Radiation Oncology Group (ILROG). Int J Radiat Oncol Biol Phys. 2014;89(4):854–62.PubMedGoogle Scholar
  53. 53.
    • Maraldo MV, Brodin NP, Vogelius IR, Aznar MC, Munck AF, Rosenschold P, et al. Risk of developing cardiovascular disease after involved node radiotherapy versus mantle field for Hodgkin lymphoma. Int J Radiat Oncol Biol Phys. 2012;83(4):1232–7 This study suggested less cardiotoxicity was associated with involved-node therapy in Hodgkin lymphoma. PubMedGoogle Scholar
  54. 54.
    Gyenes G, Gagliardi G, Lax I, Fornander T, Rutqvist LE. Evaluation of irradiated heart volumes in stage I breast cancer patients treated with postoperative adjuvant radiotherapy. J Clin Oncol Off J Am Soc Clin Oncol. 1997;15(4):1348–53.Google Scholar
  55. 55.
    Engert A, Plutschow A, Eich HT, Lohri A, Dorken B, Borchmann P, et al. Reduced treatment intensity in patients with early-stage Hodgkin's lymphoma. N Engl J Med. 2010;363(7):640–52.PubMedGoogle Scholar
  56. 56.
    • Mulliez T, Speleers B, Madani I, De Gersem W, Veldeman L, De Neve W. Whole breast radiotherapy in prone and supine position: is there a place for multi-beam IMRT? Radiat Oncol. 2013;8:151 This study suggested cardiotoxicity could be reduced with prone positioning in breast cancer patients. PubMedPubMedCentralGoogle Scholar
  57. 57.
    Formenti SC, DeWyngaert JK, Jozsef G, Goldberg JD. Prone vs supine positioning for breast cancer radiotherapy. JAMA. 2012;308(9):861–3.PubMedGoogle Scholar
  58. 58.
    Petersen PM, Aznar MC, Berthelsen AK, Loft A, Schut DA, Maraldo M, et al. Prospective phase II trial of image-guided radiotherapy in Hodgkin lymphoma: benefit of deep inspiration breath-hold. Acta Oncol. 2015;54(1):60–6.PubMedGoogle Scholar

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© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Heart and Vascular Institute, Department of Cardiovascular MedicineCleveland ClinicClevelandUSA

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